Mercyhealth Kidney Care and Dialysis Center

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 29095 Based on record review and interview, facility staff failed to audit and monitor improvement activities related to infection control, chlorine and chloramine testing, plans of care and physical environment for 1 of 1 Plan of Correction (POC) submitted by the facility on 10/17/2023 related to deficiencies identified in the statement of deficiencies issued 10/3/2023. Findings Include: Hand Hygiene Plan of Correction (POC) Review of the facility’s POC for “Hand Hygiene” dated 10/17/2023 revealed, “To prevent recurrence, 1:1 observations will be conducted through visual monitoring of hand hygiene for staff and patients. Weekly audits will be conducted to ensure compliance. These audits will be completed weekly for 12 weeks or until 100% compliance is sustained...Instances of non-compliance will prompt immediate re-education. The audit progress will be discussed during the monthly QAPI (Quality Assessment Performance Improvement) meeting...” Per review the POC “Completion Date” is 11/17/2023. Per review of the facility’s POC audits, there was no documentation of Hand Hygiene audits conducted the week of 10/30/2023 through 11/04/2023. Review of the Hand Hygiene audits revealed the following: 10/24/2023: 2 of 3 audits had “No” documented under “Opportunity successful.” 10/25/2023: 2 of 4 audits had “No” documented under “Opportunity successful.” 10/26/2023: 4 of 4 audits had “No” documented under “Opportunity successful.” 11/10/2023: 3 of 4 audits had “No” documented under “Opportunity successful.” 11/13/2023: 2 of 3 audits had “No” documented under “Opportunity successful.” Personal Protective Equipment (PPE) Plan of Correction Review of the facility’s POC for wearing of PPE dated 10/17/2023 revealed, “...Weekly audits will be conducted to ensure compliance. Audits will be conducted through visual monitoring of wearing PPE. These audits will be completed weekly for 12 weeks or until 100% compliance is sustained...Instances of non-compliance will prompt immediate re-education. The audit progress will be discussed during the monthly QAPI (Quality Assessment Performance Improvement) meeting...” Per review the POC “Completion Date” is 11/17/2023. Review of 16 PPE audits from 10/24/2023 through 11/16/2023 revealed the following: 16 of 16 audits of staff wearing PPE revealed “No” was documented for “Gown Properly Worn and Secured”; 9 of 16 audits of staff revealed “No” was documented for “Appropriate Eye Protection.” Medication Preparation Plan of Correction Review of the facility’s POC for medication preparation dated 10/17/2023 revealed, “To prevent recurrence, 1:1 observations will be conducted through visual monitoring of medication preparation to ensure compliance. Weekly audits will be conducted to ensure compliance. Audits will be completed weekly for 12 weeks or until 100% compliance is sustained...Instances of non-compliance will prompt immediate re-education. The audit progress will be discussed during the monthly QAPI (Quality Assessment Performance Improvement) meeting...” Per review the POC “Completion Date” is 11/17/2023. Per review of the facility’s POC audits, there was no documentation of medication audits conducted the week of 10/23/2023 through 10/28/2023 and the week of 10/30/2023 through 11/04/2023; audits should be completed weekly as per POC. Equipment Disinfection Plan of Correction Review of the facility’s POC for equipment disinfection dated 10/17/2023 revealed, “To prevent recurrence, 1:1 observation will be conducted of all new staff during orientation to prove competency. For existing staff, weekly audits will be conducted to ensure compliance. These audits will be completed weekly for 12 weeks or until 100% compliance is sustained...Instances of non-compliance will prompt immediate re-education. The audit progress will be discussed during the monthly QAPI (Quality Assessment Performance Improvement) meeting...” Per review the POC “Completion Date” is 11/17/2023. Per review of the facility’s POC audits, there was no documentation of equipment disinfection audits conducted the week of 10/30/2023 through 11/04/2023; and 2 audits were completed from 11/06/2023 to 11/17/2023 (12 days). Aseptic Techniques for Intravenous Medications Plan of Correction Review of the facility’s POC for aseptic techniques for IV (intravenous) medications dated 10/17/ 2023 revealed, “To prevent recurrence, 1:1 observations will be conducted of all staff to prove competency. Weekly audits will be conducted to ensure compliance. These audits will be completed weekly for 12 weeks or until 100% compliance is sustained...Instances of non-compliance will prompt immediate re-education. The audit progress will be discussed during the monthly QAPI (Quality Assessment Performance Improvement) meeting...” Per review the POC “Completion Date” is 11/17/2023. Per review of the facility’s POC audits, there was no documentation of medication audits conducted the week of 10/23/2023 through 10/28/2023 and the week of 10/30/2023 through 11/04/2023; audits should be completed weekly as per POC. Central Venous Catheter (CVC) Plan of Correction