QA Investigation Results

Pennsylvania Department of Health
Health Inspection Results
Health Inspection Results For:

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Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey conducted on November 17 through November 19, 2021, Fresenius Kidney Care Clarion, was identified to have the following standard level deficiency that were determined to be in substantial 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(b)(9)  STANDARD
Dialysis Emergency Equipment

Name - Component - 00
494.62(b)(9) Condition for Coverage:
[(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:]

(9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available.


Based on observation, and interview with staff (EMP1), the facility failed to ensure emergency equipment was immediately available at all times for one (1) of one (1) observation (OBS #1).

Findings included:

OBS #1, of facility's crash cart during flash tour with EMP1 on November 17, 2021, at approximately 10:30 a.m. revealed the oxygen tank attached to the crash cart was "empty" - PSI level gauge indicator was on zero (0) (empty), and not immediately available for use. The oxygen control valve was noticed to be "on" distributing one (1) liter of oxygen at the time of observation.

Interview with EMP1, at the time of the observation, on November 17, 2021 at approximately 10:30 AM confirmed findings.

Plan of Correction:

For immediate compliance, the empty oxygen tank on the crash cart was replaced on November 17, 2021.

For ongoing compliance, the Clinic Manager (CM) will in-service all direct patient care (DPC) staff on the following policy:
- Emergency Code Cart, Medications and Machine Hand Crank Checklist
Emphasis will be placed on ensuring that all necessary supplies are always available for use on the Code Cart. This includes checking the oxygen tanks on the cart and checking the pressure gauge on the tank and replacing the tank when the pressure reaches 500 psi.
The inservice will be completed by 12/2/2021 and the education records will be on file in the facility.
The CM and/or designee will conduct daily audits of the emergency oxygen tank for two (2) weeks. If one hundred percent (100%) compliance is observed, then audits will continue 2 times/week for four (4) weeks. If compliance has been sustained audits will continue monthly per Quality Assessment Improvement (QAI) clinical audit checks. A Plan of Correction (POC) specific audit tool will be used for the audits.

Staff found to be non-compliant will be re-educated and counseled.

The CM will review the audit results and report the findings to the QAI Committee at the monthly meeting. Sustained compliance will be monitored by the QAI committee.

Completion date: 12/31/2021

Initial Comments:

Based on the findings of an unannounced onsite Medicare survey for recertification and the addition of Home Hemo-Dialysis (home training and support) services, conducted on November 17, 2021 through November 19, 2021, Fresenius Kidney Care of Clarion, was found to be in 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: