032565 Desert Dialysis Center South Tucson (Dci)

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 52534 Based on document review, observation, and interview, it was determined that the facility failed to ensure staff appropriately disinfected (1) of (4) patients (Patient #10) vascular access prior to cannulation which has the potential risk of blood stream and vascular access infection if the site is not disinfected properly. Findings include: Facility policy titled “Cannulation and Initiation of AVF/AVG on BBRAUN” requires “Disinfectant ... Isopropyl alcohol ... Contact Time ... 30 seconds per site ...”. Observation on 05/12/2025 revealed Employee #13 cleaning Patient #10 ’ s vascular access for cannulation. Employee #13 disinfected the arterial site using isopropyl alcohol for 30 seconds, and then disinfecting the venous site with isopropyl alcohol for 26 seconds. Employee #3 confirmed on 05/12/2025 that Employee #13 did not disinfect the access site according to facility policy.”

“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: 52534 Based on document review, observation, and interview, it was determined that the facility failed to ensure: 1. Staff did not wear artificial nails; and 2. Staff changed gloves between dialysis machines. These deficient practices can increase the risk of cross contamination if infection control precautions are not maintained. Findings include: 1. Facility policy titled “Dress Code” requires “ ... no acrylic finger nails, or extenders, are allowed for employees with direct patient contact or contact with dialysis equipment. Natural nail tips should be kept to ¼ inch in length ....” Observation on 05/12/2025 revealed Employee #16 on the treatment floor providing patient care with long, black, artificial nails. Further observation on 05/12/2025 revealed Employee #12 with long, pink nails, on the treatment floor providing patient care. Observation on 05/13/2025 revealed Employee #4 on the treatment floor and in the water room with artificial, blue, sparkly nails. Employee #3 confirmed on 05/12/2025 that employees should not have artificial nails. Employee #1 confirmed on 05/13/2025 that Employee #4 had artificial nails that are not allowed according to facility policy, and that while Employee #12 ’ s nails are not artificial, they are not within the allowable length according to facility policy. 2. Facility policy titled “Universal Precautions//Infection Control” requires “... Gloves will be changed for the following: ... After touching one patient or their machine and before arriving to care for another patient or touch another patient ’ s machine ....” Observation on 05/12/2025 revealed Employee #13 grabbing a clean glove and placing it over their index finger and touching the machine at Station 3. Employee #13 then moved to Station 4, and with the same glove, covering the same finger, and touched the machine. Employee #13 did not change the glove or perform hand hygiene in between stations. Employee #3 confirmed on 05/12/2025 that Employee #13 did not perform appropriate hand hygiene. Employee #2 confirmed on 05/13/2025 that Employee #13 did not appropriately wear gloves according to facility policy.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 52534 Based on document review, observation, and interview, it was determined that the facility failed to ensure: 1. Bleach and vinegar were not stored next to each other, which has the potential risk of harmful vapors and chemical reactions that may harm patients and staff; and 2. Expired lab supplies were discarded, which poses the potential risk of altered lab results due to expired materials. Findings include: 1. The Centers for Disease Control and Prevention (CDC) document titled “Health Hazards and Protective Measures” revealed “... Toxic gas chlorine can be released if you mix sodium hypochlorite (bleaching solutions) and acidic cleaning agents ...” Facility policy regarding the storage of materials, specifically bleach and vinegar, was requested and unable to be provided. Observation on 05/13/2025 revealed a storage shelf in the storage room containing two (2) one-gallon containers of bleach, one (1) one-gallon container of vinegar, and one large plastic tub labeled “Citric Acid 50%” stored on the same shelf. Employees #4 and 22 confirmed on 05/13/2025 that bleach and vinegar should not be stored next to each other. Employee #1 confirmed on 05/13/2025 that the facility does not have a policy regarding the storage of bleach and other chemicals. 