Review of the facility’s POC for CVCs dated 10/17/2023 revealed, “To prevent recurrence, 1:1 observations will be conducted. Audits will be conducted through visual monitoring of catheter care to ensure compliance. Audits will be completed weekly for 12 weeks or until 100% compliance is sustained...Instances of non-compliance will prompt immediate re-education. The audit progress will be discussed during the monthly QAPI (Quality Assessment Performance Improvement) meeting...” Per review the POC “Completion Date” is 11/17/2023. Per review of the facility’s POC audits, there was no documentation of CVC audits conducted the week of 11/06/2023 through 11/11/2023. Review of CVC audits from 10/24/2023 to 11/17/2023 (25 days), revealed that there was 1 audit completed for “Catheter Exit Site Care.” Review of “Catheter Connection and Disconnection” audits done 10/26/2023, 11/3/2023, and 11/04/2023, revealed that 3 of 5 staff did not complete CVC care “aseptically” and there was no documentation of re-education. Chlorine/Chloramine Testing Plan of Correction Review of the facility’s POC for chlorine/chloramines testing revealed, “To prevent recurrence, 1:1 observation will be conducted to prove competency. Audits will be conducted through visual monitoring of water testing. Weekly audits will be conducted to ensure compliance. Instances of non-compliance will prompt immediate re-education. Audits will be completed weekly for 12 weeks or until 100% compliance and accuracy is sustained...The audit progress will be discussed during the monthly QAPI (Quality Assessment Performance Improvement) meeting...” Per review the POC “Completion Date” is 11/17/2023. Review of the facility’s POC audits, revealed there was 1 audit of staff performing chlorine checks from 10/24/2023 to 11/17/2023 (25 days). Patients in View during Treatment Plan of Correction Review of the facility’s POC for patients in view during treatment dated 10/17/2023 revealed, “To prevent recurrence, patients will be educated on the need to have visual access during dialysis. Audits will be conducted through visual monitoring of patients. The goal is for the dialysis staff to visualize the patient’s dialysis access at all time during dialysis. Instances of non-compliance will prompt immediate re-education. Although the goal is 100% compliance, the audit will be a daily monitoring activity without a timeline...The audit progress will be discussed during the monthly QAPI (Quality Assessment Performance Improvement) meeting...” Per review the POC “Completion Date” is 11/17/2023. Review of the facility’s POC audits, revealed there were no audits completed for ensuring patient’s access was visible during dialysis treatment, as per POC. Managing Blood Pressure Plan of Correction Review of the facility’s POC for managing blood pressure dated 10/17/2023 revealed, “7 complete patient charts will be reviewed weekly for 12 weeks or until 100% compliance is sustained...Instances on non-compliance will prompt immediate re-education. Chart review and audit progress will be part of the monthly QAPI (Quality Assessment Process Improvement) meeting discussion...” Review of the facility’s POC audits, revealed there were 3 chart audits completed for “November 2023 Chart Reviews” (17 days); not 7 charts weekly as per POC. Arteriovenous Fistula Graft (AVF/G) Access Site Plan of Correction Review of the facility’s POC for AVF/G care dated 10/17/2023 revealed, “...reviewed staff education and competencies related to...antisepsis prior to cannulation. Education included antiseptic use, scrub time, and dry time per manufacturer guidelines....Audits will be conducted through visual monitoring to ensure compliance...The audits will be completed weekly for 12 weeks or until 100% compliance is sustained...Instances of non-compliance will prompt immediate re-education. The audit progress will be discussed during the monthly QAPI (Quality Assessment Performance Improvement) meeting...” Per review the POC “Completion Date” is 11/17/2023. Per review of the facility’s POC audits, there was no documentation of AVF/G audits conducted the week of 10/23/2023 through 10/28/2023. Review of AVF/G audits from 10/24/2023 to 11/17/2023 (25 days), revealed that there were only 5 audits completed. Review of AVF/G audits done 11/02/2023, 11/03/2023, and 11/11/2023 revealed that 4 of 5 staff audited, did not complete AVF/G care “aseptically” and there was no documentation of re-education. Review of the Dialysis QAPI meeting minutes dated 10/30/2023 revealed there was no documentation of staff tracking, trending, and discussing audit results to monitor progress to goal as per POC. Per review of the above audits there was no documentation of “prompt immediate re-education” completed as per POC when audits indicated a need for re-eduation.. Per interview with Director A on 11/17/2023 beginning at 3:00 PM, the facility staff are not currently tracking and trending the audits and the percent compliance and progress to goal; per Director A audits have not been discussed in QAPI yet. Director A confirmed that staff are not documenting evidence of re-education. Director A confirmed that he/she provided all the completed audits.”