Belle Glade Dialysis Center

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 22517 Based on record review, policy review and interview, the facility failed to ensure Quality Assessment and Performance Improvement activities are conducted to correct identified areas of concerns. Furthermore, the facility failed to create a plan of correction to ensure adequate monitoring to attain and sustain improvements of clinical outcomes, that did not meet the regulatory requirements during the recertification survey. The findings included: 1) Review of the Quality Assessment and Performance Improvement (QAPI) program indicates the governing body and management staff met to review and approve the plan of correction and the tools that will keep approved plan in compliance and discuss the plan of correction on 02/24/25 . .Review of the facility’s plan for the identified concerns at V 502 documents that an in-service was done to review the importance of completing the post hospitalization assessment. It was further stressed that if the patient has been discharged from the hospital the nurse must review the hospital records and complete the Post Hospital Discharge Checklist, to note any changes in the patient’s healthcare status, medications, dry weight, etc. If any changes are noted this should be reported to the patient’s physician and current orders should be verified to determine if any new orders are needed. The clinic manager will review the hospitalization log, weekly for 3 months, to ensure that the nurse completes the Post Hospital Discharge Checklist on all patient’s discharged from the hospital and this is reviewed with the patient’s physician for any changes in orders, if indicated. The CM will ensure compliance through direct observation and use of the CM monitoring tool, monthly prior to the QAPI meeting. The CM monitoring tool will be brought to the monthly QAPI meetings, of which the medical director is a member, where findings will be discussed and further action will be taken, such as continued staff training, further monitoring, and/or disciplinary. Review of the Clinic Manager Tracking Tool documented for V 502 which noted that the CM was to review the hospitalization log to ensure the nurse completes the Post Hospital Discharge checklist on all patients discharged from the hospital and this is reviewed with the patients physician for any changes in orders, when indicated and handwritten on this tool that the March 2025 was done week 1, 2, and 3. However, review of clinical record for Patient # 1 revealed that the patient was hospitalized 02/27/25 to 03/05/25 for fever and was to receive Vancomycin 750 mg IVPB each treatment for 5 doses. The patient returned to the facility on 03/07/25. Further review of the patient clinical record failed to provide evidence that the patient received the 4 doses of the Vancomycin. An interview was conducted with the Charge Nurse on 03/26/25 at 12:00 PM who confirmed the patient did not receive but one dose of the Vancomycin on 03/07/24. The nurse who apparently put the order into the electronic system did not put the order in correctly, thus the medication was not administered. She also confirmed that the patient’s Venofer was not restarted. She will contact the physician to confirm administering the remaining 4 doses of the Vancomycin. The nurse also confirmed that they missed that the patient had not received the prescribed medication, when reviewing for post hospitalization care and services needs. This failure was not identified until 03/26/25 when it was discovered by the surveyor. The facility had allegedly conducted 3 weekly checks previously and did not identify the concern. 2) Review of the facility’s plan to monitor staff compliance for identified concerns at V 544 documented that an in-service was done reinforcing that every part of the dialysis prescription must be supported by a physician order or justified in writing on the treatment sheet as to why the order could not be achieved. This includes the prescribed Blood Flow Rates (BFR) and Dialysate Flow Rates (DFR). If the machine BFR and/or DFR cannot be achieved as ordered, the DPC staff member must document on the treatment sheet the reason that the prescribed orders could not be attained, and the charge nurse notified. The nurse in charge must perform and document an assessment of why the BFR or DFR cannot be achieved, and the physician notified. The nurse in charge must perform and document an assessment of why the BFR or DFR cannot be achieved, and the physican notified. The Charge Nurse will round on all patient shifts to verify that treatment orders are followed, including the correct BFR and DFR, on all patients and there is documentation on the treatment sheet as to why. The CM will review the treatment flow sheets weekly, for 8 weeks, to ensure all treatment orders are followed per physician order, including the BFR and/or DFR and there is documentation by the DPC staff on the treatment sheet that the CN was notified if orders cannot be obtained and if trends are identified in patient not being able to meet their ordered BFR and/or DFR that information is included in the Comprehensive Assessment. The Clinic Manager will ensure compliance