Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on April 6, 2022 through April 8, 2022, Duke Street 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 on April 6, 2022 through April 8, 2022, Duke Street Dialysis was identified to have the following standard level deficiencies that were determined to be in substantial 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:
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 policy, observations made of treatment (OBS) and interview with acting facility administrator the clinic failed to ensure teammates performed hand hygiene after contamination with blood or other infectious material for one (1) of two (2) observations made. OBS #1.
Findings include:
Review of policy: 1-05-01 completed on 4/8/22 at approximately 8:18 AM revealed:
INFECTION CONTROL FOR DIALYSIS FACILITIES: section: TEAMMATE HYGIENE:1. "Hand hygiene is to be performed upon... after removal of gloves, after contamination with blood or other infectious material,...".
Observations of treatments completed on 4/6/22 revealed the following:
OBS #1 completed at approximately 11:00AM at station #10 showed employee remove the prime bucket from the machine, she then walked the bucket from the station to the dirty sink and emptied the bucket. She removed her gloves, performed hand hygiene, donned new gloves, and returned the bucket to the machine. She then removed the bloodlines from the machine and threw them in the bio-hazard bin and returned to the machine and began wiping it with the bleach wipe.
She did not remove her gloves or perform hand hygiene a second time.
Interview with the Acting Facility Administrator completed 4/7/22 at 2:30PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all direct patient care teammates starting on 04/15/22. 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 emphasis on but not limited to: 1) teammates will remove gloves and perform hand hygiene between each patient and/or station and between clean and dirty tasks; teammates will perform hand hygiene every time gloves are removed. Verification of attendance is evidenced by teammate's signature on the Training/In-service form. The Facility Administrator or designee will conduct observational audits of teammates to verify compliance with proper hand hygiene: each shift daily on treatment days for two (2) weeks, then each shift weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during the monthly Quality Assessment Performance Improvement meeting known as Facility Health Meeting, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
494.60 STANDARD
PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT
Name - Component - 00
The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment.
Observations:
Based on review of policy, observations (OBS) and interview with the acting administrator the clinic failed to ensure a safe environment for patient receiving dialysis treatment for one (1) of one (1) observations made. OBS #1.
Findings include:
Review of policy completed on 4/8/22 at approximately 8:56AM revealed: PHYSICAL ENVIRONMENT; POLICY: 9. "Systems to assure patient safety will be in place, such as a method for patients to call for help... Access to patient treatment areas, water treatment systems, supply storage and dialysis equipment is restricted to authorized personnel only,...".
OBS#1 completed on 4/6/22 at 9:30AM revealed the following:
Surveyor entered the building through the front door of clinic, found no receptionist at desk and door to treatment area propped open. Surveyor then walked into treatment area and up to work station before being stopped by personnel.
An interview with acting administrator completed 4/7/22 at approximately 2:30PM confirmed clinic policy requires all doors to treatment area to remain closed.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all teammates starting on 04/15/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 9-01-08 "Access Control Management Policy" with the emphasis on but not limited to: 1) Teammates cannot disable the locking functionality of any door. 2) Teammates entering locked buildings or spaces are responsible for re-securing all doors and shall not prop open any doors or disable any locking mechanisms. Verification of attendance is evidence by teammate's signature on the in-service sheet. The Facility Administrator or designee will conduct observational audits to verify doors are closed and locked appropriately and the facility is maintained as secure: each treatment day 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 results with the Medical Director during the monthly Quality Assessment Performance Improvement meeting known as Facility Health Meeting, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
494.80(a)(2) STANDARD
PA-ASSESS B/P, FLUID MANAGEMENT NEEDS
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
Blood pressure, and fluid management needs.
Observations:
Based on review of policy, medical records (MR) and interview with the acting facility administrator the clinic failed to ensure the nurse documented interventions for the patient leaving treatment more than 1 kg over the estimated dry weight for one (1) of five (5) records reviewed. MR #2.
Findings include:
Review of Policy: PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT completed on 4/8/22 at 11:54 AM revealed; Policy: POST TREATMENT DATA COLLECTION/ASSESSMENT, 16."If an abnormal finding or concern is identified post treatment, this needs to be reported to the licensed nurse...17. Licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician is necessary prior to discharge of the patient from the facility".
Review of MR completed on 4/7/22 between approximately 9:00AM and 1:00pm revealed:
MR#2, Admit date: 10/21/19; Estimated dry weight: 69 Kg. Pre treatment wt. on 3/2/22: 73.5 kg Post treatment wt. 69.4 Kg (1.4 kg over) No documented interventions by nurse. On 2/28/22, Pre-treatment wt. 74.1 kg, post-treatment: 70.1 kg (2.1 kg over). No interventions documented by nurse.
On 2/25/22, Pre-treatment wt. 73.3 kg, post-treatment wt. 69.3 kg (1.3 kg over). No documented interventions by nurse.
Interview with the Acting Facility Administrator completed 4/7/22 at 2:30PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all teammates starting on 04/15/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nurse Assessment" with emphasis on but not limited to: 1) The Patient Care Technician or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 2) Abnormal Findings: Post-treatment: I patient is above or below one (1) kg from the target weight. 3) Abnormal findings or findings outside of any patient specific physician ordered parameters will be documented and reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility. 4) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will audit twenty five percent (25%) of post treatment flow sheets each treatment day for two (2) weeks, then weekly for two (2) weeks to verify nurse is notified and documents a response when patient post treatment weights are above or below one (1) kg from the target weight. Ongoing compliance will be monitored by the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during the monthly Quality Assessment Performance Improvement meeting known as Facility Health Meeting, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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