Usrc Orange Dialysis

“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: 44675 Based on a review of clinical records, interview, and policy review for Patient #14 reviewed for hepatitis B, the facility failed to report a hepatitis B seroconversion in accordance with facility policy. The findings include the following: Patient #14 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three days a week for three hours and forty five minutes with a right upper arteriovenous fistula (AVF). Review of Patient #14’s laboratory values identified the following: 1. On 7/13/23 Resident #14’s hepatitis B surface antigen was negative. 2. On 8/10/23 Resident #14’s hepatitis B surface antigen was positive (protein on the surface of hepatitis B virus that can be detected in high levels in the blood during a hepatitis B infection). Review of Patient #14’s Quest Laboratory values dated 8/15/23 identified Resident #14’s hepatitis B virus DNA was not detected. Interview with the Regional Nurse on 1/16/24 at 2:00 PM identified they did not report the seroconversion to the Department of Public Health because it was not a true conversion. They identified it was not a true seroconversion because Patient #14 received the Energix (hepatitis B vaccination) on 8/6/23 (four days before the antigen was drawn). She identified if it were a true conversion it would have been reported to the state. She further identified Patient #14 was treated in isolation from the date the antigen resulted on 8/12/23 until the negative result on 8/15/23. Review of the patient hepatitis B testing/vaccination/seroconversion policy directed that seroconversion must be reported to the state and local health department as required by law or state regulation.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 44675 Based on observation, interview and review of facility policy, the facility failed to ensure the facility was maintained in a sanitary, clean environment in accordance with facility policy. The finding included: Observations conducted during the flash tour on 1/10/24 identified the following: 1. Station #3, #13 and #14 (first floor) and station #16, #20 and #21 (second floor) had white crusted splatter on the wallboxes, surrounding walls and machine lines. 2. The wall behind Station #20 was damaged exposing dry wall, the surface would be unable to be disinfected. 3. The medication refrigerators (#1, #2, and #3) on the first floor contained a yellow, brown substance dripping from the top of the refrigerators, pooling on the bottom with black debris. 4. Observations conducted on 1/16/24 identified Stations #3, #13, #14, #16, #20 and #21 remained with white crusted splatter on the wallboxes, surrounding walls and machine lines, and the medication refrigerators (#1, #2, and #3) remained with yellow, brown substance dripping from the top of the refrigerators, pooling on the bottom with black debris. 5. Observation of the water room conducted on 1/16/24 identified on the wall containing pipes, there was a green, dried substance covering the pipes. The floor contained a brownish-red stained substance leading the drain that contained a buildup up a black and brownish-red stained substance. Interview with the Clinical Coordinator on 1/16/24 at 12:00 PM identified she was aware the screws in the refrigerator had been rusting and dripping a substance due to the condensation. She identified staff were notified to keep the medications in the front of the fridge as to not touch the substance. She further identified there was no cleaning schedule for the refrigerators and did not know when they were last cleaned. Interview with the Biomedical Supervisor on 1/16/24 at 2:00 PM identified there is no routine scheduled cleaning of the water room. He identified disinfection of the system occurs monthly and is an opportunity for the water room to be cleaned. Review of the infection control and precautions for all patient’s policy directed that the medication area will be clearly designated as a clean area an separated from contaminated areas for the preparation, handing and storage of medications. The policy further directed to clean and disinfect the dialysis station (chairs, beds, tables, keyboards, dialysis machines, ancillary equipment) after the patient had vacated the station.”

“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: 17921 Based on observation, and tour of the dialysis facilityon 01/10/2024, the facility failed to operate and furnish services to provide dialysis patients, staff, and the public a safe, functional, environment. The facility was utilizing egress pathways on the basement level of the facility to store Biomedical waste boxes, obsolete mixing equipment and furniture failing to ensure that all means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency, as required by section # 7.1.10 of the 2012 “Life Safety Code””

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 17921 1. Based on observation, and review of maintenance records, on 01/10/2024 the facility failed to operate and furnish services 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. The finding includes: a. The facility lacked documentation that the emergency generator had a Level 2 maintenance and annual fuel test conducted by qualified personnel as required by the “Connecticut Public Health Code”, the “Connecticut Fire Prevention Code” and NFPA 110 “Standard for Emergency and Standby Power Systems”. b. Documentation was not provided to indicate that the generator was exercised at least once monthly, for a minimum of 30 minutes at not less than 30 percent of the EPS nameplate rating or loading as recommended by the manufacturer, and required by section 6-4 of NFPA 110, “ Standard for Emergency and Standby Power Systems “ i.e.no documentation was provided to indicate that an annual load bank was conducted for the ESPS not attaining 30% of the 150 KW generator set, annually with supplemental loads at 50 percent of nameplate rating for 30 minutes, followed by 75 percent of nameplate rating for 60 minutes, for a total of 1.5 continuous hours as required. c. Documentation was not provided with by the Facility Administrator that the sprinkler system had been inspected in the 3rd quarter of 2023 as required by NFPA 25 “Standard for Inspection, Testing and Maintenance of Water Based Fire Protection Systems”. d. Documentation was not provided to indicate that all fire door assemblies throughout the facility that were inspected and tested annually, as required by section # 5.2 of the 2010 edition of NFPA 80, “Standard for Fire Doors and Other Opening Protectives”, section #8.3.3.1 of “Life Safety Code”, CMS (Centers for Medicare & Medicaid Services) S&C 17-38-LSC and as part of the facility maintenance program.”

