Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey completed April 27, 2023, Mt. Pocono Dialysis was identified to be in compliance with the following requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage for End-Stage Renal Disease (ESRD) Facilities-Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey completed April 27, 2023, Mt. Pocono Dialysis 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) STANDARD
IC-WEAR GLOVES/HAND HYGIENE
Name - Component - 00
Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.
Observations:
Based on a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure the staff followed infection control protocols, included but not limited to, hand hygiene/don clean gloves, for two (2) of three (3) 'Cleaning and Disinfection of the Dialysis Station' observations (Observation #1, Observation #3) and failed to ensure the staff followed infection control protocols, included but not limited to, hand hygiene/don clean gloves, for two (2) of two (2) 'Parenteral Medication Preparation and Administration' observations (Observation #1, Observation #2).
Findings include:
A review was conducted of facility policy/procedure on April 27, 2023, at approximately 9:30 a.m. Procedure: 1-03-12F 'Termination of Dialysis Utilizing Fresenius 2008 Series Dialysis Delivery System and Streamline Blood Lines' Step #20 states "Remove bloodlines and dialyzer and discard in biohazardous waste container." Step #21 states "Once patient has vacated the dialysis station; empty and rinse priming container if needed. Clean exterior surface of dialysis delivery system and the interior and exterior of reusable priming container with appropriate disinfectant."
(Note: This procedure does not emphasize removing gloves, performing hand hygiene and donning clean gloves after emptying the removing bloodlines/disposable equipment and emptying the prime waste receptacle, as pet r the CMS (Centers for Medicare and Medicaid Services) ESRD (end stage renal disease) Core Survey Version 1.6 observation checklist sheet and per CDC (Centers for Disease Control and Prevention) guidelines.)
Observations conducted in patient treatment area on 04/24/23 between approximately 9:30 a.m. - 12:30 p.m. revealed the following:
Observation #1 of 3: During observation of 'Cleaning and Disinfection of the Dialysis Station' on 04/24/23 at approximately 10:05 a.m., of patient #8, Employee #12 at station #11 did not perform hand hygiene/don clean gloves after emptying the prime waste receptacle and before using a disinfectant soaked cloth to wipe down the dialysis machine.
Observation #3 of 3: During observation of 'Cleaning and Disinfection of the Dialysis Station' on 04/24/23 at approximately 10:35 a.m., of patient #6, Employee #12 at station #12 did not perform hand hygiene/don clean gloves after emptying the prime waste receptacle and before using a disinfectant soaked cloth to wipe down the dialysis machine.
Procedure: 1-06-01A 'Preparation and Administration of Parenteral Medications (Non-EPO, Non-Parsabiv) with all Dialyzer Types' 'Administration of Parenteral Medication' step (1) states "Verify physician order." (2) "Check patient record for any known allergies or previous drug sensitivity." (3) "Perform hand hygiene. Put on PPE."
Observation #1 of 2: During observation of 'Parenteral Medication Preparation and Administration' on 04/24/23 at approximately 12:15 p.m., of patient #4, Employee #4 at station #1 did not perform hand hygiene after preparing the patient medication and prior to administering the medication. Employee #4 only donned clean gloves.
Observation #2 of 2: During observation of 'Parenteral Medication Preparation and Administration' on 04/24/23 at approximately 12:20 p.m., of patient #10, Employee #2 at station #8 did not perform hand hygiene after preparing the patient medication and prior to administering the medication. Employee #2 only donned clean gloves.
An interview with the facility Administrator on April 27, 2023 at approximately 11:45 a.m. confirmed the above findings.
Plan of Correction:V113
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/01/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" rev. April 2023 with emphasis on but not limited to: 1. Infection control policy: 1) All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves; c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact... 2) At the end of each treatment, the dialysis station will be cleaned and disinfected... Priming containers are to be emptied prior to disinfection. 3) Gloves should be changed when going from a "dirty" area or task to a "clean" area or task.
Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee reinforced the need to empty the priming container then hand hygiene with glove change before machine and station disinfection, and performing hand hygiene prior to and after every glove change.
The Facility Administrator will conduct infection control audits to verify hand hygiene is performed by teammates per policy: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment and 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.
Addendum V113 Effective 05/09/23: Education included but was not limited to a review of Procedure 1-06-
01A "Preparation and Administration of Parenteral medications (Non-EPO, Non-Parsabiv) with all Dialyzer
Types" with emphasis on but not limited to: 1) Verify physician order. 2) Check patient record for any
known allergies or previous drug sensitivity with the medication to be administered. 3) Perform hand
hygiene. Put on PPE. The Facility Administrator or designee will include observation of hand hygiene after
medication preparation and prior to gloving to administer medications, in the infection control audit
process previously detailed: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance
will be monitored with the monthly infection control audits. Instances of non-compliance will be addressed
immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom
meetings, and with the Medical Director during monthly Quality Assessment and Performance
Improvement meetings known as Facility Health Meetings, with supporting documentation included in the
meeting minutes.
494.30(a)(2) STANDARD
IC-STAFF EDUCATION-CATHETERS/CATHETER CARE
Name - Component - 00
Recommendations for Placement of Intravascular Catheters in Adults and Children
I. Health care worker education and training
A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections.
B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters.
II. Surveillance
A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site.
Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients.
VI. Catheter and catheter-site care
B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections].
Observations:
Based on a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure that clinical staff maintain aseptic technique for the care of vascular accesses, including intravascular catheters for two (2) of three (3) observations (Observation #2, Observation #3).
Findings:
A review was conducted of facility policy/procedure on April 27, 2023, at approximately 9:30 a.m. Procedure #1-04-02B 'Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure' 'Notes' states "...Perform a 15 second hub scrub every time a CVC is connected or disconnected from the bloodlines, ...." 'Procedure' (14) "Remove gloves and discard, perform hand hygiene per procedure and re-glove." (16) Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, ..." (17) "Attach sterile 10 ml syringes to the arterial and venous limbs."
Observations conducted in patient treatment area on 04/24/23 between approximately 9:30 a.m. - 12:30 p.m. revealed the following:
Observation #2 of 3: On 04/24/23 while observing 'Discontinuation of Dialysis with Central Venous Catheter' observation #2 for patient #6, station #9; employee #12 scrubbed the hubs for approximately 4 seconds after disconnecting the bloodlines and prior to attaching sterile syringes.
Observation #3 of 3: On 04/24/23 while observing 'Discontinuation of Dialysis with Central Venous Catheter' observation #3 for patient #7, station #12; employee #12 scrubbed the hubs for approximately 4 seconds after disconnecting the bloodlines and prior to attaching sterile syringes.
An interview with the facility Administrator on April 27, 2023 at approximately 11:45 a.m. confirmed the above findings.
Plan of Correction:V 147
The Facility Administrator or designee held mandatory in-service(s) for all Clinical Teammates starting on 5/1/2023. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-04-02B "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" revised April 2023, with emphasis on but not limited to: NOTES: Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason. 1) Step #16: Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue, for example blood. Hold the limbs until the antiseptic has dried. 2) Step #17: Attach sterile 10ml syringes to the arterial and venous limbs.
Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct observational audits for CVC care to verify the fifteen (15) second hub scrub: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings and with the Medical Director during Quality Assessment and 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.
494.40(a) STANDARD
ENVIRONMENT-SECURE & RESTRICTED
Name - Component - 00
8 Environment: secure & restricted
The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system.
Observations:
Based on a review of facility policy/procedure, observations, and an interview with the facility Administrator, the facility failed to ensure water treatment /preparation areas and supply storage areas were restricted to authorized personnel for one (1) of one (1) observations (Observation #1).