by direct review of the treatment records and through review of the charge nurse rounding tool. Review of the clinical records for Patient # 2 and # 4 revealed that the staff did not follow the physician order for the prescribed BFR or DFR on multiple treatment and failed to document a reason for not following the physician order. Further review of the monitoring tool and CM monitoring also revealed that this failure was not identified, until identified by the surveyor on 03/26/25. An interview was conducted on 03/26/25 at approximately 3:00 PM with the Facility Administrator, who stated that the nurses were to check 100% of their treatments and treatment sheets to confirm that the staff were following the physician order. She confirmed that the nurses did not identify that the staff were not following the physician order and correct it or document why they were unable to follow the physician order.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 51535 Based on observation, the facility failed to identify a designated sink on the treatment floor as clean or dirty for 1 of 5 sinks. The findings included: An observation of the facility’s treatment area near nurses’ station was conducted on 02/04/2025 at 10:05 AM. One of five sinks was observed without identification as clean or dirty. An observation of the facility’s treatment area near nurses’ station was conducted on 02/06/2025 at 2:45 PM, again observed sink without identification identifying the sink as clean or dirty.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 51535 Based on observation, administrative record review and staff interview, the clinical staff failed to implement infection control practices to minimize the risk of infection and cross contamination. This is evidenced by the facility’s failure to ensure the staff utilized proper medication handling and administration. The findings included: The facility’s policy for Medication Handling, Administration, Storage, and Disposal effective date 01/13/2025 (revised) documented that “Medication must never be left unsecured or unattended.” An observation on 02/04/2025 at 9:50 AM was made of two 3 cc syringes labeled as heparin which were stored at Station 10 on the chairside table, unattended by the nurse. An interview with the Medication Nurse, Staff A, was conducted on 02/04/2025 at 09:52 AM. The nurse acknowledged having left the medication at Station 10 on the chairside table.”

“BACT OF H20-MAXIMUM & ACTION LEVELS CFR(s): 494.40(a) 4.1.2 Bacteriology of water: max & action levels Product water used to prepare dialysate or concentrates from powder at a dialysis facility, or to process dialyzers for reuse, shall contain a total viable microbial count lower than 200 CFU/mL and an endotoxin concentration lower than 2 EU/mL The action level for the total viable microbial count in the product water shall be 50 CFU/mL, and the action level for the endotoxin concentration shall be 1 EU/mL. If those action levels are observed in the product water, corrective measures shall promptly be taken to reduce the levels. This Standard is not met as evidenced by: 22517 Based on administrative record review and interview, the facilty technical staff failed to provide evidence the appropriate follow-up was done when the water cultures result exceed action level for 1 of 7 testing sites. The findings included: Review of the water culture results for November revealed a result of greater than 300 for the Bicarbonate Distribution Return. There is no evidence of follow-up cultures being drawn for this site until 12/03/25, the monthly lab draw. An interview was conducted on 02/05/25 at approximately 11:00 AM with the Facility Technical Manager, who confirmed the action level results and that he would have redrawn the cultures after receiving the results a few days later. He will follow-up with the lab to verify if the labs were done. An interview was conducted on 02/06/25 at approximately 10:00 AM with the FTM. The surveyor inquired about the follow-up cultures being completed. He confirmed that there were no further cultures completed for this site until 12/03/24, when the monthly cultres were done. He further confirmed that repeat cultures should have been done within the week of receiving the results. Review of the facility’s policy Bacteria and Endotoxin Test Results Exceeding Action Level, current revision date: 02/05/24, documented the following: “The Medical Director or covering physician is notified within 24-hours of any result received which was greater than the action level, for that specific piece of equipment or system. The date and time of the notification is recorded on the contracted laboratory Service Provider summary reports. The Medical Director, in consultation with the Facility Technical Manager and Corporate Technical Services, determines the course of action required. These may include, but not necessarily limited to: Repeating the bacteria and/or endotoxin test for the specific location above action level, for four consecutive weeks. Disinfection of the specific piece of equipment or system that is affected. Following up with a repeat bacteria and/or endotoxin test, or Increasing bacteria and endotoxin sampling/monitoring.””

