Fmc Qci Salem

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 31224 Based on interview and record review, it was determined the facility failed to implement their infection control policy regarding pneumococcal vaccinations. Findings: Review of facility documentation revealed a new facility policy titled “MAB Recommended Evaluation and Immunization Against Pneumococcal Infection 3.0” was dated 11/10/2023. The policy stipulated: * Patients vaccinated with PCV13 and one or two doses of PPSV23 prior to the age of 65 should be scheduled for PCV20 five years following administration of PPSV23 or PCV13. * Patients vaccinated with one or two doses of PPSV23 at any age should be administered PCV20 one year following the PPSV23 administration. Review of the governing body meeting minutes dated 12/20/2023 revealed the new CMAB recommendations dated 11/10/2023 were approved. Review of a memo dated 02/01/2024 regarding “Pneumococcal Vaccination Recommendations Updates” included the following: “The MAB algorithm has been updated to reflect the new recommendations for the following patients: * Vaccinated with Prevnar 13 (PCV13) and Pneumovax 23 (PPSV23) with one or two doses prior to age 65. - Previous recommendation: Administer Pneumovax 23 (PPSV23) 5 years following last dose of PPSV23 or at least 8 weeks after PCV13. - Updated recommendation: Administer Prevnar 20 (PCV20) 5 years following their last dose of vaccine. * Vaccinated with Prevnar 13 (PCV13) only at any age. - Previous recommendation: Administer Prevnar 20 (PCV20) at least 8 weeks following the Prevnar 13 (PCV13) administration. - Updated recommendation: Administer Prevnar 20 (PCV20) at least 1 year following the Prevnar 13 (PCV13) administration.” The 02/01/2024 “Pneumococcal Vaccination Recommendations Updates” memo further stipulates: * While the vaccine report in the EHR is being updated, “In the interim, based on the vaccination history, follow the steps in the MAB algorithm to vaccinate patients who are candidates for immunization and those who are currently in a vaccination series.” * “Review and obtain orders for the new version of the algorithm...Utilize the MAB algorithm to vaccinate patients according to the updated APIC recommendations.” Review of the facility policy titled, “CMAB Recommended Evaluation and Immunization Against Pneumococcal Infection 2.0,” and dated 06/01/2022 revealed an additional change not highlighted in the memo. Version 2.0 identified patients “Vaccinated with Pneumovax 23 with one or two doses.” Version 3.0 was updated to identify patients “vaccinated with Pneumovax 23 (PPSV23) with one or two doses at any age.” Review of the Pneumonia Vaccination Report dated 02/26/2024 revealed patients were not reevaluated under the new policy algorithm. For example: * Patient #13, 75 years old, received two doses of PPSV23 and one dose of PCV13, with the last dose of PPSV23 administered on 07/22/2019. Patient #13 was identified as “Immunization Series Complete.” The updated MAB algorithm identified Patient #13 would have been eligible to receive PCV20 as of 07/22/2020, yet was not identified nor was the patient offered this vaccine. * Patient #14, 58 years old, received two doses of PPSV23 and one dose of PCV13, with the last dose of PPSV23 administered on 02/13/2018. Patient #14 was identified as “Review immunization status at age 65 or older 07/01/2030... Immunization Series Complete for ages 19-64.” The updated MAB algorithm identified Patient #14 would have been eligible to receive PCV20 as of 02/13/2023, yet was not identified nor was the patient offered this vaccine. During interview on 02/28/2024 at 1045, the FA contacted the LPN who was responsible for monitoring the pneumococcal vaccines for ICHD patients. The LPN stated the policy and tracking information could be found in the binder and when reviewed, the binder revealed the LPN was using the CMAB Recommended Evaluation and Immunization Against Pneumococcal Infection 2.0 dated 06/01/2022. The list the LPN used to track who was due for the pneumococcal vaccine did not identify patients who would require additional vaccines under reevaluation. The FA confirmed these findings.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 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. This Standard is not met as evidenced by: 37898 Based on interview and medical record review, it was determined the facility failed to maintain an accurate medical record for 2 of 12 patient records reviewed (Patients #6 and 10). Findings: Patient #6: Review of an “Outpatient Dialysis Rounding Note,” completed by the MD, for the “Encounter Date: 2/8/2024,” revealed the entry “Dialysis Prescription: ... BFR 450, DFR 600.” Review of Treatment Sheet data on the day of the MD encounter, 02/08/2024, and the treatment following the encounter on 02/10/2024, revealed “Hemodialysis Orders ... BFR: 400 ...DFR: Manual 500 mL/min.” Patient #10: Review of a “Visit Summary ... Outpatient Dialysis Rounding Note,” completed by the MD “at 2/9/2024 10:40 AM” revealed the entry “HD Prescription: ... Bicarb 30.” The first page of this document was signed by a facility nurse to indicate it had been reviewed on “2/10/24.” Review of Treatment Sheet data on the day of the MD encounter, 02/09/2024, and the treatment following the encounter and nurse review on 02/12/2024, revealed “Hemodialysis Orders ... Bicarb Machine Setting (mEq/L): 28.” During interview with the FA, ATL, DO and a Home Therapy RN on 02/28/2024 at 1330, the above findings regarding the prescription elements recorded by the MD and prescription being delivered during treatment not matching were presented. The DO searched the patient medical records and stated the prescription being delivered was correct; the information recorded by the MD was not the current prescription. All attendees agreed that documentation should match and the DO stated “We need to get everyone [outside MDs] on board with charting in our record.””