Davita Bayonet Point - Hudson Kidney Center

“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: 20536 Based on observation, staff interviews and record review, the facility failed to ensure one of one Acid Concentrate mixing rooms was clean and maintained, and free from loose debris over equipment during one of two days observed (6/17/2024). Findings included: On 6/17/2024 at 9:24 a.m. during a facility “flash tour”, the Acid Concentrate mixing room was observed. The room door was ajar and open to the hallway and revealed a space of approximately twenty feet by fifteen feet. There were two large “Acid” filler tanks and a very large “Acid Concentrate” mixing tank. The was a counter with a sink, three pallets of boxed product and mixing supplies, a plastic supply pushcart and two large plastic lidded trash containers. Further observations revealed: a. A hand sink with no faucet and counter space covering approximately five feet across. The countertop was spotted with heavy oxidation, metal frame plates that were heavily oxidized, and many small black pieces of debris. There were five various half full and full jugs of liquid product on the counter covered with dust and debris. Above the sink counter were with pipes covered/surrounded in black foam. The tops of the black foam throughout the room were covered with blankets of dust and debris. Photographic evidence obtained. b. A two shelved plastic rolling cart observed at the back of the room and had dust and debris blanketing it. Photographic evidence obtained. c. Two large “Acid” product fill tanks on the left side of the room were blanketed with heavy dust and debris. The floor where the fill and evacuate hose and spigot were observed lying, was blanketed with dust and debris and what appeared to be yellow fiberglass insulation from the ceiling. d. A large dark grey lidded refuse container was placed on a crushed cardboard box. The box had bagged Acid mixing product in it. The inside of the box had dust, debris and with yellow fiberglass insulation, which fell from the ceiling. The trash container lid was also observed with heavy dust and debris and with fallen pieces of fiberglass insulation. Photographic evidence obtained. e. The wall and floor area on the left side of the room next to the grey tray container revealed a dark plastic floor riser with an open cardboard box. The contents of the box revealed a bag of mixing solution product. The product bag was ripped, exposing the product within. Further, the inside of the box and top of the product bag were observed with dust, debris and pieces of yellow fiberglass insulation. The grating of the plastic floor riser had pieces of ceiling tile, pieces of fiberglass insulation, dust and debris on it. Photographic evidence obtained. f. On the left side of the room, directly between the wall and the grey refuse container revealed large empty container/jugs. The jugs were stacked three high and were observed missing lids. All the jugs were observed covered heavily with dust, thick black pieces of debris, and many pieces of yellow fiberglass insulation. There was a bag of trash/refuse positioned on top of one of these containers. The inside of the containers was observed with dust and debris and yellow fiberglass insulation. Photographic evidence obtained. g. The Right side of the room and towards the back was observed with a window with a window sill. The window sill was observed with thick paint and spackle peeling and pieces were on the floor below. There was a black foamed pipe running the entire length of this right-side wall and blanketed with heavy dust and debris. Next to the window and covered pipe was another very large plastic mixing tank. The top of the tank and the floor at and surrounding the tank was blanketed with heavy dust and debris and fallen pieces of yellow fiberglass insulation. Photographic evidence obtained. h. The floor of the space was blanketed in dust and debris with hundreds of small slivers and pieces of yellow fiberglass insulation. Photographic evidence obtained. i. The care floor area where patients receive their treatment had two refrigerator/freezers. One of the refrigerator/freezers was used to store lab vials. It was running at the appropriate temperature between 36 degrees Fahrenheit and 45 degrees Fahrenheit, however, the freezer compartment on the top shelf was observed heavily iced and frosted. The ice buildup had brown spots and black chip-like debris. Photographic evidence obtained. On 6/17/2024 at 11:30 a.m. an interview with Personal Care Technician (PCT) Staff B, as well as review of the day assignment schedule, revealed she was responsible for Acid and Citric Acid mixing room. Staff B was asked what that assignment entailed, and she revealed whoever is assigned for Acid and Citric Acid, is responsible for the Acid mixing only and not responsible for the general cleaning and or maintenance of the room. She revealed there are other staff that are contracted that clean that space. On 6/18/2024 at 8:55 a.m. an interview with the Facility Administrator (FA) revealed she has contracted housekeeping that comes in the facility daily, Monday through Saturday. The FA revealed that though Housekeeping does not clean the equipment, they are to clean in these rooms. The FA was not able to be at the survey inspection the day of 6/17/2024. However, she was available in person on 6/18/2024. She had been away from the facility for a period of time and was not aware of the uncleaned Acid Mixing room but clarified that room had some air conditioning repairs and maintenance personnel were in that room at some point and may not have cleaned up when they were done. She also confirmed that the contracted housekeeping services should have cleaned the room in the day or days after the maintenance personnel had completed their job. While touring the Acid Mixing room with the FA on 6/18/2024, it was observed the room was cleaned on the evening of 6/17/2024. The FA was not able to see the room as soiled and non-maintained. She was provided with photographs taken by the State Surveyor, and she confirmed the room should not have been left in that state for any period of time. On 6/18/2024 the FA provided the “Janitorial Statement of Work” policy and procedure for review. The policy had an effective date of 2/15/2023 and revealed; The Statement of Work (“SOW”) is governed by the Master Services Agreement (“MSA”) and this SOW, the MSA controls. Capitalized terms used but otherwise defined in this SOW shall have the meaning given in the MSA. I. SERVICES: Services are scheduled to begin on 2/15/2023 (Service Start Date). Company will perform the janitorial Services generally described in the SOW. Services will be performed at [Facility] freestanding dialysis treatment center(s) (hereinafter “Center”) listed in the individual Services, Pricing, and Frequency tables(s) below (hereinafter “SPF” Schedule”). Company agrees to provide janitorial Services as follows (including but not limited to): A. DAILY 1. Remove all trash and debris from exterior perimeters. 2. Vacuum wall to wall utilizing vacuum wand to vacuum corners, edges, and door entry. Vacuum walk off mats; 3. Dust mop and then damp mop hard surface floors with approved disinfectant cleaner. Move mats to clean underneath. Allow surface to dry prior to replacement of mat.”