Initial Comments:
Based on the findings of an off-site unannounced complaint investigation survey conducted July 8, 2022 and July 13, 2022 through July 14, 2022 and July 19, 2022 through July 20, 2022, North Central Pennsylvania Dialysis Clinic, 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:
494.60 STANDARD
PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT
Name - Component - 00
The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment.
Observations:
Based on review of Incident report from Milton Rehabilitation and Nursing Center, patient's dialysis treatment record from 6/27/2022, statement from dialysis center patient care technician (PCT), North central Pennsylvania Dialysis clinic policy and consent form for the new heated chairs, EC09 Champion chairs manual, heated chairs education, emails with Facility Administrator and Facility Director of Compliance, interview with Facility Administrator, it was determined that the agency failed to provide CR # 1 with a safe and comfortable environment.
Findings:
Review of North central Pennsylvania Dialysis clinic policy and consent form for the new heated chairs on July 14, 2022 at 3:55 PM revealed:
a. Heat options: low: ninety eight (98) degrees Fahrenheit; medium: one hundred two (102) degrees Fahrenheit; high: one hundred five (105) degrees Fahrenheit.
b. The heaters automatically turn off thirty (30) minutes after your last selection. Certain items can trap heat and elevate the temperature beyond the desired setting.
c. Do not lay or sit on any of the following items while using the heat feature: blankets, pillows, pads, hoyer pads, stuffed animals, comfort items. You may cover with a blanket while on treatment.
d. If you require any of these items to make your dialysis treatment more comfortable, you will not be permitted use of the treatment chair heaters.
Interview with Facility Administrator on July 8, 2022 at 2:20 PM revealed: "We are putting a policy together with a consent for the chairs."
Interview with Facility Administrator on 7/20/22 at 11:15 AM in response to this writer's question if staff received education on the use of the new chairs revealed: "When we first obtained the chairs - we did not do an in-service. We didn't think we really needed too. After we created a policy and consent form - we decided to add a learning module that addresses the policy for the chair. It is currently active. Staff have a couple of weeks to complete it. I can run a report for that module once it runs its course. "
An interview with the Facility Administrator on 7/20/22 at 11:30 AM confirmed the above findings.
Plan of Correction:Plan of Correction:
1. Corrective Action: Patient treatment chairs were replaced on 6.24.2022. The new chairs are identical to the old with an additional heat feature for patient comfort. The center did not perform a formal in-service, nor did it update policies related to the treatment chairs.
2. Problem Identification: The center was notified by a local nursing home by certified letter that one of our patients suffered 1st degree burn on her buttocks from a new heated chair. The incident in question took place on 6.27.2022. The patient never notified the center staff, nor did she log a complaint with the center. The patient dialyzed 3 more times before we received the certified letter from the nursing home. The center unplugged all chairs and conducted an investigation on 7.5.2022. The center determined that none of the chairs heat features were malfunctioning.
3. Process Changes: The center implemented policy EC09 pertaining to the operation of the heated chairs. The chair manufacturer recommends that pillows and pads not be placed between the patient and the chair while utilizing the heat feature. This policy specifically spells that out. A staff in-service took place utilizing the online learning module. Additionally, a patient consent form (EC09A) was issued to document patient training on the use of the heat feature on the new chairs.
4. Monitoring of Changes: Center Manager will perform 10 audits per month to ensure that the heat feature is not being used by any patient that has a pillow or pad placed between them and the chair. Audits will take place for 3 months. Audit results will be discussed monthly at QAPI. If audits are successful, then the center will cease performing them.
5. POC Completion Date: 8.2.2022
494.90(d) STANDARD
POC-PT/FAMILY EDUCATION & TRAINING
Name - Component - 00
The patient care plan must include, as applicable, education and training for patients and family members or caregivers or both, in aspects of the dialysis experience, dialysis management, infection prevention and personal care, home dialysis and self-care, quality of life, rehabilitation, transplantation, and the benefits and risks of various vascular access types.
Observations:
Based on review of Incident report from Milton Rehabilitation and Nursing Center, Patient's dialysis treatment record from 6/27/2022, statement from dialysis center patient care technician (PCT), North central Pennsylvania Dialysis clinic policy and consent form for the new heated chairs, EC09 Champion chairs manual, heated chairs education, emails with Facility Administrator and Facility Director of Compliance, interview with Facility Administrator, it was determined that the agency failed to provide education on the use of the heated chair for CR #1.
