Fkc Northwest Philadelphia

“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 ased 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 #3 and #11 Findings include: Reviewed facility ’ s policies and procedures on August 28, 2024 from 8:30AM until approximately 9:30AM and on August 29, 2024 from approximately 12:07PM until approximately 12:30PM. Observation tour of treatment area was conducted on August 26, 2024 from approximately 9:30AM until approximately 12:30PM and from approximately 2:50PM until approximately 3:30PM revealed: Policy titled “Access Assessment and Cannulation” states, “ ...Assessment of Vascular Access ...1. Prior to treatment, ask patient to wash access area with soap and water, per hand hygiene procedure. If the patient is unable to wash their own access, the staff or care partner should wear gloves to wash the patient ’ s access with soap and water. 2. Wash hands and done PPE: gloves, gown/apron, safety glasses and mask, or full-face shield ...7. Feel: Pulse not soft/not easily compressible; Thrill not strong at anastomosis; Thrill not present throughout access ...9. Remove gloves and perform hand hygiene. Don new gloves ...With the new gloves, staff may perform the full cannulation procedure including skin disinfection ... “ Observation #3: At approximately 10:10AM, PCT2 was observed preparing for the initiation of dialysis for an AV fistula patient at station #9. With gloved hands, PCT2 washed the patient ’ s access site, located and palpated the access site, and applied antiseptic to the patient ’ s skin over the cannulation site. PCT2 did not remove gloves, perform hand hygiene, or don clean gloves, prior to disinfecting the cannulation site. PCT2 used same gloved hands and inserted cannulation needles, secured tape in place, initiated treatment, and then removed gloves and performed hand hygiene. Observation #11: At approximately 11:59AM, PCT3 was observed preparing for the initiation of dialysis for an AV fistula patient at station #12. With 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. PCT3 used same gloved hands and inserted cannulation needles, secured tape in place, initiated treatment, and then removed gloves and performed hand hygiene. An interview with the Facility Administrator, Director of Operations, and Regional Vice President (virtual) on September 29, 2024, at approximately 1:15PM confirmed the above findings.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 43085 Based on review of dialysis facility policy, observations (OBS) in the clinical area, and interview with the Facility Administrator, the dialysis facility staff failed to ensure the proper handling of potentially infectious waste for three (3) of three (3) observations (OBS #1, #2, and #3). Findings include: Review of facility policy titled “General Cleanliness and Infection Control Guidelines” on September 28, 2024, at approximately 8:30AM states, “ Definitions - Regulated Waste - Liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling ...Other Regulated Waste: Regulated medical waste shall be placed in a container that is in accordance with OSHA bloodborne standard 1910.1030 and is closable, leak proof and labeled and/or color-coded ... “ Review of facility policy titled “Termination of Treatment Using an Arteriovenous Fistula or Graft and Optiflux Single Use Ebeam Dialyzer” on September 28, 2024, at approximately 8:45AM states, “ ...5. Discard the extracorporeal circuit in an appropriate biohazard waste receptable ... “ Review of facility policy titled “Prime Bucket Disinfection” on September 29, 2024, at approximately 12:10PM states, “ ...Procedure - Follow these steps below to perform surface disinfection of the prime bucket post treatment: 1. Dispose of saline solution down any marked dirty sink, utility room hopper or as directed by the home therapy staff. 2. Clean all surfaced of the prime bucket or approved receptacle, with 1:100 bleach solution or an approved 1:100 bleach disinfect wipe. 3. Return clean prime bucket or approved receptacle to the machine ... “ Observation tour of treatment area was conducted on August 26, 2024 from approximately 9:30AM until approximately 12:30PM and from approximately 2:50PM until approximately 3:30PM revealed: Observation #1: At approximately 9:55AM , PCT1 was observed cleaning and disinfecting dialysis station #8 and did not empty, clean, or disinfect the prime bucket prior to the next scheduled treatment. Observation #2: From approximately 10:00AM until approximately 12:30PM in the clinical area, two (2) Techs (PCT2 and PCT3) disposed extracorporeal circuits in trash receptacles instead of biohazardous waste containers. Observation #3: From approximately 12:10PM until approximately 12:30PM in the clinical area, PCT3 and RN1 were cleaning a blood spill at station #2 and disposed the blood-stained disposable underpads (chucks) in a trash receptacle instead of a biohazardous waste container. An interview with the Facility Administrator, Director of Operations, and Regional Vice President (virtual) on September 29, 2024, at approximately 1:15PM confirmed the above findings.”