Findings:
A review was conducted of facility policy/procedure on April 27, 2023, at approximately 9:30 a.m. Policy: 8-04-01 'Physical Environment' 'Policy' section (9) states "Systems to assure patient safety will be in place ..... Access to patient treatment areas, water treatment systems, supply storage and dialysis equipment is restricted to authorized personnel only. Access limitation does not preclude visitors or tours by individuals authorized and supervised by facility personnel."
Observations conducted in patient treatment area on 04/24/23 between approximately 9:30 a.m. - 12:30 p.m. revealed the following:
Observation #1: on 04/24/23 at approximately 12:25 p.m. the door exiting the treatment area to an adjacent hallway was not locked (there is a keypad on the door). Adjacent to the hallway is the water room and storage supply room. These two doors were unlocked and the rooms were not secure.
The opposite side of the treatment area has an adjacent hallway which leads to the bio-med technician's work area and the room where bicarbonate is mixed/prepared. The door leading into the bicarbonate preparation room was standing open unsecured (there is a keypad on this door).
An interview with the facility Administrator on April 27, 2023 at approximately 11:45 a.m. confirmed the above findings.
Plan of Correction:V184
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/01/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 2-03-01 "Water Treatment Systems Minimum Component Requirements" rev. Oct. 2021, with emphasis on but not limited to: 1) New and renovated water purification and distribution systems should be located in a secure area that is readily accessible to authorized teammates. A location will be chosen which minimizes the length and complexity of the distribution system. Access to the water treatment system should be restricted to those personnel/trained teammates responsible for monitoring, maintenance of the system and supply ordering. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
Upon notification of the identified issue from the surveyor, the Facility Administrator immediately closed doors and engaged the keypad locks to the bicarbonate mixing and water treatment rooms. Teammates were reminded to keep the doors closed and locked.
The Facility Administrator or designee will conduct observational audits to verify the doors to water treatment and preparation areas are secured and restricted to authorized personnel: daily for two (2) weeks and then weekly for two (2) weeks. Ongoing compliance will be verified with observational audits monthly. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings and with the Medical Director during Quality Assessment and 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.
494.40(a) STANDARD
CARBON ADSORP-MONITOR, TEST FREQUENCY
Name - Component - 00
6.2.5 Carbon adsorption: monitoring, testing freq
Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours.
Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet.
Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L].
Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly.
Observations:
Based on a review of facility policy/procedure, water log reviews, and an interview with the facility Administrator, the facility failed to ensure free chlorine, chloramine, or total chlorine testing was performed at least every 4 hours, per facility policy, for one (1) of one (1) 'Daily Water Log' reviews (Water Log Review #1).
Findings include:
A review was conducted of facility policy/procedure on April 27, 2023, at approximately 9:30 a.m. Policy: 2-05-02 'Daily Water System Total Chlorine Monitoring'' 'Policy' (3) states "Total chlorine testing is done on a daily basis prior to the first patient treatment and every four (4) hours until all activities that require us of dialysis quality water are completed. ... Document results on Routine Total Chlorine Testing Log and in Snappy."
Daily Water Logs reviewed on 04/26/23 at approximately 9:30 a.m. revealed the following:
Water Log Review #1: 'Routine Total Chlorine Testing Log' revealed late chlorine testing on the following dates:
On 01/12/23, Total Chlorine Testing documentation revealed time of testing 9:20 a.m. The next chlorine reading revealed time of testing 1:30 p.m. This is a total of (4) hours and (10) minutes between chlorine testing.
On 01/26/23, Total Chlorine Testing documentation revealed time of testing 7:04 a.m. The next chlorine reading revealed time of testing 12:55 p.m. This is a total of (5) hours and (51) minutes between chlorine testing.
On 03/07/23, Total Chlorine Testing documentation revealed time of testing 9:05 a.m. The next chlorine reading revealed time of testing 1:15 p.m. This is a total of (4) hours and (10) minutes between chlorine testing.
On 03/16/23, Total Chlorine Testing documentation revealed time of testing 9:08 a.m. The next chlorine reading revealed time of testing 1:35 p.m. This is a total of (4) hours and (27) minutes between chlorine testing.
