Usrc Avondale

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 52534 Based on document review, observation, and interview, it was determined that the facility failed to follow state and local rules for: 1. Ensuring the patient ’ s nephrologist reviewed and signed the history and physical (H&P) completed by another provider for the admission of 1 of 3 patients (Patient #4) which poses the potential risk of inadequate dialysis if a patient ’ s condition is not evaluated by their nephrologist.; and 2. Compliance with requirements for medication services provided under the facility’s state license. Failure to implement policies and procedures for medication chain of custody and the facility to take accountability when pharmaceuticals change hands during shipment from the facility’s pharmacy to the dialysis clinic poses a risk to patient safety which includes but is not limited to tampering, contamination, diversion of medication, and/or inability to track cases of adverse events involving medication not prescribed to an individual. Findings include: 1. The Arizona Administrative Code (A.A.C.) requires “...R9-10-1018. Dialysis Services ....E. An administrator of an outpatient treatment center that is authorized to provide dialysis services shall ensure that for a patient receiving dialysis services: ...3. If the patient ’ s medical history and physical examination required in subsection (E)(2) is not performed by the patient ’ s nephrologist, the patient ’ s nephrologist, within 30 calendar days after the date of the medical history and physical examination: a. Reviews and authenticates the patient ’ s medical history and physical examination, documents concurrence with the medical history and physical examination, and includes information specific to nephrology ....” The facility policy titled “Medical Records” requires”...Arizona Requirements: Attending physician must complete the H&P within 48 hours of admission if not completed by a physician within 30 days prior to admission. If the H&P is completed by a physician other than the patient ’ s attending physician, the H&P must be reviewed and authenticated (agree with ESRD diagnosis and treatment plan) as evidenced by documentation of concurrence no later than 30 days from date of the H&P ....” Patient #4 Patient #4 ’ s medical record review on 07/24/2025 revealed an admission date of 03/17/2025. The medical record also revealed a Comprehensive Encounter dated 02/10/2025 performed by a physician other than the patient ’ s attending physician. Patient #4 ’ s attending physician signed the document on 03/26/2025, 44 days after the Comprehensive Encounter was performed, and 9 days after Patient #4 ’ s admission. Employees #1, 2, and 3 confirmed on 07/24/2025 that the document being used for Patient #4 ’ s admission history and physical was not completed within 30 days prior to the admission date, and was signed by the attending physician more than 30 days from the date of the history and physical. 2. The Department licensing file revealed that the facility is licensed and approved to provide Medication Services in addition to Dialysis, Clinical Laboratory, and Physical Health Services. Arizona Administrative Code requires: “ ...R9-10-1010. Medication Services ...E. When medication is stored at an outpatient treatment center, an administrator shall ensure that: ...3. Policies and procedures are established, documented, and implemented for: ...a. Receiving, storing, inventorying, tracking, dispensing, and discarding medication including expired medication ....” The facility policy titled “Guidelines for Cardinal health Specialty Pharmacy” requires “...Medications Delivered to Facility:...Medications will be delivered via a contracted courier to facility; facility designee will accept and sign for delivery of medications ....Upon receipt, RN will place the unopened delivered packages in the designated secured/locked area and document receipt on C-FORMS-0810 Cardinal Medication Log ....” Observation on 07/24/2025 revealed two (2) medication packages being stored in the designated area for Patient #11. Review of the log titled “Cardinal Medication Log” on 07/24/2025 revealed no documentation of the two (2) medication packages for Patient #11. Employees #1, 3, and 6 confirmed on 07/24/2025 that the medications for Patient #11 were not logged or tracked according to the facility policy”

