Initial Comments:
Based on the findings of an unannounced, onsite Medicare recertification survey conducted September 12 through September 14, 2023, Scranton 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 unannounced, onsite Medicare recertification survey conducted September 12 through September 14, 2023, Scranton 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 for End-Stage Renal Disease Facilities.
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 facility policy/procedure, documentation and observational tour, and based on interview with the administrator, the facility failed to ensure two (2) of four (4) hemodialysis (HD) staff demonstrated compliance with agency policy/procedure regarding infection control. (Employees #4 and #5)
Findings include:
On September 14, 2023 at approximately 2:14 PM, review of facility policy 1-05-01, titled "Infection Control for Dialysis Facilities", revealed the following:
Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment...
Hand Hygiene: 1. All teammates...will perform hand hygiene...g. before touching clean areas such as supplies...
PPE (Personal Protective Equipment) (i.e. (that is)...gloves...)...
7. Disposable gloves will be worn when...touching the patient's equipment at the dialysis station...a. Gloves will be changed when...ii. When going from a "dirty" area or task to a "clean" area or task...
On September 13, 2023 at approximately 12:40 PM, review of personnel file review form revealed the following:
Employee #4: The date of hire of the registered nurse (RN) was 01/11/2024.
Employee #5: The date of hire of the RN was 09/12/1982.
Observational tour of the hemodialysis treatment room conducted between September 12, 2023 at approximately 10:25 AM and September 13, 2023 at 2:22 PM revealed the following:
Employee #4: On 09/13/2023 at approximately 10:03 AM, while wearing gloves, the RN transported a shared (common) biohazard sharps unit to the area of HD station #3 by pulling the unit by the metal handle. Without removing gloves nor disinfecting hands, the RN then proceeded to move the HD access clamp from the top of the HD machine to the chairside table at station #3. On 09/13/2023 at approximately 11:24 AM, the RN failed to wear gloves when performing the conductivity and pH verification check with a Phoenix meter for the HD machine located at HD station #13.
Employee #5: On 09/13/2023 at approximately 1:55 PM, while wearing gloves, RN transported a shared biohazard sharps unit to the area of HD station #1 by pulling the unit by the metal handle. Without removing gloves nor disinfecting hands, the RN then proceeded prepare the supplies to initiate the HD treatment for the patient seated at HD station #1.
During interview conducted on September 15, 2023 at approximately 3:40 PM, the administrator confirmed gloves are to be worn by when HD staff make contact with the HD station and that HD staff are to change gloves and perform hand-hygiene when transitioning from a dirty to clean task.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/25/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 1) All teammates ...will perform hand hygiene...b. prior to gloving and immediately after removal of gloves... g. before touching clean areas such as supplies... 2) Disposable gloves will be worn when caring for the patient or touching the patient's equipment at the dialysis station ... a. Gloves should be changed when ... ii. When going from a "dirty" area or task to a "clean" area or task... 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 teammates maintain glove wearing and hand hygiene practices per policy: 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 audit results with teammates during homeroom meetings, and with Medical Director during monthly Quality Assessment 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)(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 on review of facility policy/procedure, documentation and observational tour, and based on interview with the administrator, the facility failed to ensure three (3) of three (3) hemodialysis (HD) staff demonstrated compliance with agency policy/procedure regarding disinfection of HD equipment. (Employees #2, #3 and #5)
Findings include:
On September 14, 2023 at approximately 2:14 PM, review of facility policy 1-05-01, titled "Infection Control for Dialysis Facilities", revealed the following:
Disinfection...12. Cleaning and/or disinfection of equipment...will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. (that is) used or brought to the station)...
On September 13, 2023 at approximately 12:40 PM, review of personnel file review form revealed the following:
Employee #2: The date of hire of the patient care technician (PCT) was 07/15/2019.
Employee #3: The date of hire of the licensed practical nurse (LPN) was 11/17/2003.
Employee #5: The date of hire of the registered nurse (RN) was 09/12/1982.
Observational tour of the HD treatment room conducted between September 12, 2023 at approximately 10:25 AM and September 13, 2023 at 2:22 PM revealed the following:
Dark blue emergency pouches were hung on intravenous poles of all 14 HD machines located in the HD treatment room including the machines located at HD stations #10, #13 and #14.
On 09/13/2023, the above referenced employees failed to disinfect the emergency pouches maintained at the following HD stations:
-Employee #2--Station #3
-Employee #3--Station #10
-Employee #5--Station #14.
During interview conducted on September 15, 2023 at approximately 3:40 PM, the administrator confirmed the emergency pouches maintained on the HD machine are to be included in the HD station disinfection process.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/25/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 1) Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces. 2) At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings ... and frequently contacted by healthcare personnel ... Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify dialysis station cleaning and disinfection including but not limited to emergency take-off pouches are maintained after each treatment per infection control policy: daily for two (2) weeks then weekly for two (2) weeks, the ongoing compliance will be monitored with the monthly infection control audits. 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 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.
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