“ACID CONC DIST-CONC LABELED & COLOR-CODED RED CFR(s): 494.40(a) 5.5.3 Acid concentrate distribution systems: labeled & color-coded red Acid concentrate delivery piping should be labeled and color-coded red at the point of use (at the jug filling station or the dialysis machine connection). All joints should be sealed to prevent leakage of concentrate. If the acid system remains intact, no rinsing or disinfection is necessary. More than one type of acid concentrate may be delivered, and each line should clearly indicate the type of acid concentrate it contains. This Standard is not met as evidenced by: 22517 Based on observation and staff interview, the facility failed to ensure that the Acid Concentration distribution system at the valve panels (wall boxes) are appropriately labeled to clearly indicate the type of acid concentrate coming through the line. The facility has two strengths of acid being distributed through the central delivery system to the valve panel/wall box. Acid solutions centrally delivered to treatment stations, outlets must be clearly labeled to identify specifically the chemical make-up of the solution being delivered. The findings included: An observation of the water room as conducted on 02/04/25 at 9:30 AM revealed two acid storage tanks labeled 1 K 2.5 Ca (1 potassium 2.5 calcium) and 2 K 2.5 Ca. An observation on the dialysis treatment floor on 02/04/25 beginning at approximately 10:45 AM revealed that 7 of 27 stations wall boxes were not labeled appropriately to indicate the dialysate baths being centrally transported to the box. Additionally, 8 of 27 stations wall boxes had 1 acid labeled 2 K 2.5 Ca. The facility centrally delivers acid concentrations of 1 K (potassium) and 2.5 Ca (calcium) and 2 K (potassium) 2.5 Ca (calcium). An interview and observation was conducted on 02/06/25 at approximately 11:45 AM with the Facility Technical Manager. The surveyor informed him that the wall boxes at the dialysis stations were not labeled to identify the acid concentration being centrally piped into the station and did not clearly label the specific concentrations being delivered. He confirmed the above observation.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program 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. This Standard is not met as evidenced by: 51535 Based on observation and staff interview, the facility failed to ensure all equipment were maintained and operated in accordance with the manufacturer’s recommendations, as evidenced by the failure of staff to ensure equipment was cleaned per recommendation. The findings included: Observation of the medication refrigerator was conducted on 02/04/2025 at 10:05 AM revealed the refrigerator (inside) had black speckles of dust and debris noted on the door shelving and bottom floor inside the refrigerator. Interview with the Nurse Manager was conducted on 02/06/2025 at 2:47 PM. She confirmed the presence of dust and debris inside the medication refrigerator.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 22517 Based on administrative and clinical record review and staff interview, the facility failed to provide evidence of evaluation of the current health condition for patients who returned to the facility after a hospitalization for 4 of 9 sampled record reviewed (Patient # 2, # 3, # 4 and # 7). The findings included: Review of the facility’s Post Hospital Discharge Checklist revealed the staff after hospitalization were to complete information regarding the hospitalization. “Items listed below must be completed by nurse within one week of hospital discharge include some of the following: Correspond with hospital discharge team, acute dialysis unit and/or MD for updates and new orders Write progress note on patient’s health status post hospitalization ( 1st treatment back) Obtain DC (discharge) Summary= Medical Records Release signed by patient if applicable Enter hospitalization details in Clinic Portal/EMR Enter transfusion details in Clinic Portal/EMR Evaluate anemia management for appropriate dosing = write orders and update in Patient Web/EMR Estimated Dry Weight changes = write orders and update in Patient Web/EMR Infection present and antibiotics prescribed = write orders and update in Patient Web/EMR Review medication changes = update in Patient Web/EMR/Medical Record Access assessment/changes = update in Patient Web/EMR/Medical Record New Diagnosis = update Problem List with ICD-10 Codes & QMS New Co-Morbid Conditions = Co-Morbid Sheet with ICD-10 Codes and update Patient Web/EMR Initiate Comprehensive Assessment/Plan of Care if applicable All orders must be verified and written after discussion with