Kidney Doctor’s Dialysis Center

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 40153 Based on record review and staff interviews, the dialysis facility failed to contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. The findings included: A review of the facility’s Emergency Preparedness plan revealed that the facility contacted the local county emergency management agency on 04/29/2022. Further review showed that the last time the facility contacted the local county was in 2022. In an interview conducted on 12/22/23 at 12:30 PM with the facility’s administrator, he stated that he had not contacted Emergency Management this year and acknowledged the findings.”

“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 emergency oxygen readily available, and failed to have emergency suction readily available. The findings included: An observation of the facility’s emergency cart was conducted with the Charge Nurse (CN) on 12/22/23 at 11:00 AM. Two emergency oxygen tanks were observed next to the emergency cart. Further observation of the two emergency oxygen tanks revealed the tanks without the key needed to open the tanks in order to deliver oxygen. The CN stated there were no other oxygen tanks located at the facility. An observation of the emergency suction machine revealed the suction tubing had expired in 04/2022. The CN stated there was not another emergency suction tubing in the facility.”

“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: 40153 Based on interviews and chart review, the facility failed to obtain an immunization history regarding pneumonia and influenza vaccines for 3 of 7 patients reviewed for immunization (Patient #2, Patient #4, and Patient #5). The findings included: A review of the facility policy titled “Prevention Strategies for Seasonal Influenza in Healthcare Settings,” dated 09/14/18, showed that The center would follow recommendations from the Center for Disease Control and Prevention (CDC) to decrease the risk of influenza transmission. They will monitor influenza activities and administration of antiviral treatment to patients when appropriate. 1. A record review revealed that Patient #2 was admitted to the facility on 10/31/2019 for home Peritoneal Dialysis (PD). Further review of Patient #2 ’ s immunization history showed that the Pneumonia vaccine was given on 08/08/2018, and no other records showed that a Pneumonia vaccine was given or offered after 08/08/2018. In a phone interview with the facility ’ s home PD nurse, she stated that Patient #2 refused the Pneumonia vaccine when it was offered earlier this year. When asked to see any documentation regarding the refusal, she said, “I think it is in Patient’s #2 ’ s medical chart”. 2. A record review revealed that Patient #4 was initially admitted to the facility on 03/16/2020 for in-house Hemodialysis. Further review of Patient #4 ’ s immunization history showed that Influenza vaccines were given on 10/16/2020 and 09/26/2022. No other records showed that Patient #4 received or was offered the Influenzas vaccine after 09/26/22.. A review of the facility ’ s Quality Assurance Performance Improvement (QAPI) meeting for November 2023 shows missing data on tracking and monitoring Influenza vaccines. In an interview conducted on 12/22/23 at 12:30 PM with the facility ’ s Administrator, he was told of the findings. 36734 3. Patient #5 was admitted to the facility on 03/08/22 for Hemodialysis treatment. Record review revealed Patient #5 did not have current immunizations for influenza and pneumonia. An interview was conducted with the alternate Facility Administrator (FA) on 12/22/23 at 12:00 PM. The FA acknowledged the above.”