Findings:
Interview with Facility Administrator on 7/20/22 at 11:15 AM revealed: "When we first obtained the chairs - we did not do an in-service. We didn't think we really needed too."
An interview with the Facility Administrator on 7/20/22 at 11:30 AM confirmed the above findings.
Plan of Correction:1. Corrective Action: Patient treatment chairs were replaced on 6.24.2022. The new chairs are identical to the old with an additional heat feature for patient comfort. The center did not perform a formal in-service, nor did it update policies related to the treatment chairs.
2. Problem Identification: The center was notified by a local nursing home by certified letter that one of our patients suffered 1st degree burn on her buttocks from a new heated chair. The incident in question took place on 6.27.2022. The patient never notified the center staff, nor did she log a complaint with the center. The patient dialyzed 3 more times before we received the certified letter from the nursing home. The center unplugged all chairs and conducted an investigation on 7.5.2022. The center determined that none of the chairs heat features were malfunctioning.
3. Process Changes: The center implemented policy EC09 pertaining to the operation of the heated chairs. The chair manufacturer recommends that pillows and pads not be placed between the patient and the chair while utilizing the heat feature. This policy specifically spells that out. A staff in-service took place utilizing the online learning module. Additionally, a patient consent form (EC09A) was issued to document patient training on the use of the heat feature on the new chairs.
4. Monitoring of Changes: Center Manager will perform 10 audits per month to ensure that the heat feature is not being used by any patient that has a pillow or pad placed between them and the chair. Audits will take place for 3 months. Audit results will be discussed monthly at QAPI. If audits are successful, then the center will cease performing them.
5. POC Completion Date: 8.2.2022
494.150(b) STANDARD
MD RESP-STAFF ED, TRAINING & PERFORM
Name - Component - 00
Medical director responsibilities include, but are not limited to, the following:
(b) Staff education, training, and performance.
Observations:
Based on review of Incident report from Milton Rehabilitation and Nursing Center, Patient's dialysis treatment record from 6/27/2022, statement from dialysis center patient care technician (PCT), North central Pennsylvania Dialysis clinic policy and consent form for the new heated chairs, EC09 Champion chairs manual, heated chairs education, emails with Facility Administrator and Facility Director of Compliance, interview with Facility Administrator, it was determined that the agency's medical director failed to ensure facility staff received education on new equipment prior to use and failed to ensure a policy was created for the heated chairs for one (1) out of one (1) observation.
Findings:
Policy for heated chairs and education for heated chairs was not created until after incident occurred.
Interview with Facility Administrator on 7/20/22 at 11:15 AM revealed: "When we first obtained the chairs - we did not do an in-service. We didn't think we really needed too. After we created a policy and consent form - we decided to add a learning module that addresses the policy for the chair. It is currently active. Staff have a couple of weeks to complete it. I can run a report for that module once it runs its course. "
An interview with the Facility Administrator on 7/20/22 at 11:30 AM confirmed the above findings.
Plan of Correction:Plan of Correction:
1. Corrective Action: Patient treatment chairs were replaced on 6.24.2022. The new chairs are identical to the old with an additional heat feature for patient comfort. The center did not perform a formal in-service, nor did it update policies related to the treatment chairs.
2. Problem Identification: The Medical Director was aware of the chair change and was made aware of the incident after the center received the notification from the nursing home via certified letter.
3. Process Change: Policy LD07 addresses the roles of the governing body and the medical director as responsible for overseeing staff education and adherence to the center policy and procedures. Staff education and training are discussed at the quarterly governing body meetings. The new chair policy and education will be discussed at the next governing body meeting and will fall inline with our other center activities.
4. Monitoring of Changes: Center Manager will perform 10 audits per month to ensure that the heat feature is not being used by any patient that has a pillow or pad placed between them and the chair. Audits will take place for 3 months. Audit results will be discussed monthly at QAPI to keep the medical director informed of adherence to the updated policy. If audits are successful, then the center will cease performing them.
5. POC Completion Date: 8.2.2022
|