Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 25, 2023 through September 27, 2023, Pdi- Walnut Tower, was identified to have the following standard level deficiency that was determined to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services-Emergency Preparedness.
Plan of Correction:
494.62(d)(1) STANDARD
ESRD EP Training Program
Name - Component - 00
§494.62(d)(1): Condition for Coverage:
(d)(1) Training program. The dialysis facility must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
Staff training must:
(iii) Demonstrate staff knowledge of emergency procedures, including informing patients of-
(A) What to do;
(B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated;
(C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and
(D) How to disconnect themselves from the dialysis machine if an emergency occurs.
(iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and
(v) Properly train its nursing staff in the use of emergency equipment and emergency drugs.
(vi) Maintain documentation of the training.
(vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures.
Observations:
Based on a review of the facility Medical Records (MR), facility policy, and an interview with the facility administrator, the facility did not conduct fire safety drills according to facility policy for four (4) of ten (10) MRs. MR# 1, 2, 3 & 4.
Findings include:
A review of Policy 4-07-01 "The Facility Emergency Management Plan (ICHD Home)" occurred on 9/27/23 at approximately 12:00 PM states: "Training and Education...Patients...Quaterly fire safety preparedness...document training on applicable forms..."
A review of Medical Records was conducted on 9/26/23 and 9/27/23 from approximately 10:00 AM-2:00 PM.
MR#1 admission date 5/4/2017 did not have a fire safety drill conducted for the third quarter of 2022, fourth quarter of 2022 or the second quarter of 2023.
MR#2 admission date 1/11/2019 did not have a fire safety drill conducted for the third quarter of 2022, fourth quarter of 2022 or the second quarter of 2023.
MR#3 admission date 12/19/2016 did not have a fire safety drill conducted for the third quarter of 2022, fourth quarter of 2022 or the second quarter of 2023.
MR#4 admission date 6/1/2017 did not have a fire safety drill conducted for the third quarter of 2022, fourth quarter of 2022 or the second quarter of 2023.
An interview with the facility administrator conducted on 9/27/23 at 3:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee will in-service all clinical teammates starting 10/02/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-07-01 "Facility Emergency Management Plan (EMP)" with emphasis on but not limited to: 1) The Facility Administrator or designee, is responsible to: Conduct and review quarterly fire safety and evacuation training and drills for compliance, identify additional training and education needs. 2) Fire safety drills: a. Required on a quarterly basis; one drill to be conducted for each shift of patients; b. Include patient emergency takeoff procedure, policy: Termination of Dialysis in an Emergency; c. Document training for ... patients; d. Complete exercise evaluation... e. Document in Governing Body and maintain with facility EMP. Verification of attendance is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will audit one hundred percent (100%) of patient files for the fire drill training documentation and update as needed by 11/26/23. The Facility Administrator or designee will audit fire drill documentation for three (3) quarters to verify compliance for all shifts of patients. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during the monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 25, 2023 through September 27, 2023, Pdi- Walnut Tower, was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.
Plan of Correction:
494.30(a)(1)(i) STANDARD
IC-IF TO STATION=DISP/DEDICATE OR DISINFECT
Name - Component - 00
Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient.
-- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient.
-- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients.
Observations:
Based on observation of the clinical area, facility policy and an interview with the facility administrator, the facility did not follow its policy regarding disinfection of non-disposable equipment for four (4) of four (4) observations. Observation # 1, 2, 3 & 4.
Findings include:
A review of facility policy was conducted on 9/27/23 at 12:00PM and revealed the following:
Policy, " 1-05-01 "Infection Control for Dialysis Facilities" states: "14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses...Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 (one to one hundred) bleach solution and if they are visibly contaminated with blood or body fluids should be disinfected with a 1:10 (one to ten) bleach solution"
Observations of the clinical area were conducted on 9/25/23 from 10:15AM- 12:30 PM and from 2:15PM-3:15PM.
Observation #1 station #3: 11:00AM. RN#1 used a stethoscope to assess a patient and did not disinfect the stethoscope after use.
Observation #2 station #4: 11:15AM. RN#2 used a stethoscope to assess a patient and did not disinfect the stethoscope after use.
Observation #3 station #14: 11:32 AM. RN#1 used a stethoscope to assess a patient and did not disinfect the stethoscope after use.
Observation #4 station #18: 3:02 PM. RN#2 used a stethoscope to assess a patient and did not disinfect the stethoscope after use.