“H-MONITOR HOME ADAPT;HOME VISIT=POC CFR(s): 494.100(c)(1)(i) Services include, but are not limited to, the following: (i) Periodic monitoring of the patient’s home adaptation, including visits to the patient’s home by facility personnel in accordance with the patient’s plan of care. This Standard is not met as evidenced by: 44675 Based on a review of clinical records, interview, and policy review for 2 of 3 peritoneal dialysis patients reviewed for home visits (Patient #11 and #12), the facility failed to ensure home dialysis patients had a home visit completed annually. The findings include the following: 1. Patient #11 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed peritoneal dialysis seven days a week for seven hours. Review of the home assessment report dated 4/27/22 identified Patient #11 had a home initial assessment. Review of the medical record failed to identify a home visit was completed in 2023. 2. Patient #12 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed peritoneal dialysis seven days a week for nine hours. Review of the home assessment report dated 2/13/20 identified Patient #12 had a home follow up assessment. Review of the medical record failed to identify a home visit was completed in 2023. Interview with the Home Program Administrator on 1/11/24 at 10:00 AM identified there have been no annual home visits since covid 19 unless there was a change in care partner, a move, or initial home visit. She further identified it was not updated in the QAPI program. Review of the home visit policy dated 4/2023 directed the home evaluation will be conducted prior to the initiation of patient performing treatments at home for PD patients, prior to initiating training for the home hemodialysis patients, annually and as needed for both modalities.”

“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: 44675 Based on a review of clinical records, interview, and policy review for one (1) of three (3) hemodialysis patients reviewed for hemodialysis treatment flowsheets (Patient #8 and #10), the facility failed to ensure documentation of the effect of an as needed medication and complete against medical advice (AMA) forms in accordance with facility policy. The findings include the following: 1. Patient #8 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis three times weekly for three (3) hours and thirty (30) minutes. Review of the standing orders directed for shortness of breath oxygen via at nasal cannula at 2 Liters and to notify the physician if evident. Review of Patient #8’s hemodialysis flowsheet dated 12/30/23 identified the pre-dialysis assessment at 5:58 AM of Patient #8’s lung sounds were clear and Patient #8 had a complaint of shortness of breath and 2 liters of oxygen was given. The post-dialysis assessment at 9:24 AM of Patient #8’s lung sounds were clear. The flowsheet failed to identify when the oxygen was discontinued and the effect of the oxygen on the patient. Review of the administration of oxygen policy directed that if oxygen is ordered you must document why the oxygen is being administered, when you started the oxygen, what flow rate was delivered, what method of administration was used, and when the oxygen was discontinued. It further directed to document the effect on the patient (ex. Breathing with no difficulty). 2. Patient #10 was admitted to the clinic with diagnoses that included ESRD. Review of the physician’s orders directed hemodialysis (3) three times weekly for three (3) hours. A sample review of Patient #10’s hemodialysis flowsheets identified the following: a. On 12/31/23 Patient #10 had 1 hour and 55 minutes of treatment due to requested sign off. b. On 1/3/24 Patient #10 had 2 hours and 17 minutes of treatment due to requested sign off. c. On 1/5/24 Patient #10 had 2 hours and 31 minutes of treatment due to requested sign off. d. On 1/8/24 Patient #10 had 2 hours and 2 minutes of treatment due to requested sign off. e. On 1/10/24 Patient #10 had 2 hours and 1 minute of treatment due to requested sign off. f. On 1/12/24 Patient #10 had 2 hours and 6 minutes of treatment due to requested sign off. g. On 1/14/24 Patient #10 had two hours and 1 minute of treatment due to requested sign off. Review of Resident #10’s medical record identified Patient #10 had against medical advice (AMA) forms for 1/10/24 and 1/12/24. The record failed to identify AMA forms for 12/31/23, 1/3/24, 1/5/24, 1/8/24 and 1/14/24. Interview with the Facility Administrator on 1/16/24 at 2:00 PM identified Patient #10 should have an AMA for every treatment he/she is not meeting the prescribed treatment. Review of the against medical advice policy directed that the AMA form will be used for patients who refuse to complete the prescribed treatment. It further directed the charge nurse will review and have the patient sign the AMA form. The AMA form will be maintained in the patients medical records.”