QA Investigation Results

Pennsylvania Department of Health
DIALYSIS CARE CENTER CHAMBERSBURG LLC
Health Inspection Results
DIALYSIS CARE CENTER CHAMBERSBURG LLC
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:

Based on the findings of an onsite unannounced Medicare initial certification survey conducted on 5/1/19, Dialysis Care Center, 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 initial certification survey conducted on 5/1/19, Dialysis Care Center, was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the requirements of 42, CFR, Part 494, Subparts A, B, C, ad D, Conditions for Coverage of Suppliers of End Stage Renal Disease (ESRD) Services.








Plan of Correction:




494.30(a)(4)(i) STANDARD
IC-HANDLING INFECTIOUS WASTE

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-
(i) Handling, storage and disposal of potentially infectious waste;




Observations:


Based upon agency policy, observations in-center, and interview with clinical manager ( PF # 2), agency failed to dispose of potentially infectious waste for two (2) of two (2) observations. ( patient ID # 5, station # 5; patient ID # 6, station # 6).


Findings included:

Policy review on 5/1/19 at approximately 3:00 PM-4:00 PM titled " Dialysis Standards Precautions, # DCC-IC-IC-500-004, stated " Dialysis center will provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the facility"

Observation in-center on 5/1/19 at approximately 10:25 AM-11:00 AM revealed:

Patient ID # 5, at station # 5, observed PF # 3, discard one (1) blood filled syringe into large general trash can instead of biohazard waste receptacle.

Patient ID # 6, at station # 6, observed PF # 4, discard three (3) blood filled syringes into large general trash can instead of biohazard waste receptacle.


Interview with EMP # 2, on 5/1/19, between approximately 5:00 PM-5:30 PM confirmed above findings.









Plan of Correction:

V0121 IC-HANDLING INFECTIOUS WASTE
CFR(s): 494.30(a)(4)(i)
The facility must demonstrate that if it follows standard infection control precautions by implementing: (4) And maintain procedures, accordance with applicable State and Local laws and accepted public health procedures, for the- (i)Handling, storage and disposal of potentially infectious waste;

A Governing Body (GB) was held on 5/2/2019 to review the deficiencies as a result of a survey completed on 5/1/2019.

Based on staff interviews, and surveyor observations the facility failed to dispose of potentially infectious waste in biohazard waste container as required per policy: Dialysis Standard Precautions HDS-IC-IC-500-004.

On 5/2/2019 the Clinical Area Manager (CAM) met with the facility's clinical staff and conducted an in-service to review the surveyor's observations, requirements as stated in the Conditions for Coverage and detailed in facility Policy: Dialysis Standard Precautions HDS-IC-IC-500-004. All blood-filled syringes and visibly blood contaminated PPE will promptly be discarded in designated biohazard containers only and never in the general trash. In-Service Signature page attached for verification.

On 5/2/2019 the Clinical Area Manager (CAM) met with the Clinical Manager (CM) to review the Dialysis Standard Precautions audit tool to ensure the CM is knowledgeable as to how to utilize the audit tool.

The CM or designee will perform daily audits for two weeks and then twice a week for two weeks. If evidence of improved compliance is observed, the audits will then be completed monthly. See attached POC specific auditing tool.

The CM is responsible for reporting a summary of findings monthly utilizing the audit tool as noted above. The QAPI committee is responsible for analyzing the results and determining a root cause analysis and a new plan of action if compliance is not maintained. The QAPI committee will monitor ongoing compliance.


The GB is responsible for providing oversight to ensure the Plan of Correction (POC), as written to address the issues identified by the Statement of Deficiency, is effective and is providing resolution to the issues.


The Clinical Manager is responsible for implementing and monitoring the plan of correction. Completion date: 5/17/2019


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 agency policy, observations in-center, and interview with clinical manager ( PF # 2), agency failed to clean and disinfect the prime waste buckets for two (2) of two (2) observations. ( patient ID # 2, station # 2; patient ID # 1, station # 1).


Findings included:

Policy review on 5/1/19 at approximately 3:00 PM-4:00 PM titled " Infection Control Policy , # DCC-IC-IC-500-001, stated " Infection Control Policies & Procedures: Housekeeping to ensure clean and sanitary environment; Disinfection, decontamination of medical equipment & non-disposable devices or supplies"

Observation in-center on 5/1/19 at approximately 9:40 AM-10:30 AM revealed:

Patient ID # 2, at station # 2, observed PF # 4, fail to wipe out the inside of the prime waste container.

Patient ID # 1, at station # 1, observed PF # 4, fail to wipe out the inside of the prime waste container.

Interview with EMP # 2, on 5/1/19, between approximately 5:00 PM-5:30 PM confirmed above findings.











Plan of Correction:


V0122 IC-DISINFECT SURFACES/EQUIPMENT/WRITTEN PROTOCOL
CFR(s): 494.30(a)(4)(ii)
The facility must demonstrate that it follows standard infection control precautions by implementing (4) And maintain procedures, in accordance with applicable State and Local laws and accepted public health procedures, for the (iii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment.

A Governing Body (GB) was held on 5/2/2019 to review the deficiencies as a result of a survey completed on 5/1/2019.

