Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted between 2/7/2022-2/9/2022, Roosevelt Avenue 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 between 2/7/2022-2/9/2022, Roosevelt Avenue Dialysis was found to have the following standard level defiencies that were 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)(i) STANDARD
IC-IF TO STATION=DISP/DEDICATE OR DISINFECT
Name - Component - 00
Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient.
-- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient.
-- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients.
Observations:
Based upon review of facility policy, observation (OBS), and interview with facility manager, (EMP # 1), facility failed to clean or disinfect thermometer between patients for one (1) observation. (OBS # 1).
Findings included:
Review of facility policy on 2/9/2022 at approximately 2:00 PM titled " Infection control for Dialysis facilities Policy:1-05-01" stated " (25) Non-disposable items are to be disinfected between patients."
Observations made on 2/9/2022 between approximately 9:00AM-9:30 AM revealed: patient at station # 10 was connected to dialysis and temperature taken and recorded. Staff member, PF # 8, took the temperature and placed the thermometer on the computer stand. PF # 8 then moved to station # 12 for new patient taking the thermometer with her and placed the thermometer on the computer stand beside that second patient. PF # 8 did not clean or disinfect the thermometer prior to taking second patient's temperature.
Interview with EMP # 1 on 2/7/2022 at approximately 3:00 PM confirmed above findings.
Plan of Correction:The Facility Administrator held a mandatory in-service for all Clinical Teammates starting on 2/11/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy #1-05-01 Infection Control for Dialysis Facilities with the emphasizing non-disposable items including thermometers that do not touch the patient, are to be disinfected between patients. Verification of attendance at in-service will be evidence by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits daily for two (2) weeks then weekly for two (2) weeks then monthly during internal infection control audits to verify compliance. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the results of the audits with teammates during homeroom meetings and with the Medical Director during monthly Quality Assurance 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.
494.30(a)(1)(i) STANDARD
IC-TRAINING & EDUCATION
Name - Component - 00
Infection Control Training and Education
Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices.
Observations:
Based upon review of facility policy, observation (OBS), and interview with facility manager, (EMP # 1), facility failed to discard expired supplies for two observations. ( OBS # 1-2).
Findings included:
Review of facility policy on 2/9/2022 at approximately 2:00 PM titled " Obtaining Patient Lab Specimens" stated " (5) Teammates are to verify the expiration date on all laboratory specimen tubes prior to collection. Expired laboratory specimen tubes are not to be used and are to be discarded in the sharps container."
Observations made on 2/7/2022 between approximately 10:00AM-10:30 AM revealed:
During walking tour of facility, cabinet opened containing various blood collection tubes and bottles.
(OBS # 1)The yellow topped BD blood collection vacutainer tubes were in a container 1/2 full with thirty-four (34) yellow topped tubes present with expiration date on tubes of 1/31/2022. These tubes were not discarded upon date of expiration.
(OBS # 2) cabinet beside one containing the yellow topped BD blood vacutainer tubes had an unopened box with six (6) bottles of aerobic (+) and six (6) bottles of anaerobic lytic blood culture bottles present with expiration date of 1/31/2022.
Interview with EMP # 1 on 2/7/2022 at approximately 3:00 PM confirmed above findings.
Plan of Correction:The Facility Administrator immediately discarded the expired blood vacutainer tubes and blood culture bottles. The Clinical Team immediately performed an audit of all tubes and bottles to ensure no other expired supplies were present. Completion date of 2/07/22.
The Facility Administrator held a mandatory in-service for all Clinical Teammates starting on 2/11/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy #1-08-02 Obtaining Patient Lab Specimens with the emphasis on but not limited to: 1) Teammates are to verify the expiration date on all laboratory specimen tubes prior to collection. 2) Expired laboratory specimen tubes are not to be used and are to be discarded in the sharps container. Verification of attendance at in-service will be evidence by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct lab tube and bottle expiration audits daily for two (2) weeks then weekly for two (2) weeks then monthly for two (2) months to verify no expired items are present. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the results of the audits with teammates during homeroom meetings and with the Medical Director during monthly Facility Health Meetings with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
494.30(a)(2) STANDARD
IC-STAFF EDUCATION-CATHETERS/CATHETER CARE
Name - Component - 00
Recommendations for Placement of Intravascular Catheters in Adults and Children
I. Health care worker education and training
A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections.