attending nephrologist” 1) Review of the clinical record for Patient # 3 revealed the patient was originally admitted to the facility on 09/09/24. The patient had multiple hospitalizations as follows: 01/03/25 - Hospital emergency room - Clogged Catheter 01/04 - 01/08/25 - Non-functioning HD (hemodialysis) catheter 11/11/24 - Catheter replacement and hemodialysis 10/01/24 - 10/13/24 - weakness 09/16/24 -09/18/24 - removal of catheter Review of the 01/10/25 - treatment - the first treatment after the January hospitalization, did not identify that the patient was hospitalized. Further review of the clinical record did not disclose a progress note on the patient’s health or information regarding any access changes. Interview with the Clinical Manager was conducted on 01/06/25 at approximately 1:00 PM. She confirmed the staff have not been completing the post hospitalization form and documenting as appropriate. 2) Review of the clinical record for Patient # 7 revealed that the patient was admitted to the facility on 03/12/21. The patient had a hospitalization on 12/30/24 - 01/07/25 for infection and access complication. Further review of the clinical record did not provide evidence of the nursing staff completing the post hospitalization checklist and progress note. 3)Review of the clinical record for Patient # 2 revealed that the patient was admitted to the facility on 01/25/23. The patient had multiple hospitalization as follows: 01/14/25 - 1/18/25 - cough, shortness of breath, community acquired pneumonia 10/07/24 - 10/10/24 - Thrombectomy access complication 09/25/24 - 09/29/24 - Abdominal pain, hypertension 09/04/24 - 09/09/24 - Abdominal pain, vomiting Further review of the clinical record did not provide evidence of the nursing staff completing the post hospitalization checklist and progress note. 4) Review of the clinical record for Patient # 4 revealed that the patient was admitted to the facility on 11/16/22. The patient had multiple hospitalizations as follows: 01/20/25 - 01/21/25 Emergency Room 01/15/25 - 01/17/25 - Ascities, liver biopsy 10/24/24 - 11/05/24 Access Complication, Central Venous Catheter 09/18/24 -09/22/24 - AVF/AVG complication Further review of the clinical record did not provide evidence of the nursing staff completing the post hospitalization checklist and progress note.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 22517 Based on observations, clinical and administrative record review and staff interview, the facility failed to ensure the appropriate time monitoring for 2 of 9 sampled patients (Patient # 3 and # 7). The findings included: The facility’s policy regarding Monitoring & Documentation of Patient Care During Treatment, last revised on 11/29/2022, documented, “Data that must be documented (by direct entry and/or data feed from the dialysis machine) at least every 30 minutes and PRN (as needed) depending on the patient’s condition includes but is not limited to: Patient blood pressure and heart rate (BP & HR) Blood pump speed Compensated blow flow rate Blood flow rate (BFR) Dialysate flow rate (DFR) Arterial Pressure (AP) Venous Pressure (VP) Ultrafiltration rate (UFR) Volume removed to that point (RMVD) Volume of heparin in the heparin syringe in the heparin pump, if used Saline (when administered for symptom management; this is not for prime, rinse back or meds mixed in saline) 1) Review of the clinical record for Patient # 3 revealed that the patient was admitted to the facility on 09/09/24. The physician prescribed for the patient to receive In-center hemodialysis treatment three times a week for 4 hours and 15 minutes. Further review of treatment sheets from 01/10/25 to 02/03/25 revealed that on 4 of 12 treatment sheets the staff failed to monitor the patient for greater than 30 minutes as follows: 01/31/25 the staff documented that the staff monitored the patient at 2:02 PM. However, there is no further documentation of the staff monitoring the patient until 3:11 PM, 1 hour and 9 minutes later. 01/29/25 the staff documented that the staff monitored the patient at 2:30 PM. However, there is no further documentation of the staff monitoring the patient until 3:30 PM, 1 hour later. 01/22/25 the staff documented that they monitored the patient at 09:30 AM. However, there is no further documentation of the staff monitoring the patient until 10:30 AM, 1 hour later; then at 11:31 AM, 1 hour and 1 minute later. 01/10/25 the staff documented that they monitored the patient at 08:31 AM. However, there is no further documentation of the staff monitoring the patient until 09:31 AM, 1 hour later. 