2. Facility policy titled “Expiration Dates of Medical Supplies” requires “... Inventory expiration dates will be checked on a monthly basis during the monthly inventory and ordering process. ... Proper disposal of expired supplies will be carried out by the Inventory Manager ....” Observation on 05/13/2025 revealed nine (9) red BD Vaccutainer Serum lab tubes with expiration dates of 2025-03-31 in the laboratory testing room. Further observation on 05/13/2025 revealed two (2) flats of 100 yellow BD Vaccutainer SST lab tubes with expiration dates of 2025-04-30 in the laboratory testing room. Employee #1 confirmed on 05/13/2025 that the expired supplies were not discarded according to facility policy.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 52534 Based on document review and interview, it was determined that the facility failed to ensure staff followed the hemodialysis treatment order for prescribed Blood Flow Rate (BFR) for (1) of (5) patients (Patient #3) which has the potential risk of inadequate dialysis, decreased clearances, and hospitalizations. Findings include: Facility policy titled “Staff Reporting Parameters - ESRD Patients” requires “... To give reporting parameters to floor staff to report to RN and parameters for RN to report to MD/NP ...During Treatment ... Unable to maintain ordered BFR ...” Patient #3 ’ s medical record review on 05/12/2025 revealed a prescribed BFR of 350 mL/min. On 04/29/2025 the BFR was as follows: 10:51-13:54 BFR 300 mL/min No rationale or reporting was documented for the changes in BFR throughout treatment. On 04/22/2025 the BFR was as follows: 11:23-13:35 BFR 300 mL/min No rationale or reporting was documented for the changes in BFR throughout treatment. On 04/19/2025 the BFR was as follows: 10:44-13:48 BFR 300 mL/min No rationale or reporting was documented for the changes in BFR throughout treatment. On 04/15/2025 the BFR was as follows: 10:38-11:10 BFR 200 mL/min No rationale or reporting was documented for the changes in BFR throughout treatment. Employee #1 confirmed on 05/12/2025 that there was no documentation for the changes in BFR for Patient #3 ’ s treatments, staff were not appropriately documenting according to facility policy.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 52534 Based on document review and interview, it was determined that the facility failed to ensure (1) of (4) patient (Patient #7) discharge summaries were completed. Thisdeficient practice poses the potential risk of a disruption of continuity of care if patient medical records are incomplete. Findings include: Facility policy titled “Discharge Summary” requires “... Physician will complete the Discharge Summary second on the third page; making note of the reason the patient left the clinic, any special events and/or cause of death. Physician will sign and date the Discharge Summary ... This will be done for any patient leaving the clinic; death, withdrawal, transplant, or transfer to any clinic ....” Patient #7 ’ s medical record review on 05/12/2025 revealed no discharge summary was completed. Employee #1 confirmed on 05/12/2025 that no discharge summary was completed for Patient #7.”

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 49430 Based on a review of facility policy and procedure, observation, and staff interview, the Department determined that the facility failed to ensure that staff aseptically cleaned (2) of (2) patients’ vascular access prior to cannulation (Patients #10, #11). Failure to adhere to infection control procedures prior to cannulation poses an increased risk of bloodstream and vascular access infection as bacteria at cannulation sites may not be reduced; and Findings include: The policy/procedure titled AVF/AVG Skin Antiseptic states, “ ... Disinfectant: Isopropyl alcohol (70%): Contact time 30 seconds ... Drying time none ... Apply in an inner-to-outer circular motion.” Observation on May 1, 2024 revealed Employee #14, disinfecting patient #11’s vascular access in preparation for cannulation. Employee #14, used an alcohol pad to cleanse the arterial cannulation site for 25 seconds and immediately cannulated the access with the fistula needle. Employee #14 then used a second alcohol pad to cleanse the venous cannulation site for 26 seconds and immediately cannulated the access with the fistula needle. Observation on May 1, 2024, revealed Employee #14, disinfecting patient #10’s vascular access in preparation for cannulation. Employee #14, used an alcohol pad to cleanse the arterial cannulation site for 20 seconds and immediately cannulated the access with the fistula needle. Employee #14 then used a second alcohol pad to cleanse the venous cannulation site for 20 seconds and immediately cannulated the access with the fistula needle. Employee #2, verified in an interview conducted on May 1, 2024, that staff did not follow appropriate policy and procedures for cannulation of an AV fistula.”

