Bma Carson Community Dialysis

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 46238 Based on interview and record review, the facility failed to notify the Department of Public Health of the temporary closure of the facility [organization] due to water issues/interruptions in a timely manner in accordance with facility policy and procedure. This deficient practice resulted in the facility’s noncompliance with applicable Federal, State, and local laws and regulations in emergency situations that could compromise safety of patients. Findings: During an interview on 6/26/2024 at 11:09 a.m., with the administrator of the facility (FA), FA demonstrated a letter, dated 5/29/2024, that was sent to the Centers for Medicare and Medicaid Services (CMS), the State Agency ( any department or agency, such as the Department of Public Health) and ESRD Network (End-Stage Renal Disease (ESRD) Network is an agency that conducts specific quality improvement activities focused on patient care, maintaining a patient registry, providing educational materials, and investigating patient grievances) to notify the above-mentioned agencies of temporarily closure of the facility due to water issues/interruptions. FA stated, on 4/27/2024, the facility experienced unexpected service interruption due to water interruption caused by a burst pipe that required relocating all facility ’ s patients to contracted facilities for required dialysis services. During a further interview on 6/26/2024 at 11:09 a.m., with FA, FA stated, on 4/27/2024, when the facility experienced water interruption issues, the FA notified the governing body, and the decision was made to temporary close the facility and notify all facility’s patients of temporary closure, assisting them with selecting a referral facility (contracted dialysis facilities to provide back-up dialysis services for the organization). During a further interview on 6/26/2024, at 11:15 a.m., with FA, FA stated, that FA was not familiar with the reporting of service interruptions process to the CMS and the State Agency, but the facility’s Medical Director and Director of Operations were informed on 4/27/2024, and the FA notified the facility’s Regulatory Affairs on 4/29/2024. During a concurrent interview and record review on 6/26/2024, at 11:15 a.m., with FA, a form titled, “Facility Interruption in Service Form,” dated 4/29/2024, was reviewed. The form indicated, on 5/1/2024, FA notified ESRD Network 18 of the unplanned closure of the facility on 4/27/2024 due to water issues. The form also indicated, the checkmark was placed next to a box, indicating that local state survey agency/Department of Public Health was notified of the facility’s interruption in service. FA stated, the local state survey agency/Department of Public Health was not notified by FA and ESRD Network 18 was only notified of service interruption on 5/1/2024, after repairs took place, and the facility resumed its services. During a review of the facility’s policy and procedure (P&P) titled, “Guidelines for Emergency Preparedness,” dated 7/2023, the P&P indicated, “ Water failure is an example of type of disasters the facility may encounter; the Director of Operations (DO)/Area Manager must contact the local Emergency Operations Center or similar agency to understand the agencies capabilities and capacities and share the facility ’ s capabilities and capacities to ensure safety of patients and staff in emergency situations. The CMS, and other Federal and State agencies each have requirements intended to ensure that staff and patients are provided sanitary and safe environments as well as training in emergency preparedness to assist with ongoing safety.””