An interview with the facility Administrator on April 27, 2023 at approximately 11:45 a.m. confirmed the above findings.
Plan of Correction:V196
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/01/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 02-05-02 "Daily Water System Total Chlorine Monitoring" with emphasis on but not limited to: 1) Total Chlorine testing is done on a daily basis prior to the first patient treatment and every four (4) hours until all activities that require use of dialysis quality water are completed. All samples are to be drawn only after the water system has been operating for at least 15 minutes. Document results on Routine Total Chlorine Testing Log and in IT Clinical System.
Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
A timer set for three (3) hours was immediately implemented as a reminder for teammates to complete chlorine testing prior to four (4) hour mark.
The Facility Administrator or designee will perform audits of the Routine Total Chlorine Testing Log to verify chlorine testing is completed in compliance with policy: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored monthly during internal biomedical audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings and with the Medical Director during Quality Assessment and 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.
494.80(a)(2) STANDARD
PA-ASSESS B/P, FLUID MANAGEMENT NEEDS
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
Blood pressure, and fluid management needs.
Observations:
Based on a review of facility policy, observations, and an interview with the facility Administrator, the facility failed to ensure patient assessments, including but not limited to blood pressure monitoring, were documented every 30 minutes while receiving dialysis treatment for three (3) of five (5) medical records (MR) reviewed (MR #1 - MR#3).
Findings include:
A review was conducted of facility policy/procedure on April 27, 2023, at approximately 9:30 a.m. Policy: 1-03-08 'CWOW-Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment' 'Intradialytic Data Collection/Assessment section (9) states "Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: (a) Vital signs and treatment monitoring (i) For non-nocturnal treatments is completed at least every thirty (30) minutes."
A review of medical records conducted on 04/26/23 between approximately 1:00 p.m. - 3:00 p.m. and 04/27/23 between approximately 9:30 a.m. - 11:30 a.m. revealed the following:
MR#1 Date of admission 06/04/19:
Treatment flowsheet on 04/12/23 revealed the following Intradialytic (during dialysis) assessment was not documented every 30 minutes per policy. The post treatment flow sheet contained documentation of an assessment at 11:00 a.m. The next assessment did not occur until 11:45 a.m.
The post treatment flow sheet contained documentation of an assessment at 2:00 p.m. The next assessment did not occur until 2:43 p.m.
Treatment flowsheet on 04/17/23 revealed the following Intradialytic (during dialysis) assessment was not documented every 30 minutes per policy.
The post treatment flow sheet contained documentation of an assessment at 1:00 p.m. The next assessment did not occur until 2:10 p.m.
The post treatment flow sheet contained documentation of an assessment at 2:42 p.m. The next assessment did not occur until 3:37 p.m.
The post treatment flow sheet contained documentation of an assessment at 3:37 p.m. The next assessment did not occur until 4:31 p.m.
MR#2 Date of admission 11/14/22:
Treatment flowsheet on 04/17/23 revealed the following Intradialytic (during dialysis) assessment was not documented every 30 minutes per policy. The post treatment flow sheet contained documentation of an assessment at 7:31 a.m. The next assessment did not occur until 8:09 a.m.
The post treatment flow sheet contained documentation of an assessment at 10:09 a.m. The next assessment did not occur until 11:04 a.m.
MR#3 Date of admission 12/16/22:
Treatment flowsheet on 04/14/23 revealed the following Intradialytic (during dialysis) assessment was not documented every 30 minutes per policy. The post treatment flow sheet contained documentation of an assessment at 8:32 a.m. The next assessment did not occur until 9:18 a.m.
An interview with the facility Administrator on April 27, 2023 at approximately 11:45 a.m. confirmed the above findings.
Plan of Correction:V504
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/01/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "CWOW-Pre-Intra-Post treatment Data Collection Monitoring and Nursing Assessment" with emphasis on: 1) Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring i. For non-nocturnal treatments is completed at least every thirty (30) minutes. b. At a minimum, obtain and document the following: i. Blood pressure...
2) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct audits on treatment records to verify vital signs and treatment monitoring is documented every thirty (30) minutes: on twenty five percent (25%) of the treatment records daily for two (2) weeks, then weekly for two (2) weeks. 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 the audit results with teammates during homeroom meetings and with the Medical Director during Quality Assessment and 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 a review of facility policy/procedure, observations, and an interview with the facility Administrator, it was determined the facility failed to ensure staff followed facility policy for COVID-19 screening for one (1) of one (1) 'COVID-19 Response 'Entrance Evaluation Tracker' employee and patient screening forms reviewed (Form #1); failed to ensure staff followed facility policy for patient blood flow problems for one (1) of five (5) medical records (MR) reviewed (MR#5); and failed to ensure staff followed facility policy for dialysis machine cleaning/disinfection procedure for one (1) of one (1) 'Fresenius Dialysis Delivery System Clean and Disinfect Logs' reviewed (Log #1).
Findings include:
A review was conducted of facility policy/procedure on April 27, 2023, at approximately 9:30 a.m. Policy: 8-01-20 'COVID-19 Situation Guidance' section #1 states "Interim guidance developed by DaVita related to the COVID-19 situation ...... (a) For example but not limited to: ....., entrance evaluations, ....". 'COVID-19 Patient Management Plan Playbook (All modalities, except where otherwise indicated)' 'Step 1 Evaluate, screen, and disposition' 'First: COVID-19 Entrance Evaluation' "Conduct a timely COVID-19 Entrance Evaluation, using the COVID-19 Entrance Evaluation tracker, with 100 % of people entering your faciliy upon their arrival."
Review of facility 'COVID-19 Response 'Entrance Evaluation Tracker (All Modalities)' employee and patient screening forms on 04/25/23 at approximately 2:00 p.m. revealed the following:
Form #1: COVID-19 Response 'Entrance Evaluation Tracker (All Modalities) employee and patient screening forms were reviewed from 04/15/23 - 04/25/23. There was no documentation provided of employee/patient screening utilizing the 'Entrance Evaluation Tracker' form with all sections completed (the form contains several columns, including yes or no entries and including the evaluators initials) for the following dates: 04/15/23, 04/17/23, 04/19/23, 04/21/23, and 04/24/23.
Policy: 1-04-05 'Blood Flow Problems' 'Policy' (1) Blood flow problems may be identified by the following: Decreased ability to aspirate or maintain blood flow from CVC limb or successfully cannulate needle." 'Possible Causes' "Poor blood flow within the access ...." (2) If blood flow problem remains unresolved, notify licensed nurse. (3) The licensed nurse will assess the patient, their vascular access and extracorporeal circuit for the above and include the following: Assess the effectiveness of above interventions. Determine need to reduce blood flow and extend treatment time. Notify the nephrologist for further evaluation and/ or interventions.. (4) Document findings and interventions in patients medical record."
MR#5, Date of admit 08/22/22: 'Treatment Details Report' dated 04/24/23 reviewed on 04/27/23 at approximately 11:00 a.m.
Documentation shows treatment was started at 11:32, 'Initial Entry by (Employee #8, patient care technician): Treatment started without complications. ...."
12:07 p.m. 'Updated by (Employee #8): ".... Treatment started with complications; lines reversed."
No documentation of "complications" being defined nor of notifying the licensed nurse.
12:32 p.m. 'Submitted by (Employee #2, licensed nurse): Patient monitored eyes closed; patient resting."
No documentation of the licensed nurse being aware of the "lines being reversed" nor of any action taken by the licensed nurse, including assessment of the patient care technicians interventions nor notifying the nephrologist as per policy.
