Initial Comments:
Based on the findings of an onsite unannounced recertification survey conducted on August 24, 2022, through August 26, 2022, and offsite August 31, 2022, Cedar Grove 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 recertification survey conducted on August 24, 2022, through August 26, 2022, and offsite August 31, 2022, Cedar Grove 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 observations (OBS) of the in-center treatment area, review of facility policy and procedures, and interview with the facility administrator, it was determined that the facility staff did not practice proper infection control for one (1) of eighteen (18) observations. OBS #11
Findings include:
Reviewed facility policy, "Incenter Hemodialysis Policies Procedures DaVita Inc., Procedure: 1-04-02B " , titled, " Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure " , on August 26, 2022 at 11:30AM. Policy states, " 4. Remove old dressing and discard. 5. Observe site for signs and symptoms of infection ...Remove gloves and discard. Perform hand hygiene per procedure and re-glove ....Holding catheter with non-dominant hand and using aseptic technique, clean exit site ... "
Observation tour of in-center treatment area was conducted on August 24, 2022 from approximately 10:00AM until approximately 12:30PM revealed:
OBS #11, 8/24/2022 at 11:32AM: Station #5, while providing central venous catheter (CVC) exit site care, PCT#5 was observed performing hand hygiene, donning clean gloves, and removing an old dressing. Next, with the same gloved hands, PCT#5 began cleansing the area around the CVC exit site. After cleansing the area around the CVC exit site, PCT#5 removed gloves, performed hand hygiene, donned clean gloves, and applied a sterile dressing to the CVC exit site. PCT#5 did not remove gloves after removing the old dressing and prior to cleansing the area around the CVC exit site.
An interview with the agency facility administrator, assistant facility administrator, and clinical manager, on August 26, 2022 at approximately 12:40PM confirmed the above the findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/07/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-05 "Infection Control for Dialysis Facilities", Policy 1-04-02B "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" with emphasis on but not limited to: 1. Hand hygiene: 1) Hand hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves... 2. CVC care: 1) Step #4 - Remove old dressing and discard. 2) Step #7 - Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 3) Step #8 - Holding catheter with the nondominant hand and using aseptic technique, clean exit site ... 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 proper hand hygiene is utilized during CVC care and treatment initiation per policy: daily for two (2) weeks and 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 the audit results with teammates during homeroom meetings and with Medical Director during monthly Quality Assessment 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(b)(1) STANDARD
IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P
Name - Component - 00
The facility must-
(1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit;
Observations:
Based on observations on August 24, 2022, August 25, 2022, and August 26, 2022, it was determined that the facility staff failed to implement infection control practices, by administering COVID-19 screenings upon entry to the facility to this surveyor, for three (3) of three (3) days during the survey (August 24, 2022 through August 26, 2022).
Findings include:
Reviewed facility documentation titled " COVID-19 Patient Management Plan Playbook " on 8/31/2022 at approximately 2:15PM. Documentation states, " Step 1 - Evaluate, screen, and disposition - First: COVID-19 Entrance Evaluation - Conduct a timely COVID-19 Entrance Evaluation, using the COVID-19 Entrance Tracker, with 100% of people entering your facility upon their arrival ... "
Survey Day #1 (8/24/2022): Facility staff unlocked the door and this surveyor entered the reception area. Upon entry to the reception area, this surveyor observed no facility staff, security guard, or patients were present in the reception area. Facility staff did not implement a COVID-19 screen upon entry to facility nor throughout Day #1 of survey.
Survey Day #2 (8/25/2022): This surveyor entered the reception area of the facility and observed no facility staff, security guard, or patients were present in the reception area. Facility staff did not implement a COVID-19 screen upon entry to facility nor throughout Day #2 of survey.
Survey Day #3 (8/26/2022): Facility staff unlocked the door and this surveyor entered the reception area. Upon entry to the reception area, this surveyor observed no facility staff, security guard, or patients were present in the reception area. Facility staff did not implement a COVID-19 screen upon entry to facility nor throughout Day #3 of survey.
An interview with the agency facility administrator, assistant facility administrator, and clinical manager, on August 26, 2022 at approximately 12:40PM confirmed the above the findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 9/7/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 8-01-20 COVID-19 Situation Guidance Policy and "COVID-19 Response – Entrance Evaluation Tracker" July 19, 2022, with the emphasis on but not limited to: 1) ...Make sure everyone wears a DaVita provided mask. 2) Evaluate one hundred percent (100%) of people entering your facility in a timely manner. 3) Document responses. 4) File completed Entrance Evaluation in your COVID-19 binder and maintain for two (2) years in a secure location (not required if using the Digital Entrance Evaluation Tracker). Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will audit one hundred percent (100%) of all screening entrance evaluations: daily on treatment days for one (1) month to verify all people entering the facility are screened upon entrance. Ongoing compliance will be monitored with ten percent (10%) monthly entrance screening audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review the audit results with teammates during homeroom meetings and with the Medical Director during monthly Quality Assessment 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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