Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on December 11, 2023 through December 14, 2023, University City 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 December 11, 2023 through December 14, 2023, University City Dialysis was identified to have the following standard level deficiencies that waere determined to be in substantial compliance with 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services-Emergency Preparedness.
Plan of Correction:
494.30(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 policy and an interview with the facility administrator and clinical services manager, the facility did not ensure infection control procedure regarding glove removal and handwashing for two (2) of ten (10) observations (OBS). (OBS# 1 and 2).
Findings include:
A review of policy 1-05-01 "Infection Control For Dialysis Facilities" on December 11, 2023 at 1:30 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.
Observation of the clinical area was conducted on 12/11/23 between 9:04 am-12:19 pm.
OBS # 1 Machine 10 PCT 1, after locating and palpating cannulation site, did not discard gloves, perform hand hygiene and don new gloves prior to prior to inserting the fistula needle into the patient's vascular access.
OBS # 2 Machine 16 PCT 2 , after locating and palpating cannulation site did not discard gloves, perform hand hygiene and don new gloves prior to inserting the fistula needle into the patient's vascular access.
An interview with the facility administrator conducted on December 11, 2023 at 1:00 pm confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 12/14/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 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... 2) 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; 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. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify teammates are performing hand hygiene with glove changes appropriately, including during AV fistula or graft cannulation procedure: 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.
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 medical records (MR), facility policy, and an interview with the facility administrator, the facility did not follow its policy for heart rate management for two (2) of fifteen (15) MRs. (MR # 14 and 15).
Findings include:
A review of facility policy 1-03-08 "-Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" conducted on December 13, 2023 at 1:25 PM states: "Intradialytic Data Collection/Assessment 11. Abnormal findings...will be reported to the licensed nurse immediately. Abnormal Findings: Heart or pulse rate -Intradialytic- Less than 60 beats per minute or greater than 100 beats per minute ..........."
Findings include:
MR # 14 admission date 12/19/2022. A review of treatment sheet for 11/28/2023 revealed the following:
Pre Pulse sitting 81
18:31 Pulse 101 "Patient appears to be tolerating treatment well at this time"
19:01 Pulse 103 "Patient appears to be tolerating treatment well at this time"
19:31 Pulse 102 "Patient appears to be tolerating treatment well at this time"
20:02 Pulse 102 "Patient monitored: watching TV no complications"
20:32 Pulse 106 "Patient monitored: watching TV no complications"
21:01 Pulse 104 "Patient monitored: watching TV no complications"
21:31 Pulse 100 "Patient monitored: eyes closed patient resting"
22:01 Pulse 104 "Patient appears to be tolerating treatment well at this time"
22:34 Pulse 103 "Patient face; vascular access and blood line connection visible"
23:01 Pulse 105 "Patient appears to be tolerating treatment well at this time"
23:31 Pulse 108 "Patient awake, alert and states no complaints at this time."
00:01 Pulse 90 "Patient face; vascular access and blood line connection visible"
00:21 Pulse 108 "Treatment terminated".
Post heart rate 107
The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment.
A review of treatment sheet for 12/03/2023 revealed the following:
Pre Pulse sitting 98
18:29 Pulse 104 "Patient monitored: watching TV no complications"
19:00 Pulse 103 ""Patient monitored: watching TV no complications"
19:29 Pulse 84 "Patient monitored: watching TV no complications"
19:59 Pulse 83 "Patient appears to be tolerating treatment well at this time"
20:29 Pulse 104 "Patient appears to be tolerating treatment well at this time"
21:00 Pulse 105 "Patient face; vascular access and blood line connection visible"
21:29 Pulse 102 "Patient appears to be tolerating treatment well at this time"
22:00 Pulse 102 "Patient monitored: eyes closed patient resting"
22:30 Pulse 98 ""Patient appears to be tolerating treatment well at this time"
22:59 Pulse 108 "Patient monitored: watching TV no complications"
23:29 Pulse 105 ""Patient monitored: eyes closed patient resting"
23:59 Pulse 109 "Patient appears to be tolerating treatment well at this time"
00:03 Pulse 107 "Treatment terminated".
Post heart rate 102
The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment.
A review of treatment sheet for 12/05/2023 revealed the following:
Pre Pulse sitting 103
18:06 Pulse 102 "Treatment started without complications. Normal saline prime given: Heparin pump is on and working"
18:29 Pulse 100 "Patient monitored: watching TV no complications"
18:59 Pulse 100 "Patient appears to be tolerating treatment well at this time"
19:29 Pulse 101 "Patient appears to be tolerating treatment well at this time"
19:59 Pulse 103 "Patient monitored: watching TV no complications"
20:31 Pulse 103 "Patient appears to be tolerating treatment well at this time"
20:59 Pulse 102 "Patient monitored: watching TV no complications"
21:30 Pulse 107 "Patient appears to be tolerating treatment well at this time"
21:59 Pulse 100 "Patient monitored: eyes closed patient resting"
22:30 Pulse 102 ""Patient appears to be tolerating treatment well at this time"
22:59 Pulse 100 "Patient appears to be tolerating treatment well at this time"
23:30 Pulse 108 "Patient face; vascular access and blood line connection visible"
23:59 Pulse 109 "Patient monitored: watching TV no complications"
00:08 Pulse 110 "Treatment terminated".
