QA Investigation Results

Pennsylvania Department of Health
ALLEGHENY VALLEY DIALYSIS
Health Inspection Results
ALLEGHENY VALLEY DIALYSIS
Health Inspection Results For:


There are  11 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an unannounced onsite complaint investigation survey completed May 1, 2024, Allegheny Valley Dialysis was found 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 STANDARD
IC-SANITARY ENVIRONMENT

Name - Component - 00
The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas.


Observations:


Based on observation and interview with staff, the facility failed to provide a sanitary environment to minimize the transmission of infectious agents within the facility for three (3) of seven (7) observations. (Observation #2, Observation #4, Observation #7).

Findings include:

Review of facility policy completed on 5/1/24 at approximately 3:30 p.m. revealed: Policy: 1-05-01 with last revision date of April 2023. TITLE: Infection Control for Dialysis Facilities. PURPOSE: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment... POLICY: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients.... PPE (i.e., gown, gloves, eye protection, face shield). 5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas. PPE is to be: a. Removed prior to leaving the treatment area...c. PPE is not to be worn in non-treatment areas...6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-physicians and visitors when in the treatment area...

Observations of dialysis treatment and care completed on 5/1/24 between approximately 9:00 a.m. and 12:00 p.m. revealed the following:

Observation #2 on 5/1/24 at approximately 9:05 a.m. Registered Nurse (RN) was observed in the medication area drawing up parenteral medications with mask and gown on.

Observation #4 on 5/1/24 at approximatley 9:25 a.m. PCT#1 was observed removing the used tubing from the dialysis machine and transporting the tubing across the clinical floor to dispose of it in a biohazard waste container.

Observation #7 on 5/1/24 at approximately 11:00 a.m. transport attendant observed to be standing at Station #8 while Station #7 patient being put on treatment. PCT#2 was actively cleaning the Central Venous Catheter (CVC) site of the patient in Station #7. Surveyor observed transport attendant without mask or gown on.
Interview with facility administrator (FA) at approximatley 11:05 a.m. regarding this observation, "Yes, he should have a gown and mask on."

Reviewed findings (observation #4) on 5/1/24 at approximately 11:10 a.m. with FA."I'd have to look at the policy."

Interview with FA (observation #2) on 5/1/24 at approximately 11:15 confirmed "when in the medication room, should have gowns off."












Plan of Correction:

V 0111
Upon learning of surveyor's observations on 05/01/24, the Facility Administrator took immediate actions on the same day: 1) provided education to Registered Nurse that PPE is not to be worn in the non-treatment area; 2) advised transport attendant and team that all visitors must have PPE on when on the treatment floor; 3) held a team homeroom to educate team that biohazard bins are to be brought to chairside to remove any biohazard materials, and then wiped down before returning to proper place.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/13/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy1-05-01 "Infection Control for Dialysis Facilities" and Policy 4-03-07 "Segregation of Medical Waste" with on but not limited to: A. Infection Control: 1) Appropriate Personal Protective Equipment (PPE) will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas. PPE is to be removed prior to leaving the treatment area. PPE is not to be worn in non treatment areas. 2). Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physician (NPP) and visitors when in the treatment area. 3) Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. B. Medical Waste: 1) Medical waste is contained separately from other non-infectious waste generated in the facility. 2) Labeled medical waste containers should be lined with red bags and placed in areas where medical waste is generated. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.

The Facility Administrator or designee will conduct audits to verify PPE is worn appropriately by teammates, physicians and visitors in compliance with policy; and to verify medical waste is disposed in containers placed in areas where medical waste is generated, and containers cleaned prior to returning to designated area: daily for two (2) weeks, then weekly for two (2) weeks, then ongoing compliance will be monitored with monthly infection control audits. Instances of non-compliance will be addressed immediately.

The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.