Based on staff interviews, and surveyor observations the facility failed to clean and disinfect the prime waste buckets as required per policy: Infection Control Policy HDS-IC-650-001.

On 5/2/2019 the Clinical Area Manager (CAM) met with the facility's clinical staff and conducted an in-service to review the requirements as stated in the Conditions for Coverage and detailed in facility Policy: Infection Control Policy HDS-IC-650-001.

The Clinical staff will follow the steps to ensure Dialysis Station Routine Disinfection
Part A: Before Beginning routine Disinfection of the Dialysis Station
1. Disconnect and take down used blood tubing and dialyzer from the dialysis machine.
2. Discard tubing and dialyzers in a leak-proof container
3. Check that there is no visible soil or blood on surfaces
4. Ensure that the priming bucket has been emptied
5. Ensure that the patient has left the dialysis station
6. Discard all single-use supplies. Move any reusable supplies to an area where they will be cleaned and disinfected before being stored or returned to a dialysis station.
7. Remove gloves and perform hand hygiene.
Part B: Routine Disinfection of the Dialysis Station After the patient has left the station
1. Wear Clean gloves
2. Apply a disinfectant to all surfaces in the dialysis station using a wiping motion (with friction).
3. Ensure surfaces are visibly wet with disinfectant. Allow surfaces to air-dry.
4. Disinfect all surfaces of the emptied priming bucket. Allow the bucket to air-dry before reconnection or reuse.
5. Keep used or potentially contaminated items away from the disinfected surfaces.
6. Remove gloves and perform hand hygiene.
In-Service Signature page attached for verification.

On 5/2/2019 the Clinical Area Manager (CAM) met with the Clinical Manager (CM) to review the Hemodialysis Station Routine Disinfection audit tool to ensure the CM is knowledgeable as to how to utilize the audit tool to ensure compliance.

The CM or designee will perform daily audits for two weeks and then twice a week for two weeks. If evidence of improved compliance observed, the audits will then be completed monthly. See attached POC specific auditing tool.

The CM is responsible for reporting a summary of findings monthly utilizing the audit tool as noted above. The QAPI committee is responsible for analyzing the results and determining a root cause analysis and a new plan of action if compliance is not maintained. The QAPI committee will monitor ongoing compliance.


The GB is responsible for providing oversight to ensure the Plan of Correction (POC), as written to address the issues identified by the Statement of Deficiency, is effective and is providing resolution to the issues.


The Clinical Manager is responsible for implementing and monitoring the plan of correction. Completion date: 5/17/2019


494.60(a) STANDARD
PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY

Name - Component - 00
The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public.



Observations:


Based upon agency policy, observations during tour of facility and interview with clinical manager ( PF # 2), agency failed to maintain safety of the biohazard room for one (1) of one (1) observation rooms. ( OBS. # 1).

Findings included:

Policy review on 5/1/19 at approximately 3:00 PM-4:00 PM titled " Dialysis Standards Precautions, # DCC-IC-IC-500-004, stated " Dialysis center will provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the facility and any ... other public areas."

Tour of facility on 5/1/19 between approximately 9:00 AM-9:45 AM revealed biohazard room failed to have hand sanitizer, gowns, or gloves outside the door of the biohazard room.


Interview with EMP # 2, on 5/1/19, between approximately 9:00 AM-9:45 AM, during tour, reported " Stericycle comes in back door, enters biohazard room, takes out waste trash, and if needed returns to bring back clean bags."
Further discussion " We \ will come out to meet him to get the clean bags"















Plan of Correction:


V0402 PE-BUILDING-CONSTRUCTION/MAINTAIN FOR SAFETY
CFR(s): 494.60(a)
The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public.

A Governing Body (GB) was held on 5/2/2019 to review the deficiencies as a result of a survey completed on 5/1/2019.

Based on staff interviews, and surveyor observations the facility failed to ensure hand sanitizer, gloves and gowns are available outside the biohazard room as required per policy: Dialysis Standard Precautions HDS-IC-IC-500-004.

On 5/2/2019 the Clinical Area Manager (CAM) met with the facility's clinical staff and conducted an in-service to review the surveyor's observations, requirements as stated in the Conditions for Coverage and detailed in facility Policy: Dialysis Standard Precautions HDS-IC-IC-500-004. The facility will ensure hand sanitizer, gloves and gowns are always available outside the biohazard room. In-Service Signature page attached for verification.

On 5/2/2019 the Clinical Area Manager (CAM) met with the Clinical Manager (CM) to review the Dialysis Standard Precautions audit tool to ensure the CM is knowledgeable as to how to utilize the audit tool.

The CM or designee will perform daily audits for two weeks and then twice a week for two weeks. If evidence of improved compliance is observed, the audits will then be completed monthly. See attached POC specific auditing tool.

The CM is responsible for reporting a summary of findings monthly utilizing the audit tool as noted above. The QAPI committee is responsible for analyzing the results and determining a root cause analysis and a new plan of action if compliance is not maintained. The QAPI committee will monitor ongoing compliance.


The GB is responsible for providing oversight to ensure the Plan of Correction (POC), as written to address the issues identified by the Statement of Deficiency, is effective and is providing resolution to the issues.

The Clinical Manager is responsible for implementing and monitoring the plan of correction. Completion date: 5/17/201