Usrc Woodstock Dialysis

“CFC-WATER & DIALYSATE QUALITY CFR(s): 494.40 This Condition is not met as evidenced by: 33921 Based on observations, staff interviews, a review of facility Policy and Procedures (P & P) and a review of the manufacturer’s directions for use (DFU), it was determined that the facility failed to ensure that there was a safe environment for all in-center hemodialysis (ICHD) patients as evidenced by failure of all Direct Patient Care (DPC) Staff, {Patient Care Technicians- (PCTs) and Registered Nurses- (RNs)}, who were assigned to calibrate the Phoenix Meter, {a device used to measure pH (acidity) and Conductivity (measurement of the dialysate’s ability to conduct electricity)}, to discard and replace expired CalRite Standard Buffer Solution 7.00 (used to calibrate pH meters by providing a known pH value of 7.00), before use to ensure the pH result was accurate. In addition, the facility failed to ensure that RN CC performed the test for Residual Chlorine ( refers to the small amount of chlorine that remains in the dialysis water) that was used for mixing the Bicarbonate powder, (Naturalyte 4000 Rx-12), according to the manufacturer’s DFU and failure of RN CC to accurately perform per manufacturer’s DFU, the Peracetic Acid residual test (a procedure used to check for any remaining traces of peracetic acid disinfectant used to sanitize the water system) in dialysis water before mixing a dry pack bicarbonate. Complications as minor as nausea and fatigue or as severe as metabolic acidosis (decrease in pH that could cause rapid breathing, confusion, dizziness, shortness of breath, chest pain) could result if dialysate composition is incorrect. Additionally, testing residual chlorine in dialysis water used for mixing bicarbonate is crucial because chlorine, even at low levels, can be highly toxic to patients during hemodialysis, causing complications like methemoglobinemia (a condition where the blood’s ability to carry oxygen is impaired) due to its oxidative properties; therefore, carefully monitoring and removing chlorine from the water is essential for patient safety. Chlorine can also directly damage red blood cells and cause adverse reactions in dialysis patients, including cyanosis (blueish skin discoloration) and hemolytic anemia (destruction of red blood cells). Peracetic Acid is a potent disinfectant, if not completely rinsed, can be harmful to the patient. These deficient practices had the potential to negatively affect the health and safety of eight of eight patients (P), (P#8, P#9, P#10, P#11, P#12, P#13, P#14 and P#15), who were undergoing hemodialysis treatment at the time of this observation. The facility in-center patient census was 56. Findings were: Cross Reference: V 250 - Failure of the DPC staff (PCTs and nurses) to discard expired CalRite Standard Buffer Solution 7.00 and failure of Registered Nurse (RN CC) to perform the residual chlorine test using RPC E-Z Chek Residual Chlorine Test strip P/N K-100-0101B according to manufacturer’s DFU and failure of RN CC to accurately perform the Peracetic Residual test using RPC Microbe X Residual test strips K-100-0100 per manufacturer’s DFU, prior to Bicarbonate mixing.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 33921 Based on observations, facility record review, staff interviews, a review of the manufacturer’s Directions for Use (DFU) and a review of facility Policy and Procedure (P & P), it was determined that the Governing Body failed to demonstrate responsibility and accountability for the operations of the facility. This failure had the potential to negatively affect the health and safety of 56 in-center hemodialysis patients who were receiving in-center hemodialysis treatment at this facility. Findings were: Cross Reference: V 250 - Failure of the DPC staff (PCTs and nurses) to discard expired CalRite Standard Buffer Solution 7.00 and failure of Registered Nurse (RN CC) to perform the residual chlorine test using RPC E-Z Chek Residual Chlorine Test strip P/N K-100-0101B according to manufacturer’s DFU and failure of RN CC to accurately perform the Peracetic Residual test using RPC Microbe X Residual test strips K-100-0100 per manufacturer’s DFU, prior to Bicarbonate mixing.”

