Dci Rancho Dialysis Clinic

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 28347 Based on interview and record review, the facility failed to have a training program that included performance audits relative to technician and nursing compliance with water and dialysate (a special fluid containing water and various chemicals that pulls waste products and excess fluid from the blood during dialysis) testing procedures. This failure put the facility’s patients at risk for undergoing dialysis (An artificial process that filters blood to remove waste products and excess fluid, replacing the function of the kidneys) using incorrectly mixed dialysate, water contaminated with chlorine, or water contaminated with bacteria or endotoxins (products of bacteria). Findings: During an interview and record review with the Chief Technician (CT), on 9/8/25 at 12:02 p.m., the CT reviewed the Phoenix Meters (hand held devices that check water conductivity [salt content] and pH (acidity). The logs for the Phoenix Meters were inconsistently filled out making it difficult to know what the process entailed. The CT stated he does monthly training on all technical procedures for the staff, but does not audit the Certified Hemodialysis Technicians (CHTs) compliance with procedures visually. The CT stated he performs periodic audits of the nurses, who perform the water system checks and chlorine tests, but does not document these audits. When asked if he audits the CHTs compliance with mixing the bicarbonate for dialysis (a component of dialysate), the CT said he did not. Review of the Daily Phoenix Meter Log showed the following: 9/1/25-9/8/25 Meter #1 - The daily verification/calibration was completed and in range for both pH and conductivity. Six of the seven days indicated “Calibration Met.” Post calibration verification was completed on four of seven days. The log was being completed in a different manner by different staff. The logs for January - August contained the same inconsistencies as above. The Bicarbonate mixing log contained two batches (both mixed on 7/29/25) that were not tested for specific gravity (the measure used to ensure the mixture is correct). The facility policy titled Mixing Bicarbonate Concentrate indicated “Read the specific gravity of the bicarbonate...” and “Documentation...Specific gravity or conductivity reading.” During the QAPI review with the Administrators and Nurse Manager, on 9/9/25, clinic leadership confirmed they had no process for visual audits of bicarbonate mixing, testing dialysate pH and conductivity, testing water for total chlorine and microbiological sample collection. They indicated the audits were not being done.”

“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: 34980 Based on interview and record review, one of four sampled patients (Patient 1) was not treated for hypertension (high blood pressure) upon completion of their hemodialysis (a treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatment and facility procedure/protocol were not followed. This failure had the potential to result in negative outcomes for patients, such as a stroke (blood flow to an area of the brain is cut off) or a life-threatening bleed from the patient’s access site (needles [for dialysis] insertion sites). Findings: A review of the “Demographic Report” dated 9/9/2025, indicated Patient 1 was admitted to the facility on 10/31/2017 with a diagnoses that included chronic kidney disease. A review of the “Hemodialysis Flowsheet” dated 8/27/2025, indicated Patient 1 had completed their hemodialysis treatment with an ending blood pressure (BP) of 199/89 (a high BP reading). During a concurrent interview and record review with the Nurse Manager (NM) on 9/9/2025 at 11:09 a.m., the NM verified that the physician had not been notified of Patient 1’s ending BP of 199/89. The NM stated, “With an ending BP of 199/89, the physician should have been notified as the policy indicates.” During an interview with Registered Nurse 1 (RN 1) on 9/9/2025 at 1:02 p.m., RN 1 stated, “If the patient’s BP is elevated, we are supposed to call the doctor and give Clonidine (a blood pressure medicine).” A review of the facility policy titled, “Post-Treatment Assessment” dated 9/26/2018 indicated, “Any vital signs or assessment issues indicating distress or severe abnormality will be reported to physician along with any other issues outside of facility established parameters.””