Pure Life Renal of Miramar

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 40153 Based on interview and record review, the facility failed to ensure that Hepatitis B vaccination was given in an “appropriate timeframe” for 1 of 6 patients reviewed for vaccinations (Patient #5). The findings included: A review of the facility’s policy titled “Hepatitis B Vaccine,” revised on 04/01/08, revealed that the Hepatitis vaccine is used to prevent the hepatitis B virus in the dialysis population. It further showed the documentation of the name of the medication, dose given, time, and the signature of the person administrating it. A review of the End Stage Renal Disease Interpretive Guidelines, dated October 3, 2008, adopted by reference 42 CFR 494.30 (a), showed that a Hepatitis B vaccination schedule in an appropriate timeframe means that vaccination should be offered and initiated upon admission. A record review dated 04/10/24 revealed that Patient #5 was admitted to the facility for in-house Hemodialysis on 03/04/24. A consent form signed by Patient #5 revealed that he wished to have the Hepatitis B vaccine, signed by Patient #5 and dated 03/04/24. Further review did not show that the Hepatitis vaccine was given or started on Patient #5, which was five weeks after his initial admission. In an interview conducted on 04/08/24 at 2:00 PM with the facility’s Administrator, she knew that Patient #5 consented to receive the Hepatitis B vaccine, which has not been given yet.”

“IC-HBV-ISOLATION (EXISTING FACILITY) CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, designate a separate room for their treatment. For existing units in which a separate room is not possible, HBsAg positive patients should be separated from HBsAg susceptible patients in an area removed from the mainstream of activity. This Standard is not met as evidenced by: 47207 Based on observations and interviews, the facility failed to ensure that Staff followed isolation guidelines while initiating CVC connection for patient #1. Findings include: Patient #1 was observed walking into the dialysis room on 4/08/2024 at 2:50 PM and sitting down in the isolation room. Patient care technician (PCT) B was observed on 4/08/2024 at 3:00 PM coming into the isolation room to begin the process of initiation of the CVC catheter for dialysis. PCT B completed the initiation process without issue, however, she had not closed the door to the isolation room during initiation process. During an interview with Registered Nurse (RN) staff A on 4/08/2024 at 315 PM she was asked why the door remained open during the process of initiation of the CVC catheter. She stated, “we did not know it should be closed”. Staff A went over to the isolation room and asked staff B to close the door, which she immediately did. The Facility Administrator later on 4/10/2024 during the exit interview around 11:00 AM acknowledged that they had not been aware of this and would make sure to always close the isolation room door during initiation and disconnection of access lines during dialysis.”

“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: 40153 Based on interview and record review, the facility failed to provide a yearly up-to-date Fire Safety Inspection Report by Broward County. The findings included: During the record review, the facility ’ s Administrator could not provide the Surveyor with an updated yearly Fire Safety Inspection Report. In this review, the facility ’ s Administrator stated that the last Fire Safety Inspection was conducted in 2022.”

“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 observation and interview, the facility failed to obtain an immunization history regarding pneumonia and influenza vaccines for 2 of the six patients reviewed for vaccinations (Patient #5 and Patient #6). The findings included: A review of the facility’s policy, “Pneumococcal Vaccine Administration,” revised on 04/01/2018, revealed that the vaccine is intended for patients at risk for pneumococcal infections. A review of the facility’s policy, “Influenza Virus Policy and Information,” revised on 04/01/2018, revealed that the vaccine is intended to protect patients against the influenza virus. A chart review revealed that Patient #5 was admitted to the facility for in-house Hemodialysis on 03/04/24. Closer review showed that Patient #5 was given the consent form for the Pneumococcal vaccine. It showed “Patient refused” but did not have a date or a signature of Patient #5 on the form. A record review revealed that Patient #6 was initially admitted to the facility for in-house Hemodialysis on 06/09/23. He later started training for home Peritoneal Dialysis on 02/02/24, and his first home Peritoneal Dialysis treatment was on 03/07/24. Further review showed no Pneumococcal and Influenza immunization history for Patient #6. In an interview with the facility’s Administrator on 04/10/24 at 1:00 PM, she acknowledged all findings.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 40153 Based on record review and interview, the facility failed to have appropriate Registered Dietician interventions for two of the six patients reviewed (Patient #5 and Patient #6). The findings included: A review of the facility’s policy titled “Progress Notes,” revised on 04/01/2028, showed that Each discipline requires a monthly note to record services rendered and evaluate. Guidelines for dietary progress notes include abnormal lab values, diet-related problems, fluid weight gain, and daily average protein, potassium, and sodium intake. Record review revealed that Patient #5 received his first in-house dialysis treatment in the facility on 03/04/24. The nurse’s note dated 03/27/24 revealed a Dietary Consult, which the facility’s Dietitian still needs to address. Further review did not show that the facility’s Registered Dietitian evaluated Patient #5’s nutritional status and nutrition-related labs. A record review revealed that Patient #6 was initially admitted to the facility for in-house hemodialysis on 06/09/23. He later started training for home Peritoneal Dialysis on 02/02/24, and his first home Peritoneal Dialysis treatment was on 03/07/24. The nurse’s note dated 01/31/24 revealed a Dietary Consult, which the facility’s Dietitian did not address. In an interview with the facility’s Administrator on 04/10/24 at 1:00 PM, she acknowledged all findings.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 40153 Based on the interview and record review, the facility failed to complete an initial care plan for 2 of 6 sampled patients reviewed (Patient #4 and Patient #5). The findings included: A review of the facility ’ s policy titled “Interdisciplinary Assessment and Plan of Care,” revised on 04/01/2018, revealed that the Comprehensive Assessment and Patient Care Plan must be completed within 30 days or 13 outpatient Hemodialysis treatments. The Care Plan will specify services necessary to address needs identified in assessment and change in condition. Patient #4 was admitted for in-house Hemodialysis on 01/22/24. The Social Service note dated 01/24/24 revealed that Patient #4 is new to dialysis. A review of the medical records showed that no initial care plan was completed for Patient #4. A chart review revealed that Patient #5 was admitted to the facility for in-house Hemodialysis on 03/04/24. A closer review showed that the facility still needs to complete an initial care plan for Patient #5. In an interview conducted on 04/10/24 at 1:00 PM with the facility ’ s Administrator, she stated that some of the care plans are behind and acknowledged all findings.”

