Florida Hospital Esrd

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 13640 Based on observation and interview, the facility’s hospital campus failed to ensure that in the event of an evacuation involving a loss of the facility’s electric power, there was not an alternate means of sharing information and medical documentation with other health care providers for continuity of care in place in a manner which was not dependent on electricity. Findings: Observation of the facility’s emergency kit on 09/23/24 at approximately 1:15 PM, found that it did not have any type of paper print outs or any other non-electric power means where pertinent medical treatment information for all current patients could be shared when necessary in an emergency. During an interview with the Nurse Manager at this same time, she confirmed the absence of an alternative means (non-electric power) of sharing patients’ treatment information in an emergency.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 13640 Based on observation and interview, the facility failed to display the State agency address and telephone complaint number where it could be easily seen and read by patients. Findings: During a tour of the facility at its hospital campus on 09/23/24 at approximately 1:31 PM, posted notices were observed. However, none of these notices included a display of the State agency address and telephone complaint number as required. During an interview with the Nurse Manager at this time, she confirmed the findings.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 37965 Based on record reviews and staff interviews, the facility failed to provide evidence that dialysis facility staff demonstrated current competencies necessary to meet the comprehensive and complex needs of the dialysis patient and failed to provide evidence the staff demonstrated and sustained the skills needed to perform the specific duties of their positions for 4 of 4 staff sampled (Staff members A, B, C and D). The findings include: A review of the personnel file for staff member A, a registered nurse (RN), revealed that she had a date of hire of 09/02/2022. The review failed to reveal evidence of competencies upon hire or annually. A review of the personnel file for staff member B, RN, revealed that she had a date of hire of 05/26/2019. The review failed to reveal evidence of competencies upon hire or annually. A review of the personnel file for staff member C, a patient care technician (PCT), revealed that she had a date of hire of 01/19/2022. The review failed to reveal evidence of competencies upon hire or annually. A review of the personnel file for staff member D, a PCT, revealed that she had a date of hire of 01/14/2008. The review failed to reveal evidence of competencies upon hire or annually. On 09/24/24 at approximately 1:30 PM, an interview was conducted with the Dialysis Manager who provided copies of audits she had conducted of staff performing duties such as cleaning/disinfecting the dialysis machines, hand hygiene, infection control, accessing dialysis sites such as central venous catheters and grafts. Review of the form revealed there were no names or times of each observation. She stated some of the staff were observed twice in one day however she was not sure which staff were observed. She stated she does not have staff competencies beyond what they do as part of the orientation process for the hospital. Nothing specific for End State Renal Disease (ESRD). On 09/24/24 at approximately 2:00 PM, a follow-up interview was conducted with the Dialysis Manager in the presence of the Executive Director. During the interview the Executive Director asked if they could submit proof of training/competency for staff at a later date because they wanted to reach out to the previous manager. Explaining they were unable to locate evidence of staff competencies stating they “have been lost” and explained that they had moved locations within the hospital several times over the last several years and they have been misplaced. At this time the Manager was asked how long she had been in her position to which she replied “2 years” when ask if she had conducted any staff competencies since she has become the manager, she stated nothing outside the unnamed audits for staff provided during an earlier interview. She further stated that she had not done individualized staff skill competency reviews annually or as needed since she has been in her positions. At this time, they were asked for a staff competency policy to which they stated that there was not a policy related to staff competency.”