Fkc Delco Dialysis Center

“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: 43085 Based on observations, review of agency policy and procedures, and interview with the facility administrator, it was determined that the facility staff did not practice proper infection control during initiation of dialysis treatments, for two (2) of eighteen (18) observations. Observation #9 and #12 Findings include: Reviewed facility ’ s policies and procedures on December 7, 2023 from 10:15AM until approximately 11:00AM. Observation tour of treatment area was conducted on December 5, 2023 from approximately 9:50AM until approximately 1:40PM revealed: Policy titled “Access Assessment and Cannulation” states, “ ...Assessment of Vascular Access ...1. Prior to treatment, ask patient to wash access area with soap per hand hygiene procedure. Wash access (per above) if patients unable to clean their access. 2. Wash hands and done PPE: gloves, gown/apron, safety glasses and mask, or full-face shield ...9. Remove gloves and perform hand hygiene. Don new gloves ...Skin Disinfection - 1. Disinfect cannulation site ... “ Observation #9: At approximately 10:44AM, PCT3 was observed preparing for the initiation of dialysis for an AV fistula patient at station #12. With gloved hands, PCT3 documented on the computer, walked over to the sink that was located a few feet across from station #12, and gathered materials to wash the patient ’ s access site. With same gloved hands, PCT3 washed the patient ’ s access site, located and palpated the access site, and applied antiseptic to the patient ’ s skin over the cannulation site. PCT3 did not remove gloves, perform hand hygiene, or don clean gloves, prior to disinfecting the cannulation site. Policy titled “Changing the Catheter Dressing Procedure” states, “ ...Removal of Dressing and Inspection of Site ...1. Place an underpad under catheter limbs to protect work area and clothing ...3. Perform hand hygiene. 4. Don clean gloves. 5. Inspect and remove the old dressing. Check to see if dressing looks visibly soiled with exudate or blood. 6. Visually inspect the exit site and surrounding area ...8. Discard dressing and remove gloves. Perform hand hygiene ... “ Observation #12: At approximately 12:13PM, PCT4 was observed performing central venous catheter (CVC) exit site care for the patient at station #3. PCT4 performed hand hygiene, donned clean gloves, and performed central venous catheter exit site care using proper technique. After PCT4 applied the sterile dressing to the CVC exit site, PCT4 did not remove gloves, perform hand hygiene or don clean gloves. PCT4 used the same gloved hands to close the catheter clamps, disinfect CVC hubs, connect sterile syringes, flushed with sterile saline, and initiated treatment. PCT4 removed gloves and performed hand hygiene after connecting and flushing the sterile saline for the patient at station #3. An interview with the agency facility administrator, on December 7, 2023 at approximately 3:15PM confirmed the above the findings.”

“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: 43085 Based on observations and interview with the facility administrator, it was determined that the facility staff did not follow facility policy to maintain the quality and storage of supplies for three (3) of eighteen (18) observations. Observations #1, #3, and #4 Findings include: Policy titled “Storage of Supplies” states, “ ...Supplies must be rotated First In-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date ... “ Observation tour of medication area near the nurse ’ s station and supply carts in treatment area was conducted on December 5, 2023 from approximately 11:15AM until approximately 12:30PM revealed: The following supplies were expired: Observation #1 (Located in the prep sink area near the nurse ’ s station) One (1) Bottle of E-Z Check Blood Leak Test Strips Lot 101029, Expired 5/31/2021 (approximately 20 strips remaining) One (1) Bottle of E-Z Check Blood Leak Test Strips Lot 101041, Expired 11/30/2022 (approximately 22 strips remaining) (Located in the cabinet above the hand wash sink between station #16 and #17) One (1) Box of E-Z Check Blood Leak Test Strips (unopened), Lot 101038, Expired 4/30/2022 Observation #3 (Located in the room outside of the BioMed area) One (1) Box of 0.9% Sodium Chloride Injection USP, Lot V22D24C, Expired 10/2023 (approximately 10 bags remaining) Observation #4 (Located in the utility clean closet near the conference room) One (1) Bottle