“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: 49430 Based on document review, observation, and staff interview, it was determined that the facility failed to ensure staff aseptically performed CVC (central venous catheter) catheter care prior to termination of treatment. Failure to perform CVC catheter care correctly poses a potential risk for increased CVC and/or bloodstream infection and adverse outcomes for dialysis patients. Findings include: Facility policy titled, “Initiation of Hemodialysis with CVC on B-Braun” states that, “ ... Disinfectant: Isopropyl alcohol (70%): Contact time 30 seconds per limb ... Drying time none ... Apply in an inner-to-outer circular motion.” Observation on May 1, 2024 revealed Employee #15, disinfecting patient #12’s CVC access in preparation for dressing the CVC post treatment. Employee #15, used an alcohol pad to cleanse the arterial limb of the CVC for 10 seconds and placed a clean CVC cap on the arterial limb of the CVC. Employee #15 then proceeded to start the care for the venous limb of the CVC. Employee #15 scrubbed the venous hub for 7 seconds and placed the CVC cap on the venous limb of the CVC. Employee #2, verified in an interview conducted on May 1, 2024, that staff did not follow appropriate policy and procedures for the disinfection of a CVC catheter at the termination of treatment.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 49430 Based on review of facility policy, medical records, and interview with staff it was determined that the facility failed to ensure: 1. registered nurse notify the patient’s nephrologist when the patient’s weight deviated one (1) or more kilograms from the estimated dry weight (EDW). 2. staff administer clonidine based on physician’s standing orders. The lack of reporting EDW not achieved and neglecting to assess and respond to hypertension increases the risk for inadequate treatments, fluid overload, dehydration, hospitalizations, stroke and death. The lack of administration of a prescribed antihypertensive medication increases the risk for inadequate treatment, hospitalization, stroke, disruption of blood prefusion to vital organs, and death. Findings include: The facility policy titled “Staff Reporting Parameters” states that “Purpose: to give reporting parameters to floor staff to report to RN and parameters for RN to report to MD/NP ... Post-Treatment Assessment: Post-treatment weight {+/- 1.0 kg from EDW} Nurse reports to Physician or Designee: Yes, may fax information to patient’s Nephrologist office. “ A. Patient #6 medical records reveal leaving (1) of (6) treatments with a weight difference greater than 1 KG over the estimated dry weight without any documentation of a physician being notified. Patient #7 medical records reveal leaving (1) of (6) treatments with a weight difference greater than 1 KG over the estimated dry weight without any documentation of a physician being notified. Patient #8 medical records reveal leaving (3) of (4) treatments with a weight difference greater than 1 KG over the estimated dry weight without any documentation of a physician being notified. Patient #9 medical records reveal leaving (2) of (6) treatments with a weight difference greater than 1 KG over the estimated dry weight without any documentation of a physician being notified. B. 1. Patient #8 treatment sheet dated 04/17/24, reveals continuous hypertension prior to treatment, during, and post treatment. Treatment dated 04/06/2024 initial at with a BP of 199/102, and continued until 1432 with a BP of 186/101. The BP readings for the treatment were as followed: 1057 186/98 1123 187/101 1253 187/98 1255 189/93 1329 191/86 1356 195/101 1430 194/109 Patient #8 did have an active standing order for Clonidine, no doses were provided for the patient during this hypertensive period. There was no documentation of notification to the MD/designee regrading hypertensive crisis. Patient #8 treatment sheet dated 04/19/24, reveals continuous hypertension prior to treatment, during treatment. Initial BP for the patient was 196/87, with additional Systolic Blood Pressures (SBP) greater than 180 during treatment. There was no documentation of notifying the MD/extender for instances of hypertension. Patient #8 did have an active standing order for Clonidine, no doses were provided for the patient during this hypertensive period. Patient #8 treatment sheet dated 04/22/24, reveals continuous hypertension prior to treatment, during treatment. Initial BP for the patient was 181/100, with additional Systolic Blood Pressures (SBP) greater than 180 during treatment. There was no documentation of notifying the MD/extender for instances of hypertension. Patient #8 did have an active standing order for Clonidine, no doses were provided for the patient during this hypertensive period. Patient #8 treatment sheet dated 04/26/24, reveals continuous hypertension prior to treatment, during treatment. Initial BP for the patient was 169/89, with additional Systolic Blood Pressures (SBP) greater than 180 during treatment. There was no documentation of notifying the MD/extender for instances of hypertension. Patient #8 did have an active standing order for Clonidine, no doses were provided for the patient during this hypertensive period. 