“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 #6) vascular access prior to cannulation which has the potential risk of blood stream infection and vascular access infection if the site is not disinfected properly. Findings include: The facility policy titled “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation” requires “...Cleansing Agent ...Alcohol Prep Pad ...Cleaning Process and Contact Time ...Utilize a rubbing motion for at least 30 seconds ....” Observation on 07/23/2025 revealed Employee #15 cleaning Patient #6 ’ s vascular access for cannulation. Employee #15 disinfected the arterial site using an alcohol prep pad for 24 seconds, and then disinfected the venous site with an alcohol prep pad for 18 seconds. Employees #1 and 3 confirmed on 07/23/2025 that Employee 15 did not disinfect Patient #6 ’ s vascular access according to facility policy.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [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-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. 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 the dialysis station was fully disinfected prior to the next patient ’ s treatment, which poses the potential risk of cross contamination if the station is not fully disinfected prior to the new patient ’ s treatment. Findings include: The facility policy titled “Disinfection and Cleaning of Dialysis Machine Equipment” requires “...Clean all external surfaces of the dialysis machine to include top, sides, front and back, BP cuffs and basket; dialysate connectors and lines; hand sanitizer and holder; IV pole, items hanging on pole, attached computer monitors and keyboard/mouse ....” Observations on 07/22/2025 revealed the following: Employee # 9 did not disinfect the IV pole or the stethoscope and emergency take off bag hanging on the IV pole at station 19 Employee #10 did not disinfect the IV pole or the emergency take off bag hanging on the IV pole at Station 10. Employee #9 did not disinfect the IV pole or the emergency take off bag hanging on the IV pole at Station 4. Observations on 07/23/2025 revealed the following: Employee #15 did not disinfect the emergency take off bag hanging on the IV pole at Station 6. Employee #10 did not disinfect the emergency take off bag hanging on the IV pole at Station 4. Employee #16 did not disinfect the emergency take off bag hanging on the IV pole at Station 17. Employee #10 did not disinfect the emergency take off bag hanging on the IV pole at Station 2. Employee #12 did not disinfect the emergency take off bag hanging on the IV pole at Station 15. Employee #9 did not disinfect the emergency take off bag hanging on the IV pole at Station 9. Employee #10 did not disinfect the emergency take off bag hanging on the IV pole at Station 10. Employees #1 and 3 confirmed Employees #9, 10, 12, 15, and 16 did not disinfect the dialysis station according to facility policy.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. 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 performed equipment maintenance as required which has the potential for patient injury or harm if equipment is not maintained and normal operation is not verified. Findings include: The facility policy titled “Oxygen Concentrator Filter Cleaning Log” requires “...air intake gross particle filter will be cleaned weekly ...” Review of the Oxygen Concentrator Filter Cleaning Log dated 2024 on 07/23/2025 revealed (9) of (9) of the facility ’ s oxygen concentrators did not have filters cleaned for the following dates: 09/01/2024 through 09/27/2024 09/29/2024 through 10/11/2024 10/19/2025 through 11/01/2024 Review of the Oxygen Concentrator Filter Cleaning Log dated 2025 on 07/23/2025 revealed (8) of (8) of the facility ’ s oxygen concentrators did not have filters cleaned for the following dates: 03/30/2025 through 04/11/2025 04/13/2025 through 05/03/2025 05/18/2025 through 05/30/2025 Employees #1, 3, and 17 confirmed on 07/23/2025 that the oxygen concentrator filters were not cleaned weekly according to facility policy.”

“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: 45999 Based on a review of policy, physicians’ orders, and medical records, the Department determined that the facility failed to ensure staff followed physicians’ orders for hemodialysis treatments. Failure to follow physicians’ orders poses a risk that patients will not receive adequate care and dialysis treatment. Findings include: The facility policy titled “Initiation of Dialysis Treatment” revealed: “...Prior to walking away from patient’s dialysis machine verify that all prescribed orders are followed ...If unable to follow any part of the patient’s prescription after troubleshooting, notify the charge nurse and document the notification .... “ Patient #10: On July 12, 2024, the patient’s Blood Flow Rate (BFR) order was documented as 400ml/min. The BFR at 12:01 on the treatment sheet is 300ml/min, then at 13:00 the BFR is set to 400ml/min. No note that the provider was aware of the reason for the change. On July 22, 2024, the patient’s Blood Flow Rate (BFR) order was documented as 400ml/min. The BFR at 11:51 on the treatment sheet is 400ml/min, then at 13:20 the BFR is set to 350ml/min. No note that the provider was aware of the reason for the change. Patient #11 On July 12, 2024, the patient’s Blood Flow Rate (BFR) order was documented as 450ml/min. The BFR on the treatment sheet is 400ml/min. No note that the provider was aware of the reason for the change. On July 18, 2024, the patient’s Blood Flow Rate (BFR) order was documented as 450ml/min. The BFR at 06:10 on the treatment sheet is 400ml/min, then at 06:20 the BFR is set to 450ml/min. then changed again at 08:20 to 350ml/min. No note that the provider was aware of the reason for the change. Employee #1 confirmed on July 25, 2024, that the physician’s orders were not followed per facility policy.”

