Initial Comments:
Based upon the findings of an unannounced on-site Medicare recertification survey conducted between 4/12/19-4/17/19, Carlisle Regional Dialysis was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions of 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 4/12/19-4/17/19, Carlisle Regional Dialysis 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:
494.30(a)(4)(ii) STANDARD
IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL
Name - Component - 00
[The facility must demonstrate that it follows standard infection control precautions by implementing-
(4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-]
(ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment.
Observations:
Based upon review of facility policy and procedures, an observational tour of the facility, and an interview with the Facility Administrator, (EMP # 1), the medical director failed to ensure staff checked medications and supplies for expiration dates according to facility medication policy for one (1) of one (1) observations made. (OBS #1)
Findings included:
Review of facility policy # 1-06-01, on 4/15/19 between approximately 2:30 PM-3:00 PM titled " Medication Policy" stated " 1. " The administrator/designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medication.." 29. All medications are checked monthly for expiration dates"
Additional policy, titled " Infection Control for Dialysis Facilities" stated " 21. The contents of packages will not be used beyond the expiration date on the package."
Observation #1 on 4/12/19 between approximately 1:30 PM-2:30 PM revealed two (2) infuse aid Intravenous (IV) administration infusion sets, located in the emergency crash cart, in the patient treatment area, each had expiration dates of 6/27/18.
One box of Pneumovax, located in the medication refrigerator, within the patient treatment area, contained nine (9) bottles of vaccine with expiration date for each bottle 4/6/19.
Blood culture bottles, located in the lab section of the patient treatment area, contained six (6) BD Bactec Lytic/10 Anaerobic culture vials with expiration dates for each bottle 2/28/19.
Blood culture bottles, located in the lab section of the patient treatment area, contained six (6) BD Bactec + Aerobic/F culture vials with expiration dates for each bottle 2/28/19.
Interview with EMP # 1 on 4/15/19 at approximately 3:00 PM confirmed above findings.
Plan of Correction:V0122
The Clinical Coordinator (CC) and Group Facility Administrator (GFA) will hold an in-service for all clinical teammates (TMs) by 05/08/2019 to review Policy 1-06-01 Medication Policy and Policy 1-05-01 Infection Control for Dialysis Facilities. Education will include but not limited to: 1) the handling, storing, disposing and controlling of medications. 2) All medications are checked monthly for expiration dates. Verification of attendance will be evidenced by TM signature on in-service sheet. All expired items were immediately discarded. One hundred percent (100%) of all medications, crash cart supplies and laboratory supplies will be checked for expiration dates by 05/08/19. Moving forward, expirations dates will be checked monthly on all medications, crash cart supplies and laboratory supplies. The CC or designee will perform audits monthly for three (3) months to verify compliance. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the TMs during homeroom meetings and with the Medical Director during Facility Health Meetings with supporting documentation included in the meeting minutes. The GFA is responsible for compliance with plan of correction.
Completion date: 05/10/19
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 upon review of facility policy and procedures, medical record (MR) review, and an interview with the Facility Administrator, (EMP # 1), the physician orders were not followed to achieve specified goals for one (1) of five (5) files reviewed. ( MR # 3).
Findings included:
Review of facility policy # 1-14-01, on 4/15/19 between approximately 2:30 PM-3:00 PM titled " Interdisciplinary Team (IDT) Patient Assessment and Plan of Care" stated " 13. " .. if the expected outcome is not achieved, the interdisciplinary team ... will adjust the patient's plan of care to achieve the specified goal."
Review of MR on 4/17/19 between approximately 9:00 AM-11:45 AM and 12:15 PM-3:00 PM revealed:
MR # 3, Start of Care (SOC) 10/13/18,
Physician order, dated 10/14/18 start date stated " Clonidine 0.20 mg PO if patient has a SBP > 180 after first hour of treatment give 0.2 mg and evaluate within the hour."
No verbal order or changes to physician orders were present.
Review of treatment records, for 4/10/19, revealed: dialysis treatment was initiated at 9:16 AM, with patient stable.
10:31 AM a recorded blood pressure (BP) reading of 183/99 was documented.
11:01 AM a recorded BP reading of 182/104 was documented.
No Clonipine was documented as administered per POC for elevation in BP.
Interview with EMP # 1 on 4/15/19 at approximately 3:00 PM confirmed above findings.
Plan of Correction:V0504
The CC and GFA will hold an in-service for all clinical TMs by 5/8/2019 to review Policy 1-14-01 Interdisciplinary Team Patient Assessment and Plan of Care and Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment. Education will include but not limited to: 1) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 2) TMs must notify the patient physician and IDT and adjust the patient's plan of care if the expected outcome is not achieved. Verification of attendance will be evidenced by TM signature on in-service sheet. Ten percent (10%) of all patient treatment sheets will be audited by the GFA or designee daily for one (1) week then weekly for three (3) weeks then monthly for two (2) months to verify compliance. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the Medical Director monthly at FHM-QAPI with supporting documentation included in the meeting minutes. The GFA is responsible for compliance with the plan of correction.
Completion date: 05/10/19
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