“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: 33921 Based on observation, staff interviews, and a review of the Food and Drug Administration (FDA) recommendations and manufacturer’s Directions for Use (DFU), it was determined that the facility (specifically the Home Training Unit), failed to ensure that expired medications and supplies in one of one Emergency Crash Cart, in one of one Emergency Evacuation Box, and in one of one Medication Refrigerator, were removed and not made available for use, and re-supplied in order to be in a ready-to-operate condition. This deficient practice had the potential to negatively affect the health and safety of all 27 Peritoneal Dialysis (PD) patients, and all 12 Home Hemodialysis (HHD) patients, who were under the care of this facility. Findings were: During a tour of the Home Training Unit with the Home Program Manager on 1/14/25 at 10:30 a.m., the following was revealed: In the Emergency Crash Cart: - One pad used for an Automatic External Defibrillator (a portable device that analyzes heart rhythm and delivers an electric shock to restore a normal rhythm during cardiac arrest), expired 10/2024, therefore it was not in a ready-to-operate condition. - One of one oxygen tank was empty. - There was no oral airway access device and suctioning equipment. - Two Epinephrine Injection ampules (1 milligram/ampule), used for emergency treatment of severe allergic reactions {including anaphylaxis} to insect bites, medicines, food, or other substances), expired 10/2024. In the Emergency Evacuation Box: - Eight prefilled 0.9% sodium chloride IV lock/flush syringes (used to help prevent vascular access systems blockage and to clear any medication that may be left at the catheter site), expired 4/30/24. - Four Normal Saline Solution bags (1000 milliLiter (mL)/bag), used in intravenous drips to treat dehydration, electrolyte imbalances, and used to replace extracellular fluids such as in cases of hemorrhage, sepsis, and hypovolemia, expired 10/2024. In the Medication Refrigerator: - One Pneumococcal 13-valent conjugate vaccine (vaccine to prevent pneumococcal disease), expired 12/2024. - One Engerix B vial (20 micrograms/mL), is a Hepatitis B vaccine that protects against chronic and acute hepatitis B infection, expired 8/12/24. - The Home Program Manager, who was present during the tour, acknowledged this observation on 1/14/25 at 10:35 a.m. - The Registered Nurse (RN AA) stated on 1/14/25 at approximately 10:45 a.m., that she didn’t know she was supposed to check the evacuation box. According to FDA recommendation dated 2/8/21, drugs’ expiration dates reflect the time period during which the product is known to remain stable, which means it retains its strength, quality, and purity when it is stored according to its labeled storage conditions. Several potential harms may occur from taking an expired medication or using expired supplies. Once the expiration date has passed there is no guarantee that the medicine or supplies will be safe and effective.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 33921 Based on observation, a review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, a review of facility Policy and Procedures (P & P) and staff interview, it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse, (RN AA), who was observed during Peritoneal Dialysis (PD) training on PD patient (P#16), consistently practiced infection control techniques, and consistently performed hand hygiene (washed hands or used an alcohol-based hand sanitizer), when touching contaminated area or tasks and before touching/handling clean supplies. This deficient practice had the potential for P#16 to learn breaches in infection control techniques including poor hand hygiene practices during initiation of PD treatment which had the potential for cross contamination and infection. The PD patient census was 27. Findings were: During observation of P#16’s PD training (second day of training), on 1/15/25 between 2:43 p.m. and 3:10 p.m., by RN AA, the following was revealed: - RN AA and P#16 performed hand hygiene by handwashing. Then without wearing gloves, RN AA removed the old tape (considered dirty) from P#16’s PD catheter exit site. RN AA did not perform hand hygiene after discarding the contaminated tape. P#16 cleansed the exit site with a sterile gauze moistened with a disinfectant. The trash can was located against the wall which was approximately 3 feet from P#16. When P#16 mentioned to RN AA regarding the distance to the trash can, RN AA told P#16, just throw it over. So P#16 threw the contaminated gauze to the trash can (like shooting it up on air) trying to make sure the contaminated gauze reached the trash can. This throwing of contaminated items continued throughout the initiation of PD treatment. P#16 was also touching