An interview with the facility adminstrator on 9/27/23 at 3:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 10/01/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" revised April 2023, with the emphasis on but not limited to: 1) Non disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. 2) Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 (one to one hundred) bleach solution... Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify stethoscopes are disinfected between uses: daily for two (2) weeks, then weekly for two (2) weeks, then compliance will be monitored with monthly infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with the teammates during homeroom meetings and with the Medical Director during the monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P
Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;
Observations:
Based on review of the personnel files (PF), and an interview with the facility administrator it was determined the facility failed to follow its policy to maintain complete personnel files including obtaining a complete baseline Mycobacterium Tuberculosis (TB) evaluation and a Hepatitis B Vaccination/Declinations for one (1) of eight (8) personnel files. (PF #7)
Findings include:
Review of facility policy on 9/27/23 at approximately 12:00PM revealed the following:
Policy, "4-06-05 Tuberculosis Monitoring and Follow-up" states, "Baseline new hire requirements for all new teammates...will complete the following: TB-Risk Assessment and Symptom Evaluation Questionnaire, successful completion of Tuberculosis Education for New Treatments course and Testing options (any one of the following): a. Exemption from TST ..Negative...T-Spot completed within the past three months...documented previous positive Tuberculin Skin Test or T-Spot when the following additional documentation is provided: medical follow-up and clearance and documentation of a negative chest x-ray...or completion of treatment for LTBI (latent tuberculosis infection) and a negative chest x-ray...B. History of BCG...C. If exemption criteria for Tuberculin Skin test (TST) is not met, the following testing options are available: Baseline TST using two-step purified protein derivative (PPD)..."
Policy, "4-06-03 Hepatitis B Monitoring and Follow-up Guidance" states, "New teammates who are not able to provide documentation of hepatitis B surface antibodies of 10 mIU/ml or greater from any time in the past, regardless of documentation indicating completion of the hepatitis B vaccine series, will be screened for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) within 10 working days"
Review of personnel files completed on 9/25/23 at approximately 1:00 PM revealed the following:
PF #7, Date of hire: 1/1/2022 did not contain documentation of initial baseline TB testing and did not contain any doucmentation of Hepatitis B vaccination or declination.
An interview with the facility administrator conducted on 9/27/23 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:On 10/19/23, a Governing Body meeting with the Medical Director, Facility Administrator, Clinical Nurse Manager and Regional Operations Director was held to review the results of the survey ending on 09/27/23. The Governing Body reviewed Policy COMP-DD-017 "Medical Director Qualifications and Responsibilities" with the Medical Director, who acknowledges that he/she is responsible to ensure policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and non-physician providers. Plans of correction have been developed and initiated to correct identified deficiencies and to sustain compliance.
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 10/2/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-06-05 "Tuberculosis (TB) Monitoring and Follow-up" and Policy 4-06-03 "Hepatitis Monitoring and Follow-up Guidance" with emphasis on but not limited to:
A. Tuberculosis: 1) Baseline new hire requirements for all new teammates including volunteers, per diem teammates, non-agency personnel and teammates will complete the following: 1. TN-Risk Assessment and Symptom Evaluation Questionnaire. 2. Successful completion of Tuberculosis Education for New Teammates course. 3. Testing options ... c. If exemption criteria for TST is not met, the following testing options are available: i. Baseline TST using a two-step Purified Protein Derivative (PPD) Mantoux test (a second TST repeated one to three weeks after the first, if the initial test is negative). Test results will be recorded on the Teammate Health Monitoring Record.
B. Hepatitis: 1) New teammates who are not able to provide documentation of hepatitis B surface antibodies of 10 mIU/ml or greater from any time in the past, regardless of documentation indicating completion of the hepatitis B vaccine series, will be screened for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) within 10 working days. 2) Teammates providing evidence of hepatitis B surface antibodies of 10 mIU/ml or greater, upon hire will be considered immune and will not require initial or ongoing testing. 3) Teammates will be offered the hepatitis B vaccine series after blood borne pathogen training has occurred in accordance with Health and safety policy: Specified Control Methods. 4) Teammates that decline the hepatitis B vaccine series will be informed about the value of the vaccine and encouraged to take the series. They will sign "Hepatitis B Vaccination Consent / Declination Form".
Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
On 09/25/23 the Facility Administrator educated the Biomed Operations Manager on teammate file audit process; on 09/26/23 the Clinical Coordinator drew Hepatitis B labs and Tuberculosis labs for Biomed teammate. Actions steps in response to test results were taken and all documentation was completed and filed appropriately in teammate's records.
The Facility Administrator or designee immediately conducted a one hundred percent (100%) audit of teammates' medical records for completed "Hepatitis B Vaccination Consent/Declination Form" and TB screening documentation. Any teammate(s) with outstanding consent / declination forms, TB screening documentation, will complete the appropriate testing as needed, and sign the Hepatitis consent / declination form immediately.
The Facility Administrator or designee will conduct audits to verify new teammates have the appropriate documentation of TB screening and hepatitis results recorded with Hepatitis B Vaccination Consent / Declination Form signed and in the teammate file: monthly for three (3) months. Ongoing compliance will be monitored with the quarterly teammate file audit. Instances of non-compliance will be addressed immediately.
The Medical Director will review progress of teammate education, results of audits, and adherence to this plan of correction, as provided by the Facility Administrator during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. Action plans will be evaluated for effectiveness, new plans developed as applicable to achieve compliance with teammate adherence to policy and procedure. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction
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