2. Patient #9 treatment sheet dated 04/29/24, reveals continuous hypertension during, and post treatment. Treatment dated 04/06/2024 initial at with a BP of 168/85, and a post-treatment BP of 181/84. The BP readings for the treatment were as followed: 1055 203/100 1134 200/100 1157 217/101 1235 209/97 1306 209/101 1330 209/98 Patient #9 did have an active standing order for Clonidine, no doses were provided for the patient during this hypertensive period. There was no documentation of notification to the MD/designee regrading hypertensive crisis. Patient #8 treatment sheet dated 04/26/24, reveals continuous hypertension during treatment. Documentation reveals Systolic Blood Pressures (SBP) greater than 180 during treatment. There was no documentation of notifying the MD/extender for instances of hypertension. Patient #8 did have an active standing order for Clonidine, no doses were provided for the patient during this hypertensive period. Patient #8 treatment sheet dated 04/22/24, reveals continuous hypertension during treatment. Documentation reveals Systolic Blood Pressures (SBP) greater than 180 during treatment. There was no documentation of notifying the MD/extender for instances of hypertension. Patient #8 treatment sheet dated 04/19/24, reveals continuous hypertension during treatment. Documentation reveals Systolic Blood Pressures (SBP) greater than 180 during treatment. There was no documentation of notifying the MD/extender for instances of hypertension. Patient #8 did have an active standing order for Clonidine, no doses were provided for the patient during this hypertensive period. In an interview on May 1, 2024 Employee #13 and Employee #2 confirmed the BP was outside of parameters set in the policy titled “Staff Reporting Parameters” and that no action was taken by on duty nursing staff during the hypertensive crisis. Employee #2 and Employee #13 confirmed instances of no documentation of notification to the MD/extender regrading hypertensive crisis. Additionally, Employee #2 and Employee #13 were unable to produce documentation that included the names, medical record number, or other identifiable information for patients #6, #7, #8, #9, confirming that notification was made to the nephrologist when EDW was not reached.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 49430 Based on a review of facility policy, medical records, and staff interviews, it was determined that the facility failed to require that 1. Clinical staff to notify the nurse and the nurse provide a documented intervention for 2 out of 4 patients reviewed when the patient’s blood pressure (BP) and/or heart rate (HR) was out of range per the facility policy. This poses the potential risk of cardiovascular compromise, hospitalization and the risk that the necessary interventions are not being performed. Findings include: 1.The facility policy titled “Staff Reporting Parameters” states that “Purpose: to give reporting parameters to floor staff to report to RN and parameters for RN to report to MD/NP ... During Treatment ... Staff Reports: {+/- 20 mmHg change from previous BP check} and { Two consecutive measurements of SBP > 190 and/or DBP > 120} {SBP > 220 or DBP >130}. RN Reports: { Two consecutive measurements of SBP > 190 and/or DBP > 120} (RN) Gives PRN Medication, make MD/NP Aware if no response or patient refusal to take PRN medication. RN Reports: {SBP > 220 or DBP >130} .... Staff reports: Heart Rate: {<55 or >120}. Nurse Reports: {<55 or >120} *Some MDs allow different ranges, please check patient Misc. Orders.” Patient #7 April 29, 2024 A HR less than the parameter set forth within the facility policy was not reported to the RN on duty. Two or more consecutive SBP >180 mmHg were not reported to the RN on duty. April 22, 2024 Two or more consecutive SBP >180 mmHg were not reported to the RN on duty. April 17, 2024 A HR less than the parameter set forth within the facility policy was not reported to the RN on duty. Patient #8 April 22, 2024 Two or more consecutive SBP >180 mmHg were not reported to the RN on duty. April 17, 2024 Two or more consecutive SBP >180 mmHg were not reported to the RN on duty. Employee #13 and Employee #2 confirmed, on May 1, 2024, that this practice did not follow facility policy.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 50568 Based on a review of the staff job description and interview, it was determined that the facility failed to ensure that Licensed Social Workers were/are available to provide counseling services as required under Conditions of Participation by CMS. This lack of resources increases the risk of hospital admissions, hospital readmissions, and death and decreases the risk for adherence to dialysis prescription and treatment plan compliance. Findings include: Document titled “Job Description “ states that, “PRINCIPAL DUTIES AND RESPONSIBILITIES ... Patient Assessment/Care Planning/Counseling” and further states “Provides supportive counseling services to patients ...”. A review of employee chart for employee #12 revealed that the employee is not licensed by the state. Further review of patient charts reveals that employee #12 has been providing counseling to patients listed within the facility census. Employees #1, #2, #4 confirmed in an interview on May 1, 2024, that employee #14 is not licensed by the of Arizona state, and does not have a Licensed Social Worker providing oversight of them providing services.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 50568 Based on review of facility policies and procedures, medical records, and staff interview, it was determined that the facility failed to require a Social Worker (SW) assigned to the patient’s Interdisciplinary team (IDT) to sign (2) of (4) patient’s Plan of Care (POC). The lack of completing POC’s has the potential risk of failure of the IDT to develop an integrated treatment plan and provide an opportunity for the team to develop, coordinate and implement an effective, individualized plan of care. Findings include: On May 1, 2024 review of patient medical records (Patients’ #8, #9) revealed the following: Patient # 9’s Plan of Care (POC) meeting date 06/30/2023, was missing the signature and date/time of a Social Worker (SW) assigned to the patient’s Interdisciplinary team (IDT). Patient # 8’s Plan of Care (POC) meeting date 07/24/2023, was missing the signature and date/time of a Social Worker (SW) assigned to the patient’s Interdisciplinary team (IDT). During staff interview on May 1, 2024, Employee #1 and Employee #12 both confirmed that there was no Social Worker (SW) employed nor present for the facility during this time period. Employee #1 confirmed no signature was present on the Plans of Care (POC) due to no SW being employed by the facility at this time.”