Post heart rate 98
The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment.
MR # 15 admission date 12/03/2019. A review of treatment sheet for 11/27/2023 revealed the following:
Pre Pulse sitting 103
8:31 am Pulse 113 "Patient monitored: watching TV no complications"
9:01 am Pulse 127 "Patient monitored: watching TV no complications"
9:31 am Pulse 111 "Patient face, vascular access; and blood line connection visible"
10:01 am Pulse 98 "Patient states no complaints at this time"
10:31 am Pulse 102 Patient states no complaints at this time"
11:01 am Pulse 102 "Patient stable"
11:31 am Pulse 94 "Patient appears to be tolerating treatment well at this time"
11:51 am Pulse 101 "Treatment terminated Patient blood returned without complications"
Post heart rate 93
The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment.
A review of treatment sheet for 11/29/2023 revealed the following:
Pre Pulse sitting 120
7:16 am Pulse 107 "Treatment started without complication. Normal saline prime given, Patient face, vascular access; and blood line connection visible"
7:17 am Pulse 111 "Patient verbalized no complaints"
7:32 am Pulse 132 "Patient appears to be tolerating treatment well at this time"
8:02 am Pulse 132 "Patient appears to be tolerating treatment well at this time"
8:32 am Pulse 128 "Patient stable"
9:02 am Pulse 125 "Patient monitored: watching TV no complications"
9:32 am Pulse 120 "Patient appears to be tolerating treatment well at this time"
10:02 am Pulse 114 "Patient awake, alert and states no complaints at this time"
10:17 am Pulse 128 "Treatment terminated Patient blood returned without complications"
Post heart rate 103
The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment.
A review of treatment sheet for 12/01/2023 revealed the following:
Pre Pulse heart rate 103
9:32 am Pulse 116 "Patient awake, alert and states no complaints at this time"
10:02 am Pulse 104 "Patient awake, alert and states no complaints at this time"
10:23 am Pulse 122 "Treatment terminated"
Post heart rate 120
The PCT (patient care technician) did not report the above elevated heart rate to the licensed nurse and therefore the licensed nurse did not assess the heart rate during the treatment.
An interview with the facility administrator conducted on December 13, 2023 at 1:32 pm confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 12/14/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "Pre-Intra-Post treatment Data Collection Monitoring and Nursing Assessment" with emphasis on: 1) Patient data will be obtained and documented by the patient care technician or licensed nurse. Data collection includes... Heart or pulse rate, noting also if the beat is regular or irregular... 2) Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse... If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 3) Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: at a minimum...heart or pulse rate. 4) Abnormal findings or findings outside of any patient specific physician ordered parameters will be documented and reported to the licensed nurse immediately. 5) If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 6) Licensed nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility. 7) Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record. Within each category, definitions may be adjusted by a patient specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient's condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. 8) Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time. 9) Heart or pulse rate Pre/ Intra/ Post: Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat... 10) 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 to verify complete and accurate treatment documentation, with notification of abnormal findings to and appropriate response by the licensed nurse: 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 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.
494.90(a)(5) STANDARD
POC-VASCULAR ACCESS-MONITOR/REFERRALS
Name - Component - 00
The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.
Observations:
Based on a review of facility policy, observations, and an interview with the facility administrator, the facility failed to utilizes the vascular access clamp procedure
was seen by staff member throughout the dialysis treatment for one (1) of ten (10) treatment floor observations OBS (OBS # 1).
Findings include:
A review was conducted of facility policy/procedure on December 11, 2023 approximately 12:39 pm.
In center hemodialysis policy and procedure 1-04-08A #2 following termination of treatment and removal of fistula needle............... 8 clamp may remain in place for five-10 minutes before checking to see if bleeding has stopped 12. clamp may remain in place for an additional 5 to 10 minutes before checking to see if bleeding has stopped. Access clamp should not be left on longer than 20 minutes.
Observations conducted in patient treatment area on 12/11/23 between 9:04 am-12:19 pm revealed the following:
OBS # 1 Machine 7 PCT 1, During treatment floor observations the patients access site was clamped between 9:40 am to 10:04 am before clamp was taken off ( approximately 24 minutes)
An interview with the facility Facility Administrator on December 11, 2023 at approximately 1:00 pm. confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 12/14/2023. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-04-08A "Utilizing Vascular Access Clamps" with emphasis on but not limited to: 1) Following termination of treatment and removal of fistula needle... 2) Clamp may remain in place for 5- 10 minutes before checking to see if bleeding has stopped. 3) Clamp may remain in place for an additional 5-10 minutes before checking to see if bleeding has stopped. Access clamp should not be left on longer than 20 minutes. Verification of attendance is evidenced by a signature sheet.
The Facility Administrator or designee will conduct infection control observations to verify proper use and timing of vascular access clamps per policy: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with 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.
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