QA Investigation Results

Pennsylvania Department of Health
CHILDREN'S HOSPITAL OF PHILADELPHIA (THE)
Health Inspection Results
CHILDREN'S HOSPITAL OF PHILADELPHIA (THE)
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey and for the addition of Home Hemo-Dialysis (home training and support) services conducted on April 13, 2021 through April 14, 2021, and offsite on April 19, 2021, 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 and for the addition of Home Hemo-Dialysis (home training and support) services conducted on April 13, 2021 through April 14, 2021, and offsite on April 19, 201, Children's Hospital of Philadelphia, 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)(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 policy and procedures, observation, and an interview with the clinical manager, it was determined, the facility failed to ensure infection control procedures were followed by cleaning and disinfecting the Hansen connectors for two (2) of two (2) hemodialysis machines observed. (Dialysis machine at station #43 and 45).

Findings include:

A review of policy titled "Policy: Guidelines for Cleaning and Disinfection of Dialysis Equipment" on April 19, 2021 at approximately 8:15 am, states "4. Procedure:...B. Dialysis Equipment: a. External surfaces of non-disposable equipment (HD machines...) will be cleaned and disinfected with a 1:100 bleach solution after each patient use..."

Observations were made in the dialysis treatment area on April 14, 2021 between the hours of 10:00 AM and 12:30 PM .

Observation #1. Clinical Associate Technician #1 did not disinfect the Hansen connectors at station #43 prior to the start of the next dialysis treatment.

Observation #2. Clinical Associate Technician #1, did not disinfect the Hansen connectors at station #45 prior to the start of the next dialysis treatment.

An interview conducted with the clinical manager on April 14, 2021 at approximately 1:00 PM confirmed the above identified findings.









Plan of Correction:

The policy for Cleaning for Disinfection of Dialysis Equipment was reviewed and no changes were needed.
Staff will be educated by the Nurse Manager on the policy for Cleaning and Disinfection of Dialysis Equipment and the cleaning of the Hansen connectors after each patient via email the week of April 26. Staff will receive the policy and electronic education via email and are to respond to the email stating understanding. The process will be reinforced during the May monthly staff meeting on 5/10/2021. Visual audits of two patient stations per shift will be performed by the Nurse Manager or designee during turnover of a patient station. The audits will continue for 4 months or until 100% compliance is achieved beginning May 2021. If noncompliance is observed, immediate feedback and education will be provided. Data from observations will be reported to the monthly Dialysis Quality Improvement Committee. The responsibility for ensuring ongoing compliance is the Nurse Manager.



494.40(a) STANDARD
CARBON ADSORP-MONITOR, TEST FREQUENCY

Name - Component - 00
6.2.5 Carbon adsorption: monitoring, testing freq
Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours.

Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet.

Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L].
Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly.


Observations:



Based on reviews of water room logs, review of policy, and an interview with the clinical manager, the facility failed to ensure free chlorine, chloramine, or total chlorine testing was performed approximately every 4 hours for five (5) of seven (7) 'Children's Hospital of Philadelphia Buerger Water Room Log' reviews (Water Log Review #1, 3, 4, 5, and 7).

Findings include:

A review of facility policy titled "Job Aid: Testing Guides" was conducted on April 14, 2021 at approximately 9:45 a.m. Policy states "LaMotte Chlorine Testing: Chlorine and Chloramine testing done every four hours from post primary carbon tank..."


Daily Water Logs were reviewed on April 14, 2021 at approximately 9:00 a.m. revealed the following:


Water Log Review #1 for week of 2/22/2021 through 2/27/2021:

On 2/26/2021, "Total Chlorine-afternoon" test time was entered at 1:00 p.m. The next chlorine test "Total Chlorine-evening" was conducted at 6:00 p.m. (60 minutes late).

Water Log Review #3 for week of 3/8/2021 through 3/23/2021:

On 3/12/2021, "Total Chlorine-afternoon" test time was entered at 1:00 p.m.. The next chlorine test "Total Chlorine-evening" was conducted at 6:00 p.m. (60 minutes late).

Water Log Review #4 for week of 3/15/2021 through 3/20/2021:

On 3/15/2021, "Total Chlorine-afternoon" test time was entered at 1:10 p.m. The next chlorine test "Total Chlorine-evening" was conducted at 6:30 p.m. (80 minutes late).

On 3/16/2021, "Total Chlorine-afternoon" test time was entered at 1:30 p.m. The next chlorine test "Total Chlorine-evening" was conducted at 6:00 p.m. (30 minutes late).

On 3/17/2021, "Total Chlorine-afternoon" test time was entered at 1:00 p.m. The next chlorine test "Total Chlorine-evening" was conducted at 6:30 p.m. (90 minutes late).