her hair twice to move her hair away from her face. Without first performing hand hygiene, RN AA touched P#16 abdomen close to the exit site, then without performing hand hygiene, RN AA took more clean supplies from the drawer. A box of wrapped sterile gauze dropped to the floor (dirty area), then RN AA picked the box up and returned it to the counter of clean supplies (clean). RN AA also, after touching and pressing the effluent (the fluid that is drained from a patient’s peritoneal cavity after dialysis) drain bag that was on the floor (dirty), did not perform hand hygiene. - According to the CDC, cross contaminating (going from dirty to clean tasks or area), could cause the spread of bacteria/infections. A review of facility Policy #C-IC-0010, titled, “Infection Control and Precautions for All Patients”, with latest revision date of 07/2023, stated: 3. Clean areas will be clearly designated and separated from contaminated areas and unused supplies and equipment. 10. Hand Hygiene: b. Staff will perfomr hand hygiene: i. Using soap and water or antimicrobial hand sanitizer before/after all patient contact... This observation was reviewed with RN AA on 1/16/25 at approximately 3:00 p.m. and RN AA agreed about the potential for cross contamination.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 33921 Based on observation, staff interview, a review of the Centers for Disease Control and Prevention (CDC) guidelines and recommendations, and a review of facility Policy and Procedures (P & P), it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse, (RN DD), who was observed during initiation of hemodialysis (HD) treatment on two of two patients (P), (P#8 and P#9), who had Central Venous Catheters (CVCs), utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of (P#8 and P#9), and other patients who had CVCs, as their primary dialysis access. The facility had 56 in-center hemodialysis patients. Findings were: During observation in the Patient Treatment Room on 1/14/25 between 11:05 a.m. and 12:15 p.m., the following was revealed: - RN DD was observed during initiation of HD treatment to P#8 at Station (S3), who had a CVC as primary access. Every time RN DD performed cleansing/disinfection of each catheter hub, RN DD dropped the uncapped, disinfected hub into the blue liner (nonsterile), which had the potential for cross contamination. - When this observation was brought to RN DD’s attention on 1/14/25 at 11:10 a.m., she stated that she was new and had just completed her training. - RN DD repeated the same breach in infection control (as mentioned above), while initiating HD treatment to P#9 (who had a CVC) at S2, on 1/14/25 at 12:00 p.m. - According to the CDC, cross contaminating (going from dirty to clean tasks or area), could cause the spread of bacteria/infections. - A review of facility Policy # C-TI-0090, titled, “Accessing and De-Accessing the Dialysis Catheter”, with latest revision date of 06/2024, stated: 6. Hub disinfection: NOTE: Any time the catheter is disconnected from the bloodlines or caps are removed/applied (e.g., initiation/termination of treatment; transposing the lines), clean the sides (threads) and end of hub thoroughly with friction, making sure to remove any residue (e.g. blood); do not drop the hub or allow hub to touch non-sterile surfaces to prevent contamination.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 33921 Based on observations, staff interviews, a review of facility Policy and Procedures (P & P) and a review of the manufacturer’s directions for use (DFU), it was determined that the facility failed to ensure that there was a safe environment for all in-center hemodialysis (ICHD) patients as evidenced by failure of all Direct Patient Care (DPC) Staff, {Patient Care Technicians- (PCTs) and Registered Nurses- (RNs)}, who were assigned to calibrate the Phoenix Meter, {a device used to measure pH (acidity) and Conductivity (measurement of the dialysate’s ability to conduct electricity)}, to discard and replace expired CalRite Standard Buffer Solution 7.00 (used to calibrate pH meters by providing a known pH value of 7.00), before use to ensure the pH result was accurate. In addition, the facility failed to ensure that RN CC performed the test for Residual Chlorine ( refers to the small amount of chlorine that remains in the dialysis water) that was used for mixing the Bicarbonate powder, (Naturalyte 4000 Rx-12), according to the manufacturer’s DFU and failure of RN CC to accurately perform per manufacturer’s DFU, the Peracetic Acid residual test (a procedure used to check for any remaining traces of peracetic acid disinfectant used to sanitize the water system) in dialysis water before mixing a dry pack bicarbonate. Complications as minor as nausea and fatigue or as severe as metabolic acidosis (decrease