Initial Comments:
Based on the findings of an unannounced Medicare recertification survey conducted May 25 through May 27, 2022, Eynon 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 unannounced Medicare recertification survey conducted May 25 through May 27, 2022, Eynon Dialysis Childs 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 for End-Stage Renal Disease Facilities.
Plan of Correction:
494.60(c)(4) STANDARD
PE-HD PTS IN VIEW DURING TREATMENTS
Name - Component - 00
Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement).
Observations:
Based on review of facility policies/procedures, observations, and based on interview with administrator, the facility failed to ensure the patients being treated in the hemodialysis treatment area are in view of staff throughout the hemodialysis treatment for two (2) of two (2) observations. (Observations #1 and #2)
Findings include:
On May 27, 2022 at approximately 11:47 AM, review of facility policy 1-03-08, titled "CWOW-Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" revealed the following under "Intradialytic Data Collection/Assessment" (data collection obtained and assessments performed during the hemodialysis dialysis treatment)...
9. Intradialytic treatment monitoring and data collection which may be performed by the PCT (patient care technician) or the licensed nurse includes...c. The vascular access site, blood line connections and the patient's face should be visible throughout the treatment...
On May 25, 2022 at approximately 9:55 AM and May 26, 2022 at approximately 9:48 AM, observational tour of the in-center hemodialysis ICHD) treatment room revealed three (3) staff/computer stations were present. Staff/computer station #1 was located adjacent to the patient scale. Staff/computer station #2 was located adjacent to the isolation room. Staff/computer station #3 was located adjacent to the laboratory area. A plexiglass guard was present on the top portion of the barrier wall at all three (3) staff/computer stations.
Multiple home dialysis forms/postings were clipped to the left hand side of the plexiglass guard located at staff/computer stations #2 and #3. The computer monitor at staff/station #3 was elevated due to being placed on top of the internet router.
Observation #1: On May 25, 2022 between the approximate times of 9:55 AM and 11:55 AM, observation of the ICHD treatment area revealed patient #7 was seated at station #7 and patient #6 was seated at station #8. The vascular access sites, blood line connections and faces of patients #6 and patients #7 were not visible from staff/computer stations #1 and #2 due to the layout of the ICHD treatment room nor from the seated position at staff/computer station #3 due to the multiple forms/postings being clipped to the plexiglass guard and due to the height of the elevated computer monitor.
Observation #2: On May 26, 2022 between the approximate times of 9:48 AM and 10:45 AM, observation of the ICHD treatment area revealed patient #8 was seated at station #8. The vascular access site, blood line connections and face of patient #8 were not visible from staff/computer stations #1 and #2 due to the layout of the ICHD treatment room nor from the seated position at staff/computer station #3 due to the multiple forms/postings being clipped to the plexiglass guard and due to the height of the elevated computer monitor.
During interview conducted on May 27, 2022 at approximately 4:20 PM, the administrator confirmed the vascular access sites, blood line connections and faces of patients #6, #7 and #8 were not visible from staff/computer stations #1 and #2 due to the layout of the ICHD treatment room nor from the seated position at staff/computer station #3 due to the multiple forms/postings being clipped to the plexiglass guard and due to the height of the elevated computer monitor.
Plan of Correction:11241 Eynon PA CMS Core 052722
V0407
The Facility Administrator held a mandatory in-service for all clinical teammates starting on 5/30/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "CWOW Pre- Intra- Post data Collection, Monitoring and Nurse Assessment" with emphasis on but not limited to: 1) Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: Vascular access visible and line connections intact. 2) The vascular access site, blood line connections and the patient's face should be visible throughout the dialysis treatment. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator immediately removed postings and computer monitor was taken off of modem on 5/26/22, after surveyor's interview. The Facility Administrator or designee will conduct observational audits to verify that teammates are visualizing and documenting access site, face and bloodline connection visibility: daily on treatment days for each shift for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit finding with teammates during homeroom meetings and with Medical Director during monthly Quality Assessment 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.
Completion date: 06/22/22
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