Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on October 16, 2023 through October 19, 2023, Market Street Dialysis was found 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:
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on October 16, 2023 through October 19, 2023 Market St. Dialysis was identified to have the following standard level deficiency that was 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 observation of the clinical area, facility procedure and an interview with the facility administrator, the facility did not ensure infection control procedure regarding glove removal and handwashing for one (1) of twelve (12) observations (OBS). OBS#1).
Findings include:
A review of policy 1-05-01 "Infection Control For Dialysis Facilities" on October 16, 2023 at 12:45 pm states: " 1. All teammates...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,,,7a Gloves should be changed when: ii. When going from a "dirty" area or task to a "clean" area or task. iii. When moving from i. contaminated body site to a clean body site of the same patient; and iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient's dialysis delivery system.
A review of procedure : 1-06-27 B "Preparation and administration of Intravenous Mircera from a pre-filled syringe" on October 16 2023 at 12:30 pm states: " 1. Verify physician order. 2. Check patient record for any known allergies or previous drug sensitivity with medication to be administered. Perform hand hygeine. Put on PPE. 4. Prior to each dose administration, verify the patient.........
Observation of the clinical area was conducted on October 16, 2023 between 9:00 am-11:55 am .
OBS#1 Nurse prepared medication at medication station, opened drawer, removed alcohol swab, labeled syringe, did not perform hand hygeine or don new gloves before administration of IV medication.
An interview with the facility administrator conducted on October 16, 2023 at 1:00 pm confirmed the above findings.
Plan of Correction:V113
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 10/30/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 10-05-01 "Infection Control for Dialysis Facilities" rev. April 2023 and Policy 1-06-27B "Preparation and Administration of Intravenous Mircera from a Pre-filled Syringe" with the emphasis on but not limited to: A. Infection control policy: 1) All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene prior to gloving and immediately after removal of gloves 2) A)Disposable gloves will be worn when caring for the patient or touching the patient's equipment at the dialysis station.
B)Preparation and Administration of IV Mircera: 1) Verify physician order 2) Check patient record for any known allergies or previous drug sensitivity with medication to be administered. 3) Perform hand hygiene. Put on PPE. Rationale: Hand hygiene protects the teammate and patient from cross contamination. PPE is worn for teammate protection. Verification of attendance at in-service is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify teammates perform hand hygiene and put on PPE prior to medication administration per policy: daily for 2 weeks, then weekly for 2 weeks, with each teammate being observed at least (3) times during the first four weeks. Ongoing compliance will be monitored with the monthly infection control audit. Instances of non-compliance will be corrected immediately.
The Facility Administrator or designee will review 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. Facility Administrator is responsible for compliance with this plan of correction.
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