“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: 47207 Based on policy review, medical record review and interview, the facility failed to ensure the staff followed the guidelines for care plans for an unstable patient. The findings included: Reviewed The facility policy: Policy 1.20 Interdisciplinary Assessment and Plan of Care 3. The criteria that defines “unstable status” are: Extended or frequent hospitalizations (i.e., hospitalizations longer than 15 days, and more than 3 hospitalizations within 30 days). Review of the patient’s medical records indicate the patient was started 8/23/2023 a nursing assessment had been completed on that day and an initial care plan was completed 8/29/2023. The patient was in the facility until 9/21/2023 and was hospitalized until 12/08/2023. There was no care plan indicating the patient was unstable. During an interview with the Facility Administrator on 4/10/2024 at 1030 AM the FA stated that she had been concerned about the particular patient and his multiple visits to the hospital and the facilities documentation.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 40153 Based on record review and interview, the facility failed to have appropriate Social Work interventions for 1 of 6 patients reviewed (Patient #6). The findings included: A review of the facility ’ s policy titled “Progress Notes,” revised on 04/01/2028, showed the following: each discipline requires a note monthly(quarterly for social workers) to record services rendered and evaluate them. A record review revealed that Patient #6 was initially admitted to the facility for in-house hemodialysis on 06/09/23. He later started training for home Peritoneal Dialysis on 02/02/24, and his first home Peritoneal Dialysis treatment was on 03/07/24. Further record review showed no Social Worker interventions in the last five months. In an interview conducted on 04/10/24 at 1:00 PM with the facility ’ s Administrator, she was unaware that Patient #6 did not have Social Worker follow-up notes.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 40153 Based on record review and interview, the facility failed to have monthly physician progress notes for 4 of 6 patients reviewed (Patient #1, Patient #2, Patient #3, and Patient #6). The findings included: A review of the facility’s policy titled “Progress Notes,” revised on 04/01/2018, showed the following: Each discipline is required to enter its notes in the facility’s electronic medical record monthly to record services rendered and evaluate. A record review revealed that Patient #3 was admitted to the facility for in-house Hemodialysis on 10/20/2021. A review of the Physician follow-up monthly notes showed that none were completed after 01/29/24. A record review revealed that Patient #6 was initially admitted to the facility for in-house Hemodialysis on 06/09/23. He later started training for home Peritoneal Dialysis on 02/02/24, and his first home Peritoneal Dialysis treatment was on 03/07/24. Further review showed no monthly physician follow-up notes completed from 01/31/24 to 03/14/24. In an interview with the facility’s Administrator on 04/10/24 at 1:00 PM, she acknowledged all findings. 47207 Patient # 1 was admitted to the facility 10/11/2023 a medical record review completed 4/09/2024 showed no MD notes for the months of 11/2023 and 2/2024. In an interview with the Facility Administrator (FA) on 4/09/2024 at 200 PM she stated that the MD had not completed notes for the month of 2/2024. She stated she was not sure why there was no MD note for 11/2023. Patient # 2 was admitted to the facility 8/23/2023 a medical record review completed 4/10/2024 showed no MD notes for the month of 2/2024. In an interview with the 4/10/2024 around 11:00 AM, she again stated the MD had not completed notes for the month of 2/2024.”

“H-MONITOR HOME ADAPT;HOME VISIT=POC CFR(s): 494.100(c)(1)(i) Services include, but are not limited to, the following: (i) Periodic monitoring of the patient’s home adaptation, including visits to the patient’s home by facility personnel in accordance with the patient’s plan of care. This Standard is not met as evidenced by: 40153 Based on the interview and record review, the facility failed to conduct a home visit for a Patient who started home Peritoneal Dialysis before or at the time of the initiation of home therapy for 1 of 1 Patient reviewed for Peritoneal Dialysis (Patient #6). The findings included: A review of the facility ’ s policy titled Peritoneal Dialysis Policy and Procedure,” revised on 03/2016, showed the following: a home visit should be conducted at the initiation of home therapy to assess the patient ’ s home environment and its suitability for home dialysis. A record review revealed that Patient #6 was initially admitted to the facility for in-house hemodialysis on 06/09/23. He later started training for home Peritoneal Dialysis on 02/02/24, and his first home Peritoneal Dialysis treatment was on 03/07/24. Further review revealed that the peritoneal dialysis home visit conducted by the peritoneal dialysis nurse was done on 03/27/24, 20 days after Patient #6 started his first treatment at home. In an interview conducted on 04/10/24 at 1:00 PM with the facility ’ s Administrator, she stated that she was unaware that the Peritoneal Dialysis Nurse conducted the home visit after Patient #6 started his treatments at home.”