Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on December 13, 2023, through December 14, 2023, Concord Township 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, onsite Medicare re-certification survey conducted December 13, 2023, through December 14, 2023, Concord Township Dialysis was identified to have the following standard level deficiency that was determined to be in substantial compliance with the 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)(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 review of facility policy, observation (OBS) of treatments performed, and an interview with the Facility Administrator, the facility did not ensure that patient care staff removed gloves, performed hand hygiene, and donned clean gloves during central venous catheter (CVC) exit site care for one (1) of two (2) OBS (OBS #3), and during discontinuation of dialysis with an AV fistula for one (1) of two (2) OBS (OBS #11).
Findings include:
A review of facility policy on December 14, 2023, at approximately 2:00 P.M. revealed the following:
Policy # 1-05-01 titled "Infection Control for Dialysis Facilities" stated, "Hand Hygiene: 1. All teammates, Physicians and Non-Physicians (NPP) will perform hand hygiene: ... b. prior to gloving and immediately after removal of gloves,... d. after patient and dialysis delivery system contact,... g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse."
Policy # 1-04-02B titled "Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure" stated, "Procedure: 1. Perform had hygiene per procedure. Put on PPE (personal protective equipment)... 4. Remove old dressing and discard... 7. Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 8. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site... 9. Clean each CVC limb/cap... 10. Remove gloves and discard, perform hand hygiene per procedure and re-glove... 12. Place sterile 2x2 gauze over catheter exit site... 14. Remove gloves and discard, perform hand hygiene per procedure and re-glove..."
Observation of the treatment area was conducted on December 13, 2023, from approximately 10:00 A.M. to 12:30 P.M. and December 14, 2023, from approximately 9:30 A.M. to 10:45 A.M. revealed the following:
OBS #3, Station #2, on December 13, 2023, at approximately 11:20 A.M., during initiation of dialysis with a CVC and CVC exit site care, EMP #3 (employee) was observed initiating dialysis with a CVC. After treatment was initiated, EMP #3 did not perform hand hygiene or don new gloves before or during performance of CVC exit site care as required by facility policy.
OBS #11, Station #4, on December 14, 2023, at approximately 9:46 A.M., during discontinuation of dialysis with an AV fistula/graft, EMP #3 was observed performing hand hygiene and donning gloves, disconnecting the dialysis lines, touching the dialysis machine, preparing strips of tape, removing the fistula needles, and applying dressings to the needle sites without changing gloves and performing hand hygiene throughout the procedure as required by facility policy.
An interview with the Facility Administrator on December 14, 2023, at approximately 4:15 P.M. confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 12/18/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" and Procedure 1-04-02B "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" with the emphasis on but not limited to:
A. [Policy} Infection Control: 1) All teammates, Physicians and Non-Physician (NPP) 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... g. before touching clean areas such as supplies, supply cart and chairside keyboard/ mouse...
B. [Procedure] CVC Exit site care: 1) Step 1: Perform hand hygiene per procedure. 2) Step 4: Remove old dressing and discard. 3) Step#7: Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 4) Step 8: Holding catheter with the nondominant hand and using aseptic technique, clean exit site... 5) Step 9: Clean each CVC limb/cap with a new LARGE alcohol prep pad, starting close to the exit site and finishing with the cap. 6) Step 10: Remove gloves and discard, perform hand hygiene per procedure and re-glove. 7) Step 12: Place sterile 2x2 gauze over the catheter site... 8) Step 14: Remove gloves and discard, perform hand hygiene per procedure and re-glove. Verification of attendance is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify teammates are performing hand hygiene with glove changes appropriately, per policies, including during CVC exit site care and during discontinuation of dialysis with AV fistula / graft: 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 audit results with teammates during homeroom meetings, and with Medical Director during the 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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