of Hydrogen Peroxide (3%) 16oz, Lot 60661, Expired 11/2023 Two (2) Packs of JAMAR Monofilament Disposable Lops (sensory testing diabetic foot screening tool), Code Q0815GS, Expired 8/15/2020 (20 per pack) One (1) Pack of JAMAR Monofilament Disposable Lops (sensory testing diabetic foot screening tool), Code O0220GS, Expired 2/20/2022 Two (2) Packs of JAMAR Monofilament Disposable Lops (sensory testing diabetic foot screening tool), Code N0120GS, Expired 1/20/2023 (20 per pack) One (1) Bottle of ExSept Plus Antimicrobial Exit Site Skin and Wound Cleanser 17oz, Expired 4/23/2023 One (1) Bottle of ExSept Plus Antimicrobial Exit Site Skin and Wound Cleanser 17oz, Expired 11/7/2023 Five (5) Boxes of Sterile Medcom SafeBasics Cotton Tipped Applicators (individually wrapped), Lot 71736, Expired 10/2019 (200 units per box) Two (2) Boxes of Sterile Medcom SafeBasics Cotton Tipped Applicators (individually wrapped), Lot 85191, Expired 3/2023 (200 units per box) Six (6) Boxes of Sterile Medcom SafeBasics Cotton Tipped Applicators (individually wrapped), Lot 86869, Expired 5/2023 (200 units per box) An interview with the agency facility administrator, on December 7, 2023 at approximately 3:15PM confirmed the above the findings.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 43085 Based on review of medical records, agency policy and procedures, and interview with the facility administrator, it was determined that the facility did not maintain complete and accurate records, for one (1) of seven (7) medical records (MR) reviewed (MR3). Findings include: Reviewed facility’s policies and procedures on December 7, 2023 from 10:15AM until approximately 11:00AM. Policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care (CIA/POC)” states,”...General Policy for Patient Assessment and Plan of Care - ...The patient’s Plan of Care will be guided and developed based on the findings identified in the Comprehensive Interdisciplinary Assessment...CIA/POC for Unstable Patients - Unstable patients must be reassessed by the IDT (Interdisciplinary Team) monthly. Monthly reassessment and any POC updates related to the reason the patient is considered “unstable” must be documented until the issues have been resolved or the IDT (including the patient if possible) determines that the condition is chronic. The following are unstable criteria: Extended or frequent hospitalizations (a) Hospitalization of more than 15 days with discharge occurring within the last 30 days...” Review of medical record (MR) on December 6, 2023 at approximately 12:49PM revealed: MR3. Admit Date: 7/14/2023. DOB: 9/14/1964. Patient receives in-center hemodialysis via central venous catheter for three (3) and one-half hours per day for three (3) days per week. Reviewed facility’s list of “unstable” patients for the past three (3) months on December 5, 2023 at approximately 2:15PM. MR3’s current status listed as “unstable” during the month of October (date not determined) due to “hospitalizations”. There was no documentation to confirm that the IDT conducted a monthly reassessment of the patient’s current unstable status. An interview with the agency facility administrator, on December 7, 2023 at approximately 3:15PM confirmed the above the findings.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 43085 Based on observations, review of agency policy and procedures, and interview with the facility administrator, it was determined that the facility staff did not follow its policy for infection control practices related to patient and visitor PPE, for one (1) of one (1) observation. Findings include: Review of facility’s policies and procedures on December 7, 2023 from 10:15AM until approximately 11:00AM revealed: Policy titled “Guidance on Dialyzing and Infection Control Practices of COVID-19 in Fresenius Kidney Care (FKC) Dialysis Clinics...Patient and Visitor PPE (Personal Protective Equipment): All patients and visitors should be provided with a surgical mask upon entry to the FKC dialysis clinic and treatment floor...” Upon arrival at the facility on December 5, 2023 at approximately 8:50AM, the surveyor was greeted by the facility administrator in the reception area and was escorted through the treatment area where patients were dialyzing and led to the conference room. The surveyor was not given PPE/mask when entering the treatment area. An interview with the agency facility administrator, on December 7, 2023 at approximately 3:15PM confirmed the above the findings.”