Water Log Review #5 for week of 3/22/2021 through 3/27/2021:

On 3/22/2021, "Total Chlorine-afternoon" test time was entered at 1:00 p.m. The next chlorine test "Total Chlorine-evening" was conducted at 6:50 p.m. (110 minutes late).

On 3/24/2021, "Total Chlorine-afternoon" test time was entered at 1:00 p.m. The next chlorine test "Total Chlorine-evening" was conducted at 6:30 p.m. (90 minutes late).

Water Log Review #7 for week of 4/5/2021 through 4/11/2021:

On 4/6/2021, "Total Chlorine-afternoon" test time was entered at 1:10 p.m. The next chlorine test "Total Chlorine-evening" was conducted at 6:00 p.m. (50 minutes late).

On 4/7/2021, "Total Chlorine-afternoon" test time was entered at 1:50 p.m. The next chlorine test "Total Chlorine-evening" was conducted at 6:05 p.m. (15 minutes late).

An interview with the clinical manager on April 14, 2021 at approximately 1:00 p.m. confirmed the above findings.







Plan of Correction:

Policy for the completion of chlorine and chloramine checks of the water system was reviewed and no changes were required.
Nursing staff will be educated about the requirement of completing chlorine and chloramine checks of the water system in the required four hour time period by the Nurse Manager via email the week of April 26. Staff will receive the policy and electronic education via email and respond to email stating understanding. The process will be reinforced during the May monthly staff meeting on 5/10/2021.
The nurse manager or designee will conduct a random check once per week over the next 4 months starting in May 2021 until there is 100% compliance. If noncompliance is observed, immediate feedback and education will be provided. Data from observations will be reported to the monthly Dialysis Quality Improvement Committee. The responsibility for ensuring ongoing compliance is the Nurse Manager.



494.170 STANDARD
MR-COMPLETE, ACCURATE, ACCESSIBLE

Name - Component - 00
The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.


Observations:


Based on a review of facility policy, medical records, and an interview with the clinical Manger, it was determined the facility failed to maintain complete and accurate medical records for the care provided for one (1) of five (5) Medical Records (MR), reviewed. (MR #3).

Findings Include:

Review of facility policy titled "Nursing Standard: Two RN Timeout Check Prior to Procedure" completed on April 14, 2021 at approximately 8:45 am, states "Purpose: To establish and maintain a policy to minimize risks to the health and safety of Dialysis patients. It is important for the Dialysis machine to be set-up and programed correctly to ensure the safety of the patient...5. Procedure: Performing a 2 RN Time out: Steps: 1. Log into Epic, confirm the correct patient. 2. Verify the patient's prescription order...4. Procedure Order and Machine Data Entry: a. Primary Nurse: i. Pull up patient's procedure order on the WOW (workstation on wheels), ii. Manually program prescription settings. 1. Temperature, Dialysate, Sodium, Bicarbonate, Time, Sodium modeling, and UP profile if applicable. iii. Check all connections to esure they are tight. iv. Check CRIT-LINE connection, if applicable to ensure it is connected correctly. b. Secondary nurse: i. Pull up patient's procedure on the WOW. ii. Confirm programmed settings are in line with the procedure orders. iii. Manually enter visually confirmed settings from the machine into patient's HD flowsheet. iv. Check all connections to ensure they are tight. C. Primary Nurse: Confirm and agree with correct order entered in the hemodialysis flowsheet and cosign..."

Review of MR#3 on April 13, 2021 at approximately 1:15 p.m. revealed date of admission: 12/27/17. Diagnosis included End Stage Renal Disease. Review included two (2) weeks of treatment records dated between March 29, 2021 and April 12, 2021.

Dialysis flowsheet for April 12, 2021 revealed no verification was completed by a second RN to confirm the Dialysis treatment order.


An interview with the Clinical Manager on April 14, 2021 confirmed the above findings.







Plan of Correction:

The policy for Patient Assessment and Machine Check was reviewed and no changes were needed.
Staff will be educated by the Nurse Manager about the requirement to complete the two RN timeout check verification via email the week of April 26. Staff will receive the policy and electronic education via email and respond to email stating understanding. The process will be reinforced during the May monthly staff meeting on 5/10/2021.
10 chart audits per week will be performed by the Nurse Manager or designee to ensure there are no missed two RN timeout checks in the patient charts. The audits will occur for the next 4 months until 100% compliance is achieved beginning May 2021. If noncompliance is observed, immediate feedback and education will be provided. Data from observations will be reported to the monthly Dialysis Quality Improvement Committee. The responsibility for ensuring ongoing compliance is the Nurse Manager.