in pH that could cause rapid breathing, confusion, dizziness, shortness of breath, chest pain) could result if dialysate composition is incorrect. Additionally, testing residual chlorine in dialysis water used for mixing bicarbonate is crucial because chlorine, even at low levels, can be highly toxic to patients during hemodialysis, causing complications like methemoglobinemia (a condition where the blood’s ability to carry oxygen is impaired) due to its oxidative properties; therefore, carefully monitoring and removing chlorine from the water is essential for patient safety. Chlorine can also directly damage red blood cells and cause adverse reactions in dialysis patients, including cyanosis (blueish skin discoloration) and hemolytic anemia (destruction of red blood cells). Peracetic Acid is a potent disinfectant, if not completely rinsed, can be harmful to the patient. These deficient practices had the potential to negatively affect the health and safety of eight of eight patients (P), (P#8, P#9, P#10, P#11, P#12, P#13, P#14 and P#15), who were undergoing hemodialysis treatment at the time of this observation. The facility in-center patient census was 56. Findings were: - During a tour with the Facility Administrator on 1/14/25 at 10:55 a.m., of the facility’s Bicarbonate Mixing Room, where the Tri-Station (station for rinsing, disinfection, calibration and verification of Phoenix Meters - a device used to measure pH and conductivity) was located, it was discovered that an opened/used CalRite Standard Buffer Solution 7.00 had expired since 11/2024. The Facility Administrator acknowledged this observation on 1/14/25 at 10:55 a.m. - On 1/15/25 at 5:33 a.m., RN CC was observed performing the Chlorine Residual test of the dialysis water (to be used for mixing the bicarbonate powder), using RPC E-Z Chek Residual Chlorine Test strip P/N K-100-0101B. RN CC filled a cup with 100 ml of dialysis water sample, then swished the test strip in the water sample gently moving it back and forth for 60 seconds using his wrist watch. The wall clock was not working and RN CC had to tap on his watch several times for it to show the time. After removing the test strip from the water sample, RN CC waited 20 seconds before comparing the test result in the color chart. According to the manufacturer’s DFU (found on the strip bottle), immerse the test strip and move the test strip vigorously for 30 seconds then compare the test strip to the color chart within 10 seconds. According to the facility’s copy of the manufacturer’s DFU: (The facility highlighted the “Directions for Qualitative Results”), before presenting it to this surveyor. 1. Directions for Qualitative Results ( indicates whether chlorine is present above a certain level (e.g. “positive” or “negative”)... Hold the reagent area in the rinse stream for 5 seconds. If no color is apparent immediately upon removal, the chlorine level is less than 0.5 ppm (parts per million) and no further rinsing is indicated... 2. Directions for Quantitative Results (gives a specific concentration of chlorine (e.g. 0.5 ppm)... used when precise chlorine levels are critical like in dialysis water. Fill standard sample cup with solution. Discard solution and re-fill. Immerse reagent area of test strip in solution and move strip back and forth vigorously for 30 seconds. Remove test strip and compare to color chart within 10 seconds. Manufacturer’s warning: Improper strip activation and color interpretation may result in patient injury. - On 1/15/25 at 5:40 a.m., RN CC was also observed performing the Peracetic Acid residual test using RPC Micro X Residual Test Strips K100-0100. RN CC dipped and swished the test strip in the dialysis water sample for 20 seconds and immediately compared the strip to the color chart. - According to the manufacturer’s DFU (found in the test strip bottle): Dip the strip for one second and after five seconds compare the test strip to the color chart. A review of facility Policy # TM 03-03, titled, “Bicarbonate Mixing and Handling”, with revision date of 8/2021, stated: 4. Perform Bleach residual test. Results must be <0.5 ppm... 5. Perform Peracetic Acid (Micro X) residual test. Results must be <3 ppm... A review of the facility’s Policy #TM 06-05, titled, “Phoenix-Phoenix XL Meter Cleaning and Calibration”, with revision date of 08/2020, stated: Tri-Station Maintenance: Daily: ... Label bottles with initials, date & time solutions were changed. Verify expiration dates on all calibration and cleaning solutions. discard any solution bottle that has visible microbial growth. There was no specific instructions in the Policy to make sure to discard all calibration and cleaning solutions when expired (both manufacturer’s expiry date and specific DFU when to discard after opening the different solution bottles.”

