Davita Phoenix Home Dialysis Pd Only

“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 the computer server room was maintained in a clean, sanitary, and organized manner which has the potential risk of harm to an individual. Findings include: The policy titled “Physical Environment” requires “... Access to patient treatment areas, water treatment systems, supply storage and dialysis equipment is restricted to authorized personnel only. ... The facility will store supplies in a manner that is consistent with fire safety and other appropriate regulations. ... Supplies will not be stored directly on the floor but stored on shelves or pallets ...” Observation on 04/08/2025 revealed the computer server room unlocked. There was no walking space in the room as it was entirely filled with a combination of supplies, equipment, and clutter as follows: · A shelving unit that had two (2) one gallon bottles of bleach and three (3) 500mL graduated cylinders on the bottom shelf. The second shelf contained a one gallon bottle of bleach next to holiday decorations. The third shelf contained three small rectangular white plastic lids for sharps containers and a cardboard box of 16 Coastwide Multifold Paper Towels packs. The fourth shelf contained 5 rolls of brown paper towels next to 14 packaged rolls of toilet paper. The top shelf contained 3 empty sharps containers next to holiday decorations. · Next to the shelving unit was a computer server tower with a computer monitor and cords stored beneath it, and an inflatable disco ball sitting on top of the machines. · A canvas wall art piece was stored on the floor between the shelving unit and computer server tower. · Stored on the ground next to the server tower were 4 boxes labeled with a flammable lithium battery sticker on each box. · On top of the 4 boxes was a plastic tub containing yellow disposable isolation gowns, an open package of yellow isolation gowns, a canvas bag containing a Halyard Qualitative Fit Test Kit and disposable face masks. · Next to the pile of boxes was another computer server tower with various machines running. · Next to the second server tower were three red biohazard containers stored on top of cardboard boxes. A cardboard box was stored on top of the biohazard containers. · Between the biohazard containers and the shelving unit was a tall cardboard box stored on the ground, and a mop bucket containing old disposable gloves and a dirty rag. · In the corner next to the biohazard containers was a pile of cardboard boxes that contained multiple cans of paint, old computer components, a desk phone, flooring tiles, and a plastic bin of holiday decorations stored on top. · Next to the pile of cardboard boxes was a shop-vac with the tubing unsecured and laying on the ground. · The shop vac was stored on the ground in front of the fire panel, making it difficult to access the fire panel. · Stored on top of the fire panel was an AgaMatrix Jazz Wireless 2 blood glucose monitoring system. · Next to the shop-vac was a Swiffer mop stored with the cleaning pad on the ground. · Next to the Swiffer mop was a cardboard box of Coastwide Recycled Bath Tissue stored directly on the ground. · On the ground next to the toilet paper box appeared to be a spill or organic matter that was brown and crusted. · Along the floor of the storage room were various pieces of trash, including a sticky note, a small red cap for a pen, small pieces of paper, and a spilled white substance. Employee #1 confirmed on 04/08/2025 that the storage closet was not kept clean and sanitary per facility policy and was a potential fire hazard.”

“PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This Standard is not met as evidenced by: 37489 Based on document review, and interview, it was determined that the facility failed to ensure staff meet the personnel qualifications according to their job description, which has the potential for a lapse in patient care. Findings include: Review of Employee #3 ’ s personnel file revealed a job description for Learner Home RN. The facility’s description of Learner Home RN requires “ ... The learner home RN will provide professional nursing care under the direst supervision of a licensed, experienced Home RN (with greater than 12 months experience in nursing, 3 months of modality-specific training, and at least 3 months in PD). ... This position reports to the Facility Administrator or Regional Home Manager ... Document patient ’ s physical assessment, vital signs, treatment reviews and observations in patient medical records, and bring issues to the attention of the physician and experienced Home RN. ... communicate emergencies, patient life-threatening complications, and related incidents to the FA, experiences Home RN, and the patient ’ s nephrologist. ... Administrative: Verify accurate charges and documentation are submitted in a timely manner. Enter treatment data accurately and in a timely manner. Learner Home RN will attend homeroom meetings and mandatory in-services as required. They will understand their own professional limitations and seek appropriate assistance when required. The document titled “Job Description ... Clinical Coordinator ...” requires “ ... Essential duties and responsibilities ... proficient in all RN I and RN II duties ... directs the work of other staff ... supervises and monitors direct patient care administered by PCTs, LPN/LVNs and RNs ... assists in the evaluation of facility nursing care teammates under the guidance of the Facility Administrator ...” Review of the personnel file revealed the job description of Employee #3 does not meet the qualifications for Clinical Coordinator. Document titled “Governing Body Meeting Facility Phoenix Home PD” states “ ... Effective 11/22/2024 ... (Name of Employee #3), RN governed in as a nurse in charge of clinical services ...” Employee #3 confirmed on 04/08/2025 that they were an RN-I for three years and were governed-in as Clinical Coordinator in November 2024. Employee #3 also confirmed that they did not have the oversight of other staff including ability to schedule, hire, and fire staff. Additionally Employee #3 confirmed that they are a full time employee of the business, but not a full time employee at Phoenix Home Dialysis. Employee #11 confirmed on 04/08/2025 that Employee #3 did not meet the requirement of a full time employee because the employee was working at two separate clinics.”