Davita Miami Jewish Dialysis

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 47207 Based on observation and interview, the facility failed to ensure that staff followed the standard infection control precautions for 1 out out of 13 sampled patients by not disposing of potentially infectious waste appropriately. The findings included: During an observation conducted at Station #1 for Patient #12 at approximately 10:20 AM, Staff H/ Patient Care Technician (PCT) was observed putting syringes with blood on a clean table instead of disposing of them in a sharp container. During an interview conducted on 9/09/2025 at 10:40 AM, Staff H/PCT acknowledged the above findings. During an interview conducted on 9/11/2025 at 5:00 PM, Staff B/ Facility Administrator acknowledged the above findings.”

“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: 47207 Based on policy review, observation and interviews, the facility failed to demonstrate that staff followed the standard infection control precautions by not cleaning the dialysis chair appropriately for 1 out of 13 sampled patients. Patient #8 The findings included: A review of the facility’s policy titled Infection Control for Dialysis Facilities Policy 1-05-01 Section Disinfection revealed it included but was not limited to: 12. Cleaning and/or disinfection of equipment and work surface will be performed as soon as possible following exposure to blood or other potentially infectious materials( i.e., used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. ... b. Use an appropriate disinfection such as 1:100 bleach solution for routine disinfection of environmental surfaces. iii Surfaces should be allowed to air dry in order to provide sufficient disinfection contact time. On 9/11/2025 at approximately 10:00 AM, Staff M/ Patient Care Technician (PCT) was observed cleaning Station #5 which had been previously used by Patient #8. Staff M (PCT) was observed cleaning the side wings of the dialysis chair with bleach solution and immediately closed them. When the surveyor asked Staff M (PCT) approximately how long he was supposed to leave the sides of the chairs open; Staff M (PCT) replied “for 2 to 3 minutes”; he then stopped and proceeded to open the chair sides. During an interview conduced on 9/11/2025 at approximately 11:30 AM, Staff L (Manager Clinical Services) acknowledged the above findings.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 47207 Based on observations and interviews, the facility failed to educate 4 out of 13 sampled patients on the appropriate Guidelines for the Prevention of Intravascular Catheter-Related Infections” . Patient #3, Patient #5, Patient #11 and Patient #12 The findings included: A Review of the facility’s Policy titled Infection Control for Dialysis Facilities Section Hand Hygiene revealed it included but was not limited to: 1. All teammates, Physicians and Non physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area b. prior to gloving and immediately after removal of gloves c. After contamination with blood or other infectious materials d. after patient and dialysis delivery system contact e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines from dialysis machine, changing acid types, when exchanging dialysis machine) f. between patients even if contact is casual g. before touching clean areas such as supplies, supply cart and chair side keyboard/mouse 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to initiation of dialysis. b. Perform hand hygiene after treatment leaving treatment area. 1) Observation conducted on 9/09/2025 at approximately 10:15 AM, revealed Staff F, Patient Care Technician (PCT) touched the dialysis machine, and proceeded to touch Patient #12’s central catheter without changing gloves. 2) Observation conducted on 9/10/2025 at approximately 10:16 AM revealed Staff H/ PCT did not change gloves between touching the central catheter and Patient #5 throughout the treatment process. Additionally, Patient #5 was then observed leaving the facility without being asked to wash his hands by Staff H/ PCT. The surveyor informed Staff L (Manager Clinical Services) and Staff B (Facility Administrator) of the above findings on 9/11/2025 at approximately 11:30 AM and 4:30 PM respectively. 3) During an interview conducted on 9/11/2025 at approximately 11:00 AM, Patient #3 stated that he had never been informed that he should wash his hands and access extremity upon entering the treatment area prior to initiation of dialysis. 4) On 9/11/2025 at approximately 1:30 PM, Patient #11 was observed being brought in for dialysis treatment. Further observation revealed that Patient #11 did not wash his hands and the fistula was not cleaned by the staff. During an interview conducted on 9/11/2025 at 5:00 PM, Staff B (Facility Administrator) acknowledged the above findings.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 47207 Based on observation, interviews, and policy review, the facility failed to ensure all policies and procedures relative to patient care are adhered to by all individuals who treat patients in the facility for 1 out of 13 sampled patients. Patient #11 The findings included: A review of the facility’s Nursing Home Dialysis Agreement policy under section 2 Center obligations revealed it included but was not limited to: 3. Designated Resident Information e. Treatment presently being provided to the Designated Resident, including medications and any changes in a patient’s condition (physical or mental), change of medication, diet or fluid intake:” Record review revealed that Facility B is supposed to provide a Dialysis Communication Form to Facility A when a patient is brought down from the floor. 1) During an interview conducted on 9/10/2025 at approximately at 2:30 PM, Staff L (MCS) was asked about the communications policy and to show that this form had been brought down for Patient #11. After looking through the documentation provided from the floor for other Nursing Home patients, Staff L (MCS) stated “I don’t see it here. I was looking at the envelope for him and I do not see one for him here. The staff is supposed to call the floor if they do not receive it.” 2) During an interview conducted on 9/10/2025 at approximately 3:00 PM, Staff B/ Facility Administrator was asked about the facility’s process when the Nursing Home fail to send the communication form, he stated: “The nurse should call the floor to get a communication report sent for the patient.””