2) Review of the clinical record for Patient # 7 revealed that the patient was admitted to the facility on 03/12/21. The physician prescribed for the patient to receive In-center hemodialysis treatment three times a week for 4 hours. Further review of treatment sheets from 01/10/25 to 02/05/25 revealed that on 2 of 12 treatment sheets the staff failed to monitor the patient for greater than 30 minutes as follows: 02/05/25 the staff documented that the staff monitored the patient at 12:30 PM. However, there is no further documentation of the staff monitoring the patient until 1:30 PM, 1 hour later. 02/03/25 the staff documented that the staff monitored the patient at 1:00 PM. However, there is no further documentation of the staff monitoring the patient until 2:00 PM, 1 hour later. An interview was conducted with the Nurse Manager on 02/06/24 at approximately 1:30 PM. The surveyor reviewed the irregularities with the Nurse Manager, who confirmed the issues discussed.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 22517 Based on record review and interview, the facility failed to ensure dialysis prescription was followed for 4 of 9 sampled patients (Patient # 2, # 3, # 4 and # 7). This is evidenced by the clinical staff failure to follow the dialysis prescription for the prescribed Blood Flow Rate (BFR) and Dialysis Flow Rate (DFR) and failed to document the clinical rationale for not following the prescribed treatment prescription. The findings include: 1) Review of the clinical record for Patient # 7 revealed that the patient was admitted to the facility on 03/12/21. The physician prescribed for the patient to received in-center hemodialysis treatment for 4 hours three times a week. The physician prescribed a Blood Flow Rate (BFR) of 400 and a Dialysis Flow Rate (DFR) of 500. The staff failed to follow the prescribed treatment plan on 7 of 12 treatment as follows: a. On 02/03/25, 01/29/25, 01/27/25, 01/13/25, and 01/08/25, the staff documented a BFR of 350 throughout the treatment. Also on 01/10/25, the staff documented a BFR of 320 throughout the treatment. The staff did not document an explanation of why the prescribed treatment plan was not followed. b. On 01/17/25, the staff documented a DFR of 500 throughout the treatment. The staff did not document an explanation of why the prescribed treatment plan was not followed. 2) Review of the clinical record for Patient # 4 revealed that the patient was admitted to the facility on 11/16/22. The physician prescribed for the patient to received in-center hemodialysis treatment for 4 hours and fifteen minutes three times a week. The physician prescribed a Blood Flow Rate of 450 and a Dialysis Flow Rate of 800. The staff failed to follow the prescribed treatment plan on 6 of 12 treatment as follows: a. On 01/13/25, the staff documented a BFR of 400 and a DFR of 500 throughout the treatment; 01/06/25, the staff documented a BFR of 500; 01/03/25, the staff documented a DFR of 500 throughout the treatment; 12/31/24, the staff documented a BFR of 300-450; 12/29/24, the staff documented a BFR of 350-400; 12/24/24, the staff documented a BFR of 400 and a DFR of 500 throughout the treatment. The staff did not document an explanation of why the prescribed treatment plan was not followed. 3) Review of the clinical record for Patient # 2 revealed that the patient was admitted to the facility on 01/25/23. The physician prescribed for the patient to received in-center hemodialysis treatment for 4 hours three times a week. The physician prescribed a Blood Flow Rate of 400 and a Dialysis Flow Rate of 600. The staff failed to follow the prescribed treatment plan on 2 of 12 treatment as follows: a. On 01/31/25, the staff documented a DFR of 700 throughout the treatment. Also on 01/06/25, the staff documented a DFR of 500 throughout the treatment. The staff did not document an explanation of why the prescribed treatment plan was not followed. 4) Review of the clinical record for Patient # 3 revealed that the patient was admitted to the facility on 09/09/24. The physician prescribed for the patient to received in-center hemodialysis treatment for 4 hours and 15 minutes three times a week. The physician prescribed a Blood Flow Rate of 400 and a Dialysis Flow Rate of 800. The staff failed to follow the prescribed treatment plan on 2 of 12 treatment as follows: a. On 01/29/25 the staff documented a DFR of 500 throughout the treatment and on 01/10/25, the staff documented a DFR of 700. The staff did not document an explanation of why the prescribed treatment plan was not followed. An interview was conducted with the Nurse Manager on 02/06/24 beginning at 1:30 PM. The above discrepancies were discussed with the nurse and she confirmed the above findings.”