“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: 45999 Based on a review of facility policy, medical records, and staff interviews, the department determined that the facility failed to require clinical staff to notify the nurse and provide a documented intervention for 4 out of 5 patients reviewed when the patient’s blood pressure (BP) and/or heart rate (HR) were out of range per the facility policy, which poses the potential risk of cardiovascular compromise and hospitalization. Findings include: The facility policy titled “Intradialytic Monitoring of Patient” revealed that “ ...Direct patient care staff will monitor the following parameters during each dialysis treatment...Report to the CN (Charge Nurse) if outside the standing orders and/or reportable parameters, refer to the C-FORMS-0081 Reportable Parameters to the CN ... Systolic blood pressure greater than 180 mm/Hg, Diastolic blood pressure greater than 110 mm/Hg, Blood Pressure less than or equal to 90 mm/Hg systolic ...Blood pressure less than 50 mm/hg diastolic...Heart rates that have dropped below 50 or risen above 100...Report to the nurse any significant findings....” “...Treatment Sheets....” revealed: Patient # 9 April 25, 2024, revealed: 10:02 BP 101/46 11:42 BP 100/48 11:57 BP 96/45 April 27, 2024, revealed: 13:41 HR 101 14:01 HR 103 14:21 HR 106 14:24 HR 102 There was no documentation of the RN being made aware of vital signs out of range. Patient #10 July 13, 2024, revealed: 13:41 BP 130/115 July 17, 2024 14:21 BP 183/101 15:21 BP 188/100 July 15, 2024, revealed: 12:07 BP 203/104 12:09 BP 202/101 13:00 BP 200/102 13:45 BP 181/65 There was no documentation of the RN being made aware of vital signs out of range. Patient # 11 July 12, 2024, revealed: 19:26 BP 57/36 There was no documentation of the RN being made aware of vital signs out of range. Patient #12 July 11, 2024, revealed: 11:42 BP 188/90 July 13, 2024, revealed: 09:22 HR 110 09:42 HR 111 10:02 HR 106 10:21 HR 105 10:41 HR 106 11:01 HR 107 11:41 HR 105 12:01 HR 107 12:21 HR 105 12:21 HR 109 There was no documentation of the RN being made aware of vital signs out of range. Employee #1 confirmed during an interview on July 25, 2024, that no documentation of RN notification and/or intervention for out of range vitals was provided as required per facility policy.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 50568 Based on a review of facility policy, medical records, and staff interviews, it was determined that facility failed to ensure that Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) were conducted in every thirty days for patients designated with a health status of unstable. The failure to identify, assess and update the CIPA in a timely manner can pose a serious risk to the patient, and may lead to an increase in hospitalization, readmissions, and death. Findings include: Facility policy titled “ Medical Records” which states, “ ...Plan of Care: b.Unstable/AKI patients require monthly plans of care ...” Review of Patient #7 Chart revealed: An Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) dated 01/11/2024 designating the patient status as unstable. The next Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) was dated 02/15/2024,deeming the patient unstable, with the time interval being 35 days. An Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) dated 04/04/2024 designating the patient status as unstable. The next Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) was dated 05/16/2024, deemed the patient status as stable, with the time interval being 42 days. Review of Patient #9 Chart revealed: An Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) dated 04/12/2024 designating the patient status as unstable. The next Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) was dated 05/20/2024, deemed the patient status as stable, with the time interval being 38 days. In an interview conducted on July 25, 2024, Employee #1 confirmed that CIPAs were not being performed in a timely manner. Employee #1 that the matter of completing CIPA were the subject of a recent internal audit, and stated that it is to be addressed during Quality Assurance and Performance Improvement (QAPI) monthly meeting.”

“POC-EFFECTIVE NUTRITIONAL STATUS CFR(s): 494.90(a)(2) The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient’s albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate. This Standard is not met as evidenced by: 50568 Based on review of facility documents, observations and staff interviews, it was determined that the facility failed to ensure that the interdisciplinary team provide the necessary care and counseling to achieve and sustain an effective nutritional status. The lack of consistently addressing established target goals for a patient’s albumin, with additional markers of nutritional status including potassium, level with an individualized plan of care can lead to poor patient outcomes as it relates to their comprehensive health, increased hospitalizations, and interruptions of the continuum of care for the patient. Findings include: Facility policy titled “ Medical Records” which states, “ ...will contain complete and accurate documentation ... will reflect the condition of the patient from the time of the first dialysis treatment until the patient is discharged ...Progress Notes: ... either a single discipline or integrated interdisciplinary progress notes may be utilized ...” 1. Review of Patient #11’s chart Facility provided document titled, “CIPA” dated 05/19/2024 that reads, “ ... Plan of Care ... Nutritional Status goal: >/= 4.0 ... Current Albumin 3.9 05/07/2024 ... POC Action Comments: Labs within acceptable range. Continue to monitor and address as needed ... Goal Met: Yes ...” 2. Review Patient #12 chart Facility provided document titled, “CIPA” dated 06/7/2024 that reads, “ ... Plan of Care ... Nutritional Status goal: >/= 4.0 ... Current Albumin 3.9 05/07/2024 ... POC Action Comments: Labs within acceptable range. Continue to monitor and address as needed ... Goal Met: Yes ...” In contrast, a facility provided document titled “CIPA” dated 07/02/2024 that reads, “ ... Plan of Care ... Nutritional Status goal: >/= 4.0 ... Current Albumin 3.9 06/03/2024 ... POC Action Comments: Discuss appropriate sources of protein with patient and/or caregivers.. needed ... Goal Met: No ...” Facility provided document titled, “CIPA” dated 06/7/2024 that reads, “ ...06/03/2024.. Potassium 5.9 ... Potassium Assessment ... Goal: 3.5 - 5.5 ... Goal Met: Yes ... Actions: Labs within acceptable range. Continue to monitor and address as needed. Comments: prescribed lokelma ...” In an interview conducted on July 25, 2024 with Employee #1 confirmed the findings within patient #11 and patient #12 charts. Employee #1 confirmed that the Registered Dietician monthly notes are reflected within the Comprehensive Interdisciplinary Plan of Care meetings are not typically preformed separately. Employee #1 confirmed that current internal audits have been conducted recently to address charting guidelines with licensed staff, however no further documentation was provided.”