Initial Comments:
Based on the findings of an onsite unannounced initial Medicare certification survey conducted on April 9, 2021, Upper Darby 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 initial Medicare certification survey conducted on April 9, 2021, Upper Darby Dialysis was identified to have the following standard level deficiency that was 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)(i) STANDARD
IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES
Name - Component - 00
Isolation of HBV+ Patients
To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients.
Observations:
Based on an observational tour and an interview with the administrator, the facility did not dedicate separate equipment and supplies for its isolation room.
Findings include:
An observational tour of the facility was conducted on April 9, 2021 from approximately 8:45 AM through 10:30 AM.
It was observed that the isolation room did not contain dialysis machine, furniture, centrifuge, meter, and other supplies labeled as "isolation" so as not to be routinely removed from the isolation room to be used in the general patient population.
An interview with the administrator on April 9, 2021 at 1:00 PM confirmed the above findings.
Plan of Correction:"V0130
The Facility Administrator, immediately labeled all items in the isolation room on 4/9/2021, prior to the surveyors leaving the building. Items in the isolation room including but not limited to: the chair, TV and TV arm, sharps container, paper towel holder, Snappy cart and Snappy computer, trash can, centrifuge, and Myron-L meter labeled as ""isolation"" so as not to be routinely removed from the isolation room to be used in the general patient population.
The Facility Administrator educated all clinical teammates that any item that can be taken out of the isolation room must be properly labeled. All items were labeled and the surveyors walked the room prior to leaving the facility. The Facility Administrator or designee will audit the isolation room weekly for four weeks then monthly during internal infection control audits to verify labels are in place. The results of the audits will be reviewed with the Medical Director during monthly Facility Health Meetings (FHM_QAPI) with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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