Innovative Renal Care Central Kittanning

“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: 44820 Based on a review of facility policy/procedure, treatment area observations, interview with facility staff and an interview with the facility Administrator, the facility failed to ensure the staff followed infection control protocols, included but not limited to, performing hand hygiene/donning clean gloves prior to touching an electronic key pad when exiting dialysis clinic treatment floor and prior to entering “clean” supply area, for one (1) of one (1) observation. Findings include: A review was conducted of facility policies on 1/23/24 at approximately 3:15 p.m. to 4:00 p.m.: “Policy Number: G40 Infection Control ...Purpose: To decrease the potential for spread of infection within Innovative Renal Care and American Renal Associates (IRC/ARA) care centers.... POLICY: ...7. Gloves are required whenever caring for a patient or touching a patient’s equipment or supplies...” “Innovative Renal Care/American Renal Associates... PPE To Be Worn... Clinical Duties... Procedure: Touching Machine... Staff: Clinical... Gloves: (X)... Gown: (X)...” Observations conducted in the patient treatment area on 1/23/24 between approximately 9:00 a.m. and 11:00 a.m. revealed: Approximately 10:35 a.m. surveyor observed EMP #9, without wearing (PPE) personal protective equipment, touch dialysis machine #8 at station #4 while a patient (WB) was actively receiving dialysis treatment. EMP #9 touched the machine with bare hands without wearing gloves. EMP #9 proceeded to chart with an independent electronic key pad and computer system on wheels, that was not part of the dialysis machine, and then document in a facility log paper binder immediately after touching the active dialysis machine without performing hand hygiene. Approximately 10:40 a.m. interview conducted with EMP #9 confirmed above findings. “I know I should’ve had gloves on and no I did not use hand sanitizer or wash my hands before documenting on seperate equipment.” Approximately 10:42 a.m. interview conducted with EMP #10 (facililty administrator) confirmed above findings. “Gloves should be worn and hand hygiene performed.””

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 44820 Based on review of facility policy and procedure, chloraprep one-step manufacturer’s directions for use (DFU), observation, and staff (EMP) interview, the facility failed to ensure staff (EMP # 3 and EMP #9) followed facility policy and procedure when caring for a patient’s central venous catheter (CVC) for two (2) of two (2) observations. (OBS#1 and OBS #2). Findings included: Review of facility policy and procedure “Procedure Number: IC05C CVC: Dressing Change” on 1/22/24 at approximately 2:00 PM revealed: “...6. Depending on the type of catheter and patient’s tolerance, the exit site may be cleaned disinfected with various products. Unless otherwise recommended by the catheter manufacturer, the Innovative Renal Care and American Renal Assocciates’ (IRC/ARA) procedure for dressing changes will require cleanin and disinfection with one of the following, used per the manufacturer’s instructions: · 2% Chlorhexidine with alcohol...” Review of manufacturer’s directions for use on 1/22/24 at approximately 2:15 PM revealed: “ChloraPrep One-Step: 2% w/v chlorhexidine gluconate (CHG) and 70% v/v isopropyl alcohol(IPA)... Directions... dry surgical sites (e.g. abdomen or arm): use gentle repeated back and forth strokes for 30 seconds. Allow to air dry approximately 30 seconds...” OBS #1: CVC Exit Site Care performed on 1/22/24 at approximately 9:50 AM at station #15 with EMP #3 revealed: EMP #3 cleansed exit site with chlora prep one-step swab stick applicator for less than 10 seconds and applied new dressing to site in less than 10 seconds after cleansing. Interview conducted with EMP #3 at approximately 10:00 AM confirmed above findings. Surveyor asked EMP #3 how long is the cleanse time and then the dry time for CVC exit site care. EMP #3 responded “We only scrub the solution for about 5 (five) seconds. We let the area dry for 5 (five) seconds as well.” OBS #2: CVC Exit Site Care performed on 1/22/24 at approximately 10:35 AM at station #21 with EMP #9 revealed: EMP #9 cleansed exit site with chlora prep one-step swab stick applicator for less than 10 seconds and applied new dressing to site in less than 15 seconds after cleansing. Interview conducted with EMP #9 at approximately 10:45 AM confirmed above findings. Surveyor asked EMP #9 how long is the cleanse time and then the dry time for CVC exit site care. EMP #9 responded “I scrub for about 10 seconds in a ‘z’ motion and then let it dry for about 5 (five) seconds.””

“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: 44820 Based on review of policy/procedure, observations and an interview with the Facility administrator the facility failed to ensure that medications were drawn up, prepared and labeled properly - facility not following policies for two (2) of two (2) observations made OBS #1 and OBS #2. Findings include: Review of policy completed on 1/22/24 at approximately 2:30 PM revealed: “Policy Number: G48 Medications: “Handling, Administration, Storage & Disposal...” “Purpose: To ensure safe: · preparation of parenteral medications · adminstration of medications to patients Policy: Handling & Administration ... 4. Medications must never be left unsecured or unattended... ...14. Any medication drawn up before the time i is to be administered shall be labeled with: · patient name · medication name · dose of medication · date/time medication was drawn up · initials of nurse who drew up the medication...” OBS #1 completed on 1/22/24 at approximately 10:20AM revealed eight (8) prefilled syringes in two (2) seperate locked drawers that did not contain labels with the time of preparation or initials of person who prepared/drawn up/filled the syringes. An interview with the Facility Administrator completed on 1/22/24 at approximately 10:25 AM confirmed the above findings. OBS #2 completed on 1/23/24 at approximately 9:15 AM revealed two (2) prefilled syringes in a locked drawer and did not contain labels with the name of the medication or the strength of the medication that was in the syringes. An interview with the Facility Administrator completed on 1/23/24 at approximately 9:20 AM confirmed the above findings.”