Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on November 16, 2022 through November 18, 2022, Fresenius Kidney Care Fox Chase, was identified to have the following standard level deficiency that was determined 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:
494.62(d)(1) STANDARD
ESRD EP Training Program
Name - Component - 00
§494.62(d)(1): Condition for Coverage:
(d)(1) Training program. The dialysis facility must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
Staff training must:
(iii) Demonstrate staff knowledge of emergency procedures, including informing patients of-
(A) What to do;
(B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated;
(C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and
(D) How to disconnect themselves from the dialysis machine if an emergency occurs.
(iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and
(v) Properly train its nursing staff in the use of emergency equipment and emergency drugs.
(vi) Maintain documentation of the training.
(vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures.
Observations:
Based on a review of the facility emergency preparedness plan, facility policy, patient medical records (MR), and an interview with facility staff, the facility did not document training and testing of emergency preparedness training for patients for three (3) of seven (7) medical records. MR# 2, 6, & 7.
Findings include:
A review of the facility emergency preparedness program was conducted on November 18, 2022 at approximately 10:00 AM.
A review of facility policy, "Fire Drills" conducted on November 18, 2022 at 10:30 AM states: "Fire Drills: Quaterly all FKC facilities shall perform a fire drill for each shift of patients and staff..."
A review of facility documentation titled "Fresenius Medicare: Patient Participation in Fire and Disaster Drills" states "complete the form for each drill (4 per year, quaterly) and place form in patient's Medical Record. Twice per year will include both a fire and a disaster drill."
A review of MRs was conducted on November 17, 2022 between 9:30 AM and 2:00 PM.
MR#2. Admission date 7/17/19 did not contain documentation of a fire drill for the 3rd quarter of 2022.
MR#6. Admission date 9/5/17 did not contain documentation of a fire drill for quarters 1 and 3 of 2022.
MR#7. Admission date 6/22/18 did not contain documentation of a fire drill for the 3rd quarter of 2022.
An interview with the clinical manager on November 18, 2022 at 1:30 PM confirmed the findings, and that the above cited policies are current.
Plan of Correction:E 038
To ensure compliance, Fire Drills will be completed for the fourth quarter of 2022 for all patients and staff by November 30, 2022. Records of the drills will be available at the facility for review.
For ongoing compliance, the Clinic Manager (CM) or designee will educate all staff on the following policy:
- Fire Drills
Emphasis will be placed on ensuring that fire drills are completed for all patients quarterly. Documentation of the fire drills will be completed on the Patient Participation in Fire Drill and Disaster Drills and placed in the patients' medical records.
Inservicing will be completed by November 28, 2022. All training documentation will be on file at the facility.
To ensure ongoing compliance with quarterly fire drills, the CM or designee will develop a Fire Drill tracking calendar for the remainder of 2022 and for 2023 with the weeks in the quarters that the fire drills are to be held clearly identified. This calendar will be posted at the nurse's station. The CM will also have the weeks of the fire drills for 2023 marked in the computer's electronic calendar. The Fire Drill Tracking calendar will be reviewed in Quality Assessment and Performance Improvement (QAPI) meetings.
The QAPI committee will be informed of the weeks that the drills are scheduled for 2022 and 2023. The results of the fire drills, when conducted, will be reviewed by the CM at the monthly QAPI meeting for ongoing oversight.
Issues of non-compliance will include re-education and counseling by the Director of Operations (DO).
Completion date: December 30, 2022
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on November 16, 2022 through November 18, 2022, Fresenius Kidney Care Fox Chase, was found to be in 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:
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