Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey conducted Ocotber 5 through October 8, 2021, Northside 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 on October 5 through October 8, 2021, Northside 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)(i) STANDARD
IC-IF TO STATION=DISP/DEDICATE OR DISINFECT
Name - Component - 00
Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient.
-- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient.
-- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients.
Observations:
Based on review of facility policy, observation and an interview with the facility Administrator the facility failed to ensure items taken to the dialysis station were disinfected before being taken to a common clean area for four (4) of four (4) observations made. (OBS#1, OBS#2, OBS#3, OBS#4).
Findings included:
Review of Policy: 1-05-01 completed on 10/6/21 at approximately 4:00 p.m. revealed:
" 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.... section: Facility Hygiene, 46. Equipment including the dialysis delivery system,... outside of sharps containers...as well as all work surfaces will be wiped clean with a bleach solution of the appropriate strength after completion of procedures, before being used on another patient, after spills of blood, throughout the work day, and after each treatment".
Observations of dialysis treatment and care completed on 10/6/21 between approximately 9:30 a.m. and 4:00 p.m. revealed the following:
OBS#1 at 10:08 a.m., surveyor observed employee #7 taking a sharps container from a common clean area to station # 14. Following use, the sharps container was returned to the common clean area without being wiped down.
OBS#2 at 10:37 a.m., surveyor observed employee #4 taking a sharps container from a common clean area to station # 14. Following use, the sharps container was returned to the common clean area without being wiped down.
OBS#3 at 11:29 a.m., surveyor observed employee #5 taking a sharps container from a common clean area to station # 15. Following use, the sharps container was returned to the common clean area without being wiped down.
OBS#4 at 2:00 p.m., surveyor observed employee #8 taking a sharps container from a common clean area to station # 16. Following use, the sharps container was returned to the common clean area without being wiped down.
An interview with the facility administrator conducted on 10/6/21 at approximately 4:00 p.m. confirmed the policy as current and above findings.
Repeat deficiency: 9/5/17, 11/6/12, 7/28/09.
Plan of Correction:The Facility Administrator (FA) will hold in-service(s) for all ICHD clinical teammates starting 10/29/21 to review Policy # 1-5-01 Infection Control for Dialysis Facilities with focus on all sharp containers will be wiped down with appropriate bleach solution prior to removing from a patient station and being placed back into the common area. Verification of attendance at in-service evidenced by TMs signature on in-service sheet.
The FA or designee will conduct infection control audits with focus on verifying sharps containers are being wiped down appropriately on random shifts 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 FA will review audit results with the teammates during homeroom meetings and with the Medical Director during the monthly Quality Assurance and Performance Improvement known as Facility Health Meetings with supporting documentation included in the meeting minutes. The FA 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 facility policy, medical records (MR), and staff (EMP) interview the facility failed to assess and/or manage patient's blood pressure for two (2) of seven (7) records reviewed with five (5) of those records being in center hemodialysis MR. (MR5-ICHD, MR14-ICHD).
Findings Included:
Review of facility policy on 10/7/21 at approximately 3:00 p.m. revealed: "TITLE: Pre-intra-post treatment Data Collection, Monitoring and Nursing Assessment: Policy: 1-03-08...Revision Date: April 2021...1. Patient data will be obtained and documented by the patient care technician (PCT or a licensed nurse...a...i...temperature ii...blood pressure (BP) ...iii. Heart or pulse rate...INTRADIALYTIC DATA
COLLECTION/ASSESSMENT...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: Vital signs and treatment monitoring...i...is completed at least every thirty (30) minutes...b. At a minimum...i. BP...ii..pulse...11. Abnormal findings...will be reported to the licensed nurse immediately.
Review of MRs on 10/7/21 at approximately 12:10 p.m. to 3:00 p.m. revealed the following:
MR5, admission date of 7/17/2020. Review of treatment records dated 9/17/21 through 10/4/21. Treatment sheet dated 9/22/21 revealed patient was assessed at 2:03 p.m. and patient was not assessed again until 3:07 p.m. (64 minutes between assessments).
MR14, admission date of 9/9/21. Review of treatment records dated 9/17/21 through 10/5/21. Treatment sheet dated 9/25/21 revealed patient was assessed at 1:01 p.m. and patient was not assessed again until 2:01 p.m. (60 minutes between assessments).
An interview with the facility administrator conducted on 10/7/21 at approximately 3:15 p.m. confirmed the policy as current and above findings.
Repeat deficiency: 9/28/18, 9/5/17.
Plan of Correction:The FA will hold in-service(s) for all ICHD clinical teammates starting 10/29/21 to review Policy # 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment. Education to include surveyor findings as examples, and emphasizing vital signs and treatment monitoring must be completed at least every thirty (30) minutes and documented in the medical record. Verification of attendance will be evidenced by teammate signature on in-service sheet.
The Clinical Coordinator or designee will review all treatment sheets for two (2) days a week for four (4) weeks, then one (1) day a week for four (4) weeks, then on ten percent (10%) of the medical records monthly during medical records audits. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the teammates during homeroom meetings and with the Medical Director during monthly Facility Health Meetings with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
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