Dci Philadelphia

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 46632 Based on a review of the facility emergency preparedness program, policy and an interview with facility administrator, the facility failed to conduct either a full-scale exercise that is community- based or when a community-based exercise is not accessible, an individual, facility-based exercise or a tabletop exercise that includes a group discussion that challenges an emergency plan at least annually. Findings include: A review of facility policy was conducted on July 23, 2024 at 12:31 p.m.. “Emergency Preparedness Plan” states “Testing” The facility will participate in one exercise annually. a. community based full scale exercise, or an individual facility based functional exercise is required every 2 years. b. In the opposite years, the facility will choose one of the following exercises to conduct: i. A second full scale exercise, either community based or individual, facility based functional exercises; or ii. A mock disaster drill; or iii. A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using narrated, clinically relevant emergency scenario and a setup of problem statements, direct messages or prepared questions designed to challenge emergency plan. A review of the facility emergency preparedness program was conducted on July 23, 2024 at approximately 11:48 a.m. A review of the emergency preparedness program contained documentation that testing the facility’s emergency plan was conducted for February 2024. There was no documentation for 2023. An interview with the facility administrator on July 23, 20245 at approximately 1:20 p.m. confirmed the above findings.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) 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. This Standard is not met as evidenced by: 46632 Based on observation of the clinical area, facility policy and an interview with the Facility Administrator, the facility did not ensure infection control procedure regarding glove removal and handwashing for five (5) of fourteen (14) observations (OBS). (OBS# 1, 2,3, 4 and 5). Findings include: A review of policy “ Use of Gloves Including Hand Hygeine” on July 22, 2024 at 1:13 p.m. states: “Gloves will be worn while performing procedures which have the potential for exposure to blood, dialysate and other potentially infectious substances. Including but not limited to: Caring for patients vascular access or catheters. Setting up reprocessed dialyzer pretreatment. Inserting or removing access needles. Connecting the bloodlines to the vascular access needle lines. Touching the dialysis bloodlines, dialyzer or machine pre and post treatment. Administering intravenous medications. Cleaning and disinfecting the dialysis machine and chair post treatment. 2) Gloves must be provided to patients and visitors if these individuals assess what procedures ... ... ... ... ... ... ...... 3) Chairside computer keyboard screens can easily become contaminated because of their proximity to the patient station. Hand hygiene is imperative after contact with the chairside computer and before contact with the patient, regardless of whether contact with the computer occurred through gloved or ungloved hands. 4) Gloves will be changed for the following: When soiled with blood, dialysis or other body fluids. When going from a “dirty” area or task to a “clean” area or task. When moving from a contaminated body site to a clean body site of the same patient. After touching one patient or their machine and before arriving to care for another patient or touch another patient’s machine. 5) A new pair of clean gloves must be used each time for the following: access site care. Vascular access cannulation. Administration of parenteral medications. To perform invasive procedures. 6) Hand hygiene will be performed: after touching blood, body fluids, secretions, excretions, and potentially contaminated items. Before and after direct contact with patients. Before performing any invasive procedures such as vascular access cannulation or administration of parental medications. Immediately after gloves are removed. After contact with inanimate objects, including medical equipment or environmental service at the patients station. Before entering and or exiting patient treatment areas. When moving from a contaminated body site to a clean body site of the same patient. 7) Physicians, non physician practitioners, social workers, and dietitians must follow the same requirements ... ... ... ... ... ... ... ... 8) Staff caring for central venous catheters will: Wear clean or sterile gloves when changing the dressing on the intravascular catheters. Observe strict hand hygiene before and after palpating catheter insertion sites. Observe strict hand hygiene and after accessing or dressing in intravascular catheter. A review of procedure “General preparation procedure for medication administration procedure 9.01” on July 22, 2024 at 12:55 p.m. 1) Put on personnel protective equipment. 2) Wash hands. 3) Verify the patient’s name and the amount of medication............ 4) Verify that the patient does not have sensitivity to drug. 5) always check the 5 R’ s’ and medication administration: right patient name............. 6) Use aseptic technique. Observation of the clinical area was conducted on June 22, 2024 between 8:50 am-12:24 pm. OBS # 1 Machine 14 PCT 1, Discontinuation of Dialysis with Central Venous Catheter, PCT closed CVC clamps touched dialysis screen then disinfected CVC hub, did not discard gloves, perform hand hygiene and don new gloves. OBS # 2 Machine 29 Nurse 1, Access of AV Fistula or Graft for Initiation of Dialysis, Prior to inserting cannulation needle went to supply cart for alcohol pad with gloves on, did not discard gloves, perform hand hygiene and don new gloves. OBS # 3 Machine 32 PCT 2, Access of AV Fistula or Graft for Initiation of Dialysis, washing skin over access with soap and water, pushed patients sleeve up and continues to wash access did not discard gloves, perform hand hygiene and don new gloves. OBS # 4 Machine 13 PCT 3 Discontinuation of Dialysis and Post Dialysis Access Care for AV Fistula or Graft. Before removing needle aseptically touched dialysis screen, did not discard gloves, perform hand hygiene and don new gloves. OBS# 5 Nurse 2, prepared medication at medication station, withdrew first medication then touched medication sheet to review order. Withdrew second medication, took glove off to review medication order, filled a cup with water for pills. Did not perform hand hygeine, put new glove on. Went to patient station looking for alchol swab took one glove off, went to medication room to get alcohol swab put one glove back on. Did not perform hand hygeine. Gave patient first medication, touched dialysis screen, gave second medication. Did not discard gloves, perform hand hygeine and don new gloves. An interview with the Administrator conducted on July 22, 2024 at 1:45 p.m. confirmed the above findings.”