Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on April 8, 2024 through April 10, 2024, Children's Hospital of Philadelphia 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 Medicare recertification survey conducted on April 8, 2024 through April 10, 2024, Children's Hospital of Philadelphia was identified to have the following standard level deficiencies that were determined to be in substantial compliance with 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services-Emergency Preparedness.
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 observation of the clinical area, facility policy and an interview with the Administrator, Clinical Nurse Expert and Manager of Regulatory & Accreditation, the facility did not ensure infection control procedure regarding glove removal and handwashing for three (3) of seven (7) observations (OBS). (OBS# 1, 2 and 3).
Findings include:
A review of policy "Hand Hygeine" on April 9, 2024 at 12:30 PM states: "It is the policy of the Children Hospital of Philadelphia that employees shall follow the World Health Organization's Five Moment for Hand Hygeine during patient care and perform hand hygeine: 1) Before patient contact, 2) Before an aseptic procedure, 3) After contact with body substances, 4) After patient contact and 5) After contact with patients environment".
Observation of the clinical area was conducted on April 8, 2024 between 9:30 am-12:24 pm.
OBS # 1 Machine 45 RN 1, Initiation of Dialysis with Central Venous Catheter, after disinfecting the CVC hub touched patients shirt and then connected the sterile syringe the RN did not discard gloves, perform hand hygiene and don new gloves. The RN then touched the dialysis machine screen and connected the blood lines to the CVC port, did not discard gloves, perform hand hygiene and don new gloves.
OBS # 2 Machine 41 RN 2 , Discontinuation of Dialysis with Central Venous Catheter, closed CVC clamps touched patient shirt and preceded to disinfect hub, did not discard gloves, perform hand hygiene and don new gloves.
OBS # 3 Machine 45 RN 2, Discontinuation of Dialysis with Central Venous Catheter, removed blood lines, discarded in biohazard waste, removed gloves and donned new gloves, did not perform hand hygeine. Removed crib sheet and disinfected the crib.
An interview with the Administrator, Clinical Nurse Expert and Manager of Regulatory & Accreditation conducted on April 10, 2024 at 11:45 am confirmed the above findings.
Plan of Correction:A specific dialysis hand hygiene policy will be developed. This policy will clearly call out the difference between a clean vs. dirty environment, when to change gloves during the steps of initiation of dialysis and discontinuation of dialysis, and the final removal of the blood lines, discarding tubing in biohazard waste, and the final cleaning of the dialysis station.
The Clinical Nurse Expert will educate the staff on the dialysis hand hygiene policy through staff meetings, unit huddles, and a policy sign off sheet. Staff education will be completed by 5/15/2024.
Weekly, for three weeks or until 100% compliance is achieved, the Clinical Nurse Expert or designee will observe staff members during the initiation of dialysis, the discontinuation of dialysis, and the final cleaning of the dialysis station with the focus on glove removal and proper hand hygiene to ensure infection control procedures are followed. The results of the observations will be reported to the Dialysis Committee and included in the Dialysis report to the QAPI Committee.
The dialysis administrator is responsible for the plan of correction.
494.90(a)(1) STANDARD
POC-MANAGE VOLUME STATUS
Name - Component - 00
The plan of care must address, but not be limited to, the following:
(1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient's volume status;
Observations:
Based on a review of policies, medical records (MR), interview with the Administrator, Clinical Nurse Expert and Manager of Regulatory & Accreditation the agency failed to provide the necessary care and services to manage a patient's volume status for one (1) of five (5) medical records reviewed (MR # 1).
Findings include:
Review of facility policy "- Post-Dialysis Documentation on April 9, 2024 at approximately 1:00 p.m. 1. Enter Post weight and complete hemodialysis treatment record portion. 2. Post HCT/HGB, BV, SVO2, and minimum O2. 3. Vascular Access- assessment, ....... 4. Post Dialysis assessment comments".
Review of medical records on 4/9/24 at approximately 10:30 a.m. revealed the following:
MR # 1 admission date 7/28/2022. Treatment Flow sheet for 3/25/24, revealed undocumented post dialysis assessment comments.
An interview with the Administrator, Clinical Nurse Expert and Manager of Regulatory & Accreditation conducted on April 10, 2024 at 11:45 am confirmed the above findings.
Plan of Correction:A review of the dialysis job aide "Hemodialysis Unit Documentation" identified that no changes needed to be made to the document.
The Clinical Nurse Expert will educate the staff on the hemodialysis unit documentation requirement to document post dialysis assessment comment. Education will be provided through staff meetings, unit huddles and email. Staff education will be completed by 5/15/2024.
Weekly, for three weeks or until 100% compliance is achieved, the Safety Quality Specialist or designee will audit patient 10 records to ensure the post dialysis assessment comment is completed. The results of the chart audit will be reported to the Dialysis Committee and included in the Dialysis report to the QAPI Committee.
The dialysis administrator is responsible for the plan of correction.
494.90(a)(6) STANDARD
POC-P/S COUNSELING/REFERRALS/HRQOL TOOL
Name - Component - 00
The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis.
Observations:
Based on a review of patient medical records, and an interview with Administrator and Manager of Regulatory &Accreditation, the facility failed to ensure the standardized mental and physical assessment tool (PedsQL) was administered annually for one (1) of five (5) patient medical records (MR) reviewed (MR# 3).
Findings:
An interview with the Manager, Regulatory & Accreditation on April 10, 2024 at approximately 12:43 pm stated there is no policy related to the standardized mental and physical assessment tool being performed yearly only PedsQL module.
A review of patient medical records conducted on April 9, 2024 at approximately 12: 46 pm revealed the following:
MR# 3 Date of admission: 7/11/2022 No documentation of a 2023 annual PedsQL.
An interview with the Administrator and Manager, Regulatory & Accreditation on April 10, 2024 at approximately 12:00 p.m. confirmed the above findings.
Plan of Correction:A policy addressing the need to ensure the standardized mental and physical assessment tool (PedsQL) will be administered annually to all outpatient dialysis patients will be developed. This policy will outline that all patients receiving outpatient dialysis, ages 2-25, and their caregivers, will receive an annual ESRD PedsQL. This will be completed by the patient and family within the first 4 months of dialysis initiation, and then annually or on as as-needed basis thereafter.
The social work manager will educate the dialysis social workers on the completion of the PedsQL tool annually for patients 2-25 years old. Education will be provided through staff meetings. Staff education will be completed by 5/15/2024.
Weekly, for three weeks or until 100% compliance is achieved, the Social Work Manager or designee will audit 10 patient records to ensure the PedsQL tool is completed. The results of the chart audit will be reported to the Dialysis Committee and included in the Dialysis report to the QAPI Committee.
The dialysis administrator is responsible for the plan of correction.
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