Usrc Watervliet Dialysis

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [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. This Standard is not met as evidenced by: 47415 Based on observation, interview, and record review, the facility failed to ensure that cleaning and disinfection of contaminated surfaces was complete, following dialysis treatment in 2 (# 5, 10) of 2 patient stations where cleaning was observed, resulting in the potential to spread infectious agents to 2 patients that were coming on to treatment in those stations. Findings include: On 8/13/24 at 1455, CCHT (certified clinical hemodialysis technician) Staff G was observed cleaning the dialysis chair at station #10, and at 1530, CCHT Staff F was observed cleaning the dialysis chair at station #15. In both observations chairs were immediately closed and returned to the upright position after cleaning. The staff failed to leave the sides of the chairs open, and footrests in an extended position to remain visibly wet as required for disinfectant contact time. Both Staff G and Staff F, immediately after station cleaning was complete, were asked about disinfectant contact time and allowing the wings of the chair, and inner areas of footrest to dry before closing. Both CCHT’s stated the chairs could be closed and returned to upright position immediately after cleaning. On 8/13/24 at approximately 1545, Facility Administrator Staff A asked about the disinfection of the dialysis chairs and contact time of disinfectant, and she stated she would check the policy. Review of facility policy C-IC-0080 titled, “Disinfection and Cleaning Dialysis Machine Equipment”, revised 7/2023 revealed: “A 1:100 dilution bleach solution will be made daily ...The bleach solution will have at least a (5) minute contact time as per manufacturer’s recommendation for external disinfection of ...dialysis chairs ...Clean chair by placing in the reclining positions and swing arms out to clean seat, footrest, backrest and sides, armrest, inside of chair arms and chair frame and side tray ...Adhere to appropriate contact time between external disinfection of the machine/chair ...””

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 22050 Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant affecting 62 patients, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 08/13/24 at 1050, an environmental tour of the facility was conducted with Biomed D and Biomed E, the following items were noted: Hazardous Waste Storage Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. Patient Isolation Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. Receptionist Room: The return-air-exhaust ventilation grill was observed heavily soiled with accumulated dust and dirt deposits. Biomed E indicated “(Name) EVS for Healthcare” was the current contractual service for facility housekeeping services. Patient Treatment Room: Sixteen dialysis machine chase connection boxes were observed (etched, scored, particulate), creating a porous non-cleanable and non-sanitizable surface. Dialysis Machines #11 and #15 were observed with acidic and corroded pipe connections, within the pipe chase inspection cover access panel. Nurse Station 1 and Nurse Station 2 return-air-ventilation grills were both observed heavily soiled with accumulated dust and dirt deposits. The return-air-ventilation grills measured approximately 2-feet-wide by 4-feet-long. The metal hand sanitizer stand support column connection was observed heavily corroded, adjacent to Nurse Station 1. The drywall surface was observed with adhesive residue, adjacent to the laboratory alcove. The soiled drywall surface measured approximately 11-inches-wide by 18-inches-long. The pipe chase perimeter wooden railing system was observed (etched, scored, dented, chipped, porous), directly behind all 16 dialysis machines. The wooden railing system could no longer be effectively cleaned and/or sanitized. On 08/13/24 at 1500, record review of the “(Name) EVS for Healthcare” service contract dated (2017) revealed under Category/Service: “Dust blinds, windowsills, jams, light fixtures, and ceiling vents with electrostatic dusting cloths monthly.” On 08/13/24 at 1515, record review of the “QAPI Meeting Minutes” dated (no date) revealed under Plan of Action/Follow-Up Needed/Root Cause: “Findings: Acid build-up at multiple wall boxes. Multiple kick panels need replacing. Action To Correct Deficiency: Bio-Med to replace T fittings to negate leaks when parts arrive. Bio-Med working with vendor to replace damaged kick panels. Monitor Procedure: Monthly Person Responsible: BMT/FA Due Date: 2024-08-31””

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 29955 Based on interview and record review, the facility failed to implement the plan of care within 15 days of the interdisciplinary assessment for 5 of 7 patients reviewed (P-1,P-2, P-5,P-6, and P-7) resulting in the potential for unrecognized and unmet patient needs. Findings include: On 8/14/2024 during record review for P-1, it was revealed the initial interdisciplinary plan of care was dated 7/3/2024. The plan of care for each of the team was signed as completed by home peritoneal dialysis nurse, staff K, signed before the plan of care on 7/1/2024. Staff A, the facility administrator confirmed these findings. On 8/14/2024 during record review for P-2, it was revealed the annual interdisciplinary plan of care was dated 1/17/2023. The interdisciplinary assessment for each of the team was signed as completed as follows: physician staff L, signed on 1/8/2024, incenter dialysis nurse staff C, no date provided signed by staff J, social worker, staff I, 1/8/2024. Further record review for P-2 revealed the annual interdisciplinary plan of care from 1/23/2023. The interdisciplinary assessment for each of the team was signed as completed as follows: staff A, signed on 1/14/2023. On 8/14/2024 during record review for P-7, it was revealed the initial interdisciplinary plan of care was dated 7/18/2024. The interdisciplinary assessment for each of the team was signed as completed as follows: incenter dialysis nurse, staff K, signed on 8/14/2024. Staff A, the facility administrator confirmed these findings. On 8/14/2024 at 1035 an interview was conducted with staff O, the regional clinical manager. Staff O asked to be provided with the regulation which stated when the plan of care needed to be signed by the Interdisciplinary team. Staff O stated, “We are unaware of any regulation that requires dates of staff signatures....I don’t understand what the big deal is.” Explanation was provided. Staff O stated, “I may have to get IT involved.” On 8/14/2024 a record review occurred of the policy titled, “Comprehensive Interdisciplinary Assessment/Plan of Care (CIPA/POC),” policy C-AD-0480, revision date of 04/2024. According to the policy, “5. Frequency of CIPA/POC completion, e., The POC (plan of care) will be implemented with 15 days in the response to completion of any re-assessment... 47415 On 8/14/2024, during record review for P-5, it was revealed the annual interdisciplinary plan of care was dated 11/8/23. The interdisciplinary plan of care for each of the team was signed by staff A, until 12/12/23. On 8/14/2024, during record review for P-6, it was revealed the annual interdisciplinary plan of care was dated 4/11/24. The interdisciplinary plan of care for each of the team was not signed as completed by incenter dialysis nurse, staff B.”