B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters.
II. Surveillance
A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site.
Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients.
VI. Catheter and catheter-site care
B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections].
Observations:
Based upon review of facility policy, observation (OBS), and interview with facility manager, (EMP # 1), facility staff failed to utilize infection control measures with a CVC \ patient for one (1) observation. (OBS # 1).
Findings included:
Review of facility policy on 2/9/2022 at approximately 2:00 PM titled " Central Venous Catheter (CVC) with clearguard HD Antimicrobial end caps procedure Policy:1-04-02B" stated " (3) Verify patient's clothing is secured away from the exit site/work area."
Observations made on 2/7/2022 between approximately 11:00AM-11:30 AM revealed: patient at station # 10 was sitting up in chair, getting ready for treatment. Patient shirt had a neck line which was pulled to the side. During the removal of the CVC dressing the shirt collar slid back over the CVC site and rubbed against the catheter. (PF # 1) pulled the shirt back away from the CVC and placed a blue barrier under the catheter.
Interview with EMP # 1 on 2/7/2022 at approximately 3:00 PM confirmed above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-service(s) for all Clinical Teammates starting on 2/11/22. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-04-02B: Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure emphasizing that teammates must verify patient's clothing is secured away from the exit site/work area. Teammates were reminded of availability of clamps to assist with securing clothing away from the site. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct observational audits for CVC care daily for two (2) weeks then weekly for two (2) weeks then ongoing monthly during internal infection control audits to verify compliance. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the results of the audits with teammates during homeroom meetings and with the Medical Director during monthly with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
494.80(a)(7) STANDARD
PA-MSW-PSYCHOSOCIAL NEEDS
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
(7) Evaluation of psychosocial needs by a social worker.
Observations:
Based upon review of facility policy, medical record review (MR), and interview with facility manager, (EMP # 1), social worker failed to obtain annual KDQOL's for two (2) of three (3) records reviewed. ( MR # 1-2).
Findings included:
Review of facility policy on 2/9/2022 at approximately 2:00 PM titled " Quality of Life Assessment Survey" stated " (1) The quality of life (QOL) assessment survey is to be administered by the Social Worker to patients within four (4) months ... and repeated at least annually thereafter."
Review of MR on 2/8/2022 between approximately 10:00 AM-12:00 PM and 12:30 PM-1:30 PM revealed:
MR # 1, (ID # 3); Admission date: 5/9/2018. Diagnoses: ESRD renal stenosis and anemia.
KDQOL was documented as completed on 11/9/2020 and none produced for 2021.
MR # 2, (ID # 6); Admission date: 2/26/2020. Diagnoses: ESRD diabetesand hypertension KDQOL was documented as completed on 10/2020 and none produced for 2021.
Interview with EMP # 1 on 2/7/2022 at approximately 3:00 PM confirmed above findings.
Plan of Correction:The Facility Administrator or designee held a mandatory in-service for the Social Worker on 2/11/22. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 3-01-10 Quality of Life Assessment Survey emphasizing the Quality of Life (QOL) assessment survey is to be administered by the Social Worker to patients within four (4) months of initiating treatment, on an as needed basis, and repeated at least annually thereafter. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will audit all patient charts for KDQOL completion. Any outstanding surveys will be brought up to date. The Facility Administrator or designee will audit twenty five percent (25%) of the medical record weekly for four (4) weeks and then ten percent (10%) monthly to verify compliance. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the results of the audits with the Social Worker and with the Medical Director during monthly 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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