Policy 2-02-01 'Fresenius Dialysis Delivery System Cleaning and Disinfection Policy' 'Purpose' "To promote patient safety by cleaning and disinfection of Fresenius dialysis delivery systems." Section (4) 'Examples of Cleaning/Disinfection Procedures and Intervals/ 'Procedure' 'Heat Disinfection' "Each Treatment Day (unless chemical disinfect day)." 'Citric Acid, Vinegar Rinse' "Each treatment Day." Section (6) "Facilities will develop a specific Dialysis Delivery System Cleaning and Disinfection Log .... Cleaning and disinfection of dialysis delivery systems will be documented on this log."
Log #1: On 04/26/23 at approximately 10:30 a.m. the 'Fresenius Dialysis Delivery System Clean and Disinfect Log' was reviewed. On 3/30/23 no documentation for machines #2, #5, #6, #7, #13, and #14 of employees utilizing citric acid and heat disinfecting per facility policy. The sections for these machines were left blank with no entries. Patient treatment flowsheets were requested/provided which show the machines were being utilized for patient treatment on 03/30/23. Documentation provided of these machines being utilized for patient treatment the next day, 03/31/23.
An interview with the facility Administrator on April 27, 2023 at approximately 11:45 a.m. confirmed the above findings.
Plan of Correction:V715
A Governing Body meeting was held on 5/2/2023 with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 04/27/23. 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 facility teammates are trained and follow policies and procedures relative to patient admissions, patient care, infection control, and safety.
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 005/01/23. Surveyor observations were reviewed. Education included but was not limited to a review of facility policies with areas of emphasis on but not limited to:
1. "COVID-19 Response" Entrance Evaluation Tracker (All Modalities)" with emphasis on but not limited to: 1) Evaluate 100% of people entering your facility in a timely manner. Document responses on the following pages; escalate any 'yes' answers to a licensed nurse so the individual can receive an Advanced Screening in an appropriate dedicated space will be reviewed with the team. 2) File completed Entrance Evaluations in your COVID-19 binder and maintain them for 2 years in a secure location (not required if using the Digital Entrance Evaluation Tracker). The Facility Administrator or designee will conduct audits of the Entrance Evaluation forms or in the digital files to verify one hundred percent (100%) of people entering the facility complete an entrance evaluation: daily for two (2) weeks, then weekly for two (2) weeks than monthly during internal audits. Instances of non-compliance will be addressed immediately.
2. Policy 1-04-05 "Blood Flow Problems" with emphasis on but not limited to: 1) 1. Blood flow problems may be identified by the following: Decreased ability to aspirate or maintain blood flow from CVC limb or successfully cannulate needle; changes in patient's arterial or venous pressures at a given flow rate. Possible causes and interventions listed... 2) If blood flow problem remains unresolved, notify licensed nurse. 3) The licensed nurse will assess the patient, their vascular access and extracorporeal circuit for the above and include the following: assess the effectiveness of above interventions; determine need to reduce blood flow and extend treatment time; notify nephrologist for further evaluation and/or interventions. 4) Document findings and interventions in patient's medical record.
The Facility Administrator or designee will audit treatment records to verify documentation by teammates of "blood flow problems" also includes notification of the licensed nurse, with appropriate nurse actions per policy: on twenty five percent (25%) of the treatment records daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.
3. Policy 2-02-01 "Fresenius Dialysis Delivery System Cleaning and Disinfections Policy" with emphasis on but not limited to: 1) 'Examples of Cleaning/Disinfection Procedures and Intervals: Procedure: a. Heat disinfection each treatment unless it is a chemical disinfect day. b. Procedure: Citric Acid, Vinegar rinse each treatment day. 2. Facilities will develop a specific Dialysis Delivery System Cleaning and Disinfection Log... Cleaning and disinfection of dialysis delivery systems will be documented on this log."
The Facility Administrator or designee will audit the disinfection log to verify each machine is disinfected each treatment per policy: daily for two (2) weeks, then weekly for two (2) weeks, and monthly during internal audits. Instances of non-compliance will be addressed immediately.
Verification of attendance at all in-services will be evidenced by teammates' signatures on the in-services sheets. 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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