Fkc Fox Chase

“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: 40929 Based on observation of the clinical area, facility policy and an interview with the facility administrator/clinical manager, the facility did not ensure infection control procedure regarding glove removal and handwashing for one (1) of three (3) observations of “cleaning and disinfection of the dialysis station.” (OBS# 3) Findings include: A review of facility policy occurred on 1/8/25 at approximately 11:00 AM and revealed the following: Policy titled, “Hand Hygiene”... The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination. All staff, patients, ... must follow the same requirements for hand hygiene. ... Hands Will Be ... Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water ... When ... Immediately after removing gloves.” Observations conducted in the patient treatment area on 1/7/26 between 9:45 AM and 12:45 PM revealed the following: OBS #3. Station # 3, PCT # 2. PCT #2 removed old contaminated chair covering from previous patient then proceeded to clean the chair/dialysis machine without first cleaning hands/applying new gloves. An interview with the clinical manager and facility administrator conducted on 1/9/25, at approximately 2:00 PM confirmed the above findings.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 40929 Based on employee (EMP) interviews, observations (OBS), review of facility policy and an interview with the facility administrator, the facility failed to ensure staff/employees follow its policy for medication preparation for two (2) of four (4) medication preparation observations (OBS#3 &4) facility failed to ensure expired items were discarded for one (1) of one (1) observations (Observation #1). Findings include: A review of policy, “Medication Preparation and Administration” on 1/8/26 at approximately 11:00 AM stated “Monitoring Expired Medications...Expired dates for all stored medications are to be monitored on a monthly basis, expired medications are to be discarded....Infection Control...Cleanse the diaphragm of a vial with alcohol prior to accessing the vial. If the vial is a multidose vial, cleanse the diaphragm with a new alcohol pad each time the vial is accessed with a needle using friction and 70% alcohol... Observation of the treatment area was conducted on 1/7/26, from approximately 9:45 A.M. to 12:45 P.M. OBS#1 was conducted on 1/7/26 at approximately 10:00 AM. the following expired items were observed in the treatment area medication supply refrigerator: One (1) Pneumococcal Vaccine 13 single dose vial (0.5 ml) expired 12/2024 and Six (6) Pneumovax-23 single dose vials (0.5 ml) expired 11/22/24. OBS#3 was conducted on 1/7/26 at approximately 12:30 PM. Medication preparation performed by PCT # 3. PCT #3 failed to utilize alcohol prep pad per policy and procedure and did not wipe the vial of Heparin with alcohol or other antiseptic prior to entering the vial for two (2) times with a needles syringe. OBS#4 was conducted on 1/7/26 at approximately 12:35 PM. Medication preparation performed by RN#1. RN#1 failed to utilize alcohol prep pad per policy and procedure and did not wipe the vial of Heparin with alcohol or other antiseptic prior to entering the vial for one (1) time with a needles syringe. An interview with the clinical manager and facility administrator on 1/9/25, at approximately 2:00 P.M. confirmed the above findings.”