Davita Weston Dialysis Center

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 36734 Based on observation and interview, the facility failed to have readily available oxygen, ambu bag, and suction on/near the emergency cart. The findings included: An observation of the facility’s emergency cart was conducted on 09/03/24 at 12:00 PM with the Clinical Manager (CM). The oxygen tank directly adjacent to the cart was empty. The bag containing the ambu bag on top of the cart was observed without an accompanying mask, making it not usable. The suction machine located on top of the cart was not functioning when the CM attempted to demonstrate the use by suctioning water out of a cup. The CM acknowledged the above.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 36734 Based on interview and record review, the facility failed to participate in a full -scale exercise that was community-based to test the emergency plan. The findings included: An interview was conducted with the Facility Administrator (FA) on 09/05/24 at 1:00 PM during a review of the facility’s emergency preparedness review. The FA stated she had never participated or attempted to participate in a full-scale exercise that was community-based.”

“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: 36734 Based on observation and interview, the facility failed to have a designated clean sink for hand washing for 2 of 5 sinks. The findings included: An observation of the facility’s treatment area was conducted on 09/03/24 at 11:00 AM. Two of five sinks were observed without identification as clean or dirty. An observation of the facility’s treatment area was conducted on 09/05/24 at 11:00 AM with the Clinical Manager (CM). Two of five sinks were again observed without identification identifying them as clean or dirty. The CM acknowledged the above.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 36734 Based on observation and interview, the facility failed to maintain clean surfaces and equipment. The findings included: An observation of the facility’s treatment area was conducted on 09/03/24 at 11:00 AM. A refrigerator in the medication preparation area was observed with dust and debris on the outer surface. The laboratory area was observed with dust and debris on the countertop, ledge, and plastic divider. Fifteen of fifteen treatment chairs were observed with copious amounts of tape residue on the chair arms/table, which prevents effective disinfection. An observation of the facility’s treatment area was conducted on 09/05/24 at 11:00 AM with the Clinical Manager (CM). Again, a refrigerator in the medication preparation area was observed with dust and debris on the outer surface. The laboratory area was observed with dust and debris on the countertop, ledge, and plastic divider. Fifteen of fifteen treatment chairs were observed with copious amounts of tape residue on the chair arms/table. The CM acknowledged the above.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to have completed Hepatitis B vaccination for 2 of 7 patients reviewed (Patient #1 and Patient #5). The findings included: 1. Patient #1 was admitted to the facility on 02/05/16. A review of the patient’s record revealed a Hepatitis (Hep) B antibody of 8 on 07/12/23, and 3 on 07/10/24 (less than 10 indicates no immunity). Further review of Patient #1’s record did not reveal any documentation of Hep B vaccination or booster offered. 2. Patient #5 was admitted to the facility on 10/10/23. A record review revealed a Hep B antibody of 27 on 01/09/24, 7 on 02/27/24, and 3 on 07/05/24 (no immunity). Further review of Patient #5’s record revealed the resident received the Hep B vaccination on 11/4/23, 01/27/24, and 05/01/24. The facility failed to administer the vaccine as per protocol. The second and third dose were not administered timely and there was no documentation of the 4th dose/series of the Hep B vaccination offered to Patient #5. An interview was conducted with the Clinical Manager (CM) on 09/05/24 at 11:00 AM. The CM stated the Hep B vaccine is administered in a series of 4: at 0, 1, 2, and 6 months. The CM acknowledged the above.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to complete a comprehensive reassessment for 1 of 7 patients reviewed (Patient #5). The findings included: A review of the facility’s policy titled Interdisciplinary Team Patient Assessment and Plan of Care, dated 01/14/01, documented: “A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment. A comprehensive assessment will be conducted within 30 days of a change in modality (or within 13 treatments). A follow up 90 day re-assessment will be completed to evaluate patient status and provide information to adjust the patient’s plan of care. Patient #5 was admitted to the facility on 10/10/23. Record review revealed Patient #5 had a modality change assessment dated 02/29/24. Further review of Patient #5’s records did not reveal a 90 day re-assessment completed. An interview was conducted with the registered Dietician (RD) on 09/05/24 at 12:00 PM. The RD acknowledged the above.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to complete a monthly re-assessment for a patient deemed unstable for 2 of 7 patients reviewed (Patient #1 and Patient #4). The findings included: A review of the facilities policy titled Interdisciplinary Team Patient Assessment and Plan of Care dated 01/14/01 documented: A comprehensive reassessment of each patient and a revision in the plan of care will be conducted at least monthly for unstable patients. 1. Patient #1 was admitted to the facility on 02/05/16. Record review revealed an unstable plan of care dated 03/08/23. Further record revealed the next plan of care was an annual plan of care dated 11/01/23. An interview was conducted with the Registered Dietician (RD) on 09/05/24 at 12:00 PM. The RD stated she could not locate a plan of care for the month of 02/24 when Patient #1 was deemed unstable. 2. Patient #4 was admitted to the facility on 07/11/23. A review of the facility’s log for unstable patients revealed Patient #4 was deemed unstable on 07/24/24 due to “concurrent conditions”. Record review revealed an unstable plan of care dated 07/24/24. Further record review did not reveal a completed plan of care dated 08/22/24. The plan of care did not have all Interdisciplinary team members signatures. An interview was conducted with the Registered Dietician (RD) on 09/05/24 at 12:00 PM. The RD acknowledged the above.”

“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: 36734 Based on observation, interview, and record review, the facility failed to use the correct ordered treatment for 1 of 3 observed treatments (Patient #2). The findings included: Patient #2 was admitted to the facility on 09/12/23. An observation of Staff A, a Patient Care Technician, initiating treatment on Patient #2 was conducted on 09/03/24 at 12:00 PM. After treatment was initiated on Patient #2, a review of the patient’s orders were reviewed with Staff A. The order dated 07/11/24 was to use an F160NR dialyzer. Patient #2 was observed receiving treatment with an F180NR dialyzer. Staff A acknowledged Patient #2 was receiving treatment with the wrong dialyzer. An interview was conducted with the Clinical Manager (CM) on 09/03/24 at 12:10 PM. The CM was made aware of the above. The CM went to observe the treatment for Patient #2, who was still receiving treatment with the wrong dialyzer, and informed Staff A to stop treatment.”

“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: 47207 Based on record review, and staff interviews the facility failed to provide an initial nursing assessment prior to first treatment for 1 of 7 patients reviewed (Patient #7). The findings included. Record review revealed Patient #7 started training for Home Peritoneal Dialysis (HPD) on 06/05/2024. The patient discontinued his HPD training on 06/10/2024, as documented in the medical records by the HPD nurse stating the patient and mother “Would like to try Hemodialysis”. The HPD nurse confirmed this on 09/05/2024 at approximately 1:20 PM in her office saying”Yes, he started as HPD but he and his mother, who takes care of him and is his power of attorney, decided it was too difficult to do at home so he went to In Center Hendiadys (ICHD).” The next nursing note for the patient occurred on 06/16/2024 the nurse note state “58 yo male patient here for treatment”. When asked if there was an initial assessment completed prior to this treatment, the Registered Dietician (RD) was unable to find any nursing assessment of the patient the day of or before his initial HD treatment on 06/16/24 to assess for any immediate needs. At approximately 2:30 PM on 8/05/2024 the Facility Administrator and Home Program Manager came in, they confirmed that the patient had discontinued HPD training and had chosen ICHD. Both then stated they where not aware that prior to a first treatment, an initial nursing note must be completed.”