HospitalInspections.org

Based on an interview and review of facility documents on 7/17/20, it has been determined that this facility failed to include the review of drugs and biologicals in the Utilization Review Plan.

Findings include:

1. Upon review of facility document, "Utilization Review Plan 2020," the plan failed to include review of the necessity of drugs and biologicals.

2. During an interview at 12:15 PM, Staff #7 confirmed that drugs and biologicals were not reviewed by the Utilization Review Committee.

Based on document review and administrative staff interview on 7/17/20, the facility failed to provide evidence that the Utilization Review Committee reviewed all professional services to determine the medical necessity.

Findings Include:

1. Upon review of the Utilization Review Committee Meeting Minutes dated 1/22/19, 2/26/19, 10/22/19, 11/26/19 and 2/26/20, there was no evidence that Professional Services were reviewed by the Utilization Review Committee.

2. During an interview at 11:50 AM, Staff #7 confirmed the above findings.

A. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure implementation of policies and procedures addressing the management of respiratory care equipment during the Coronavirus Disease 2019 (COVID-19) pandemic.

Findings include:

Reference: Facility policy titled, "Management of Respiratory Care Equipment" states, " ... Procedure: A. Procedure for Discontinuation and Storage Between Patients: ... 2. Remove all re-usable components including temperature probes and expiratory cassettes; wipe with an approved disinfectant wipe and place non-disposable equipment that will be sent to Central Sterile Department in a sealed plastic bag identifying the equipment as "contaminated"; return such equipment to the designated dirty equipment storage area."

1. During an observation in the soiled respiratory equipment room at 11:15 AM on 7/16/2020, one (1) ventilator circuit temperature probe and one (1) expiratory cassette were found on top of a gray bin.

a. Upon interview, Staff #8 stated that those items need to get reprocessed by the central sterile department.

b. The equipment was not placed in a sealed plastic bag identifying the equipment as "contaminated."

2. The above finding was confirmed with Staff #10.

B. Based on observation, staff interview, and document review, it was determined that the facility failed to ensure implementation of protocols for COVID-19 Pandemic N-95 Respirator Reprocessing using Ultraviolet germicidal irradiation (UVGI).

Findings include:

Reference: Facility document titled, "COVID-19 Pandemic N-95 Respirator Reprocessing using UVGI" states, " ... Background: RWJBH (Robert Wood Johnson Barnabas Health) will use this decontamination process for limited reuse of N95 masks during this time of emergent surge situation to provide a safe and effective means for decontaminating and reprocessing of N95 respirators. ... HEALTHCARE WORKER: ... 2. Document CLEARLY with a permanent marker on front side of the N95 respirator: First initial; Last name; Assigned unit (if float, write "float"); Date of first use ... 5. Document on Unit Log Sheet: First initial; Last name; Unit; Date sent for reprocessing. 6. Once N95 respirator is returned from reprocessing, reuse N95 and repeat process up to 3 times total. ... UV WORKER: ... 5. Place tally mark ("I") on bottom of mask to record the decontamination process/cycle ..."

1. On 7/16/2020 at 1:30 PM, a decontaminated and reprocessed N-95 respirator was inspected, and the following was identified:

a. The healthcare worker's date of first use and his/her assigned unit was not documented with a permanent marker on front side of the N-95 respirator.

b. There was no tally mark on the bottom of the N-95 respirator to record the decontamination process or cycle.

2. Upon request, Staff #12 was not able to provide evidence of the unit log sheet which documents the healthcare worker's name and the date sent for reprocessing.

3. Upon request, Staff #12 was not able to identify the date this N-95 respirator was sent for reprocessing.

4. Upon request, Staff #12 was not able to provide evidence that this N-95 respirator was reprocessed up to 3 times total.

5. The above findings were confirmed with Staff #10.