Davita Northern Philadelphia Dialysis

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) 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. This Standard is not met as evidenced by: 40929 Based on observation of the clinical area, facility policy and an interview with the facility administrator, the facility did not follow its policy regarding disinfection of non-disposable equipment for five (5) of five (5) observations. Observation # 1, 2, 3, 4, & 5. Findings include: A review of facility policy was conducted on 12/7/23 at approximately 12:00PM and revealed the following: Policy, “ 1-05-01 “Infection Control for Dialysis Facilities” states: “14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses...Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 (one to one hundred) bleach solution and if they are visibly contaminated with blood or body fluids should be disinfected with a 1:10 (one to ten) bleach solution” Observations of the clinical area were conducted on 12/4/23 from 10:00 AM to 12:00PM and on 12/5/23 from 10:00AM to 11:00AM. Observation #1 station #20. 12/4/23 at 10:45 AM. RN#2 used a stethoscope to assess a patient and did not disinfect the stethoscope after use. Observation #2 station #18. 12/4/23 at 11:20 AM. RN#2 used a stethoscope to assess a patient and did not disinfect the stethoscope after use. Observation #3 station #6. 12/4/23 at 11:25 AM. RN#1 used a stethoscope to assess a patient and did not disinfect the stethoscope after use. Observation #4 station #11. 12/4/23 at 11:45AM. RN#3 used a stethoscope to assess a patient and did not disinfect the stethoscope after use. Observation #5 station #12. 12/4/23 at 11:48 AM. RN#2 used a stethoscope to assess a patient and did not disinfect the stethoscope after use. An interview with the facility adminstrator on 12/7/23 at 1:30 PM confirmed the above findings.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 40929 Based on review of agency policy/procedure, observation, and interview with facility administrator (FA), agency failed to complete preventative maintenance of one (1) of four (4) oxygen concentrators present at facility (Concentrator #4). Findings include: Policy Review conducted on 12/7/23, at approximately 12:00PM and policy “2-01-09 Preventative Maintenance schedules for Equipment” stated, “Purpose: the dialysis delivery systems and any ancillary equipment, are maintained in good working condition and are operating according to the manufacturer’s specifications...all miscellaneous equipment will receive PM (preventative maintenance) by trained Biomed teammate or outside vendor per manufacturer’s recommendations. Example of Miscellaneous equipment...oxygen concentrators...” Treatment floor observation occurred on 12/4/23 at approximately 10:30 AM. Concentrator #4 located at station #15 was observed with a preventative maintenance sticker stating the preventative maintenance/calibration was due on 9/2023 and was last done on 9/2022. Facility Administrator was unable to locate any preventative maintenance paperwork for further review. Interview conducted on 12/7/23, at approximately 1:30PM with Facility Adminstrator who confirmed the above findings.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) 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; This Standard is not met as evidenced by: 40929 Based on review of facility policies/procedure, medical records (MR), hemodialysis (HD) treatment records, and interviews with the facility administrator (FA), the facility failed to follow its policy for monitoring vital signs, reporting and/or documenting abnormal findings during HD, for one (1) of seven (7) MR reviewed: MR#4. Findings include: A review of the facility’s policy Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment (Policy: 1-03-08) on 12/7/23 at approximately 12:00PM stated,”Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes ... measurement of BP (blood pressure), Heart or pulse rate;” “The nursing assessment will be performed and documented by a licensed nurse. The assessment includes the following components: review of patient reports, data collection, response to treatment...Pre-Treatment Data Collection/Assessment: any abnormal findings during pre-treatment data collection will be documented and immediately reported to the licensed nurse. If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis ...the licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner if applicable) will be notified of any concerns that may preclude the initiation of dialysis. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated....Intradialytic Data Collection/Assessment: the licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation .... Vital signs and treatment monitoring - for non-nocturnal treatments is completed at least every thirty (30) minutes ....Abnormal findings will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The licensed nurse notifies the physician (or non physician practitioner if applicable) as needed of changes in patient status...Abnormal Findings - any weight loss from last post weight .... Blood Pressure Pre-Dialysis: Systolic greater than 180 mm Hg or less than 90 mm Hg; Diastolic greater than or equal to 100 mmHg; Blood Pressure - Intradialytic: Difference of 20 mmHg increase or decrease from patient ’ s last Intradialytic treatment BP reading; Blood Pressure Post Treatment: Standing systolic BP greater than 140 mmHg or less than 90 mmHg; Standing diastolic BP greater than 90 mmHg or less than 50 mmHg; Sitting BP for patient ’ s that cannot stand: Sitting systolic BP greater than 140 mmHg or less than 90 mmHg; Sitting diastolic BP greater than 90 mmHg or less than 50 mmHg; Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minutes or greater than 100 beats per minutes and/or an irregular heart beat.” A review of medical records took place on 12/5/23 from approximately 12:00PM-3:00PM and 12/6/23 from approximately 10:00-2:00PM and revealed the following: MR #4. Start of Care at facility: 2/25/22. HD Treatment on 11/17/23 was initiated at 11:32 AM by the PCT. At 12:57 PM, the PCT documented a BP of 100/54. BP was checked again by the PCT at 1:30PM and found to be 194/92. There was no documentation about RN notification about the sudden difference in blood pressure readings. BP was not checked again until 1:57 PM and was 141/114. There was no documentation about RN notification. In addition, Post-Treatment there was no RN assessment completed. An interview conducted with Facility Administrator on 12/7/23 at approximatley 1:30PM confirmed the above findings.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 40929 Based on a review of medical records (MR), policies and procedures and an interview with the Facility Administrator, the facility failed to ensure an initial “Comprehensive Interdisciplinary Assessment/Plan of Care” was completed within thirty (30) days or thirteen (13) outpatient hemodialysis treatments of the initial hemodialysis treatment for one (1) of seven (7) hemodialysis patients. (MR # 6) Findings include: A review of the Facility Policy 1-14-01 titled “ Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” was conducted on 12/7/23 at approximately 12:00 PM. and stated “An initial Plan of Care, based on the findings from the comprehensive assessment will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.” A review of medical records took place on 12/5/23 from approximately 12:00PM-3:00PM and 12/6/23 from approximately 10:00-2:00PM and revealed the following: MR #6. The first hemodialysis treatment at this facility for the patient was 2/17/23. The medical record showed an initial comprehensive interdisciplinary assessment/ Plan of Care was completed on 10/16/23 (approximately 8 months after the first outpatient dialysis treatment was completed). An interview was conducted with the Facility Administrator on 12/7/23 at approximately 1:30 P.M. who confirmed the above identified findings.”