“PE-PT CARE ENVIRONMENT-SUFFICIENT SPACE CFR(s): 494.60(c)(1) The space for treating each patient must be sufficient to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. This Standard is not met as evidenced by: 33921 Based on observation and staff interview, it was determined that the facility failed to ensure that the passageway to the three electric circuit breakers were free from obstacles to ensure safety and easy passage for Direct Patient Care Staff (nurses) to reach the electric circuit breakers as needed, and ensuring lights were maintained and functioning. This deficient practice had the potential to negatively affect the safety of one of one Peritoneal Dialysis (PD) Registered Nurse (RN AA) and two of two Home Hemodialysis (HHD)/PD RNs (RN BB and RN EE), who worked at the Home Program Training Unit. Findings were: During a tour of the Home Program Training and Support Unit with the Home Program Manager on 1/14/25 at 10:00 a.m., the following was observed: The three electric circuit breakers located in a small room off of Home Training PD #2, had cardboard and styrofoam boxes on top of a refrigerator, that blocked the door of the three electric circuit breakers. The room was also dark because the overhead flourescent light was not functioning. The Home Program Manager acknowledged these findings during the tour on 1/14/25 at 10:00 a.m.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 33921 Based on a review of records and staff interview, it was determined that the facility failed to ensure that two of two sampled home hemodialysis (HHD) patients’ (P#3’s and P#4’s) treatment flowsheets were reviewed at least every two months, to determine if the patients were following their prescribed treatment plans and/or having problems with dialysis at home. Failure to monitor home patient’s status by reviewing dialysis treatment records, and especially testing of total chlorine prior to treatment when using a new batch of dialysate (SAK), could negatively affect the health and safety of P#3 and P#4, and all the other 10 HHD patients who were under the care of this facility. Findings were: A review of P#3’s and P#4’s treatment flowsheets revealed the following: - There was no documentation to confirm that all the patients’ home treatment flowsheets were reviewed by a nurse, to determine if P#3 and P#4 were following their prescribed treatment plan or if they were having any documented problems with home dialysis. - P#3 was using NxStage Pureflow SL (a water purification system that’s used to make dialysate for home hemodialysis treatments). A review of P#3’s flowsheets from 11/15/24 through 1/12/25) did not show any total chlorine testing prior to each P#3’s treatments. - A review of the facility’s Policy # SC-TE-0070, titled, “Total Chlorine Testing - NxStage Pureflow”, with latest revision date of 02/2021, stated: 5. The NxStage Pureflow SL requires total chlorine testing after the preparation of each batch of dialysate (SAK). Once a batch is made, no change to the chemical composition can occur with respect to chlorine and chloramines. If the test fails, the patient must drain the batch, install and prime a new PAK, prepare a new batch, then retest for total chlorine. 6. If the result of total chlorine testing is <0.1 ppm (parts per million) on product water, no additional testing is needed until the next batch (SAK) is prepared. - P#4 was also using NxStage Pureflow SL. A review of P#4’s flowsheets between 11/14/24 through 1/6/25, showed that total chlorine was not tested prior to HHD treatment on 12/2/24, 12/17/24 and 12/20/24. - During an interview with the HHD Registered Nurse (RN BB) on 1/16/25 at approximately 1:00 p.m., RN BB stated that she had reviewed P#3’s and P#4’s flowsheets, and had encouraged and reminded P#3 to record her total chlorine test prior to each treatment. RN BB further stated that P#3 told her that she (P#3), checked the total chlorine prior to each treatment, however, there were no documentary evidences that P#3 tested the total chlorine prior to each treatment. RN BB also stated that P#3 used a new batch of dialysate (SAK) every treatment. - There was no documentary evidence that the treatment flowsheets of P#3 and P#4 were reviewed by RN BB. P#3 and P#4 were not available for an interview. - According to the AAMI (Association for the Advancement of Medical Instrumentation), the maximum allowable level of total chlorine in dialysate is 0.1 mg/L ppm. High levels of total chlorine can directly damage red blood cells and cause adverse reactions in dialysis patients, including cyanosis (blueish skin discoloration) and hemolytic anemia (destruction of red blood cells).”

“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: 33921 Based on medical record review, staff interview, and facility Policy review, it was determined that the facility failed to ensure that a follow up home visit (to minimize the risk of recurrent peritonitis by addressing potential sources of contamination in the patient’s home environment) and retraining (to reinforce proper catheter handling, aseptic technique, and other important aspects of Peritoneal Dialysis management to prevent future infections), was conducted for one of one Peritoneal Dialysis (PD) patient, (P#6) sampled, who had a history of Peritonitis (a life-threatening condition that occurs when the peritoneum {the tissue lining the abdomen}, becomes inflamed which is usually caused by bacterial or fungal infection, injury or other diseases), on 3/29/24. This deficient practice had the potential to negatively affect the health and safety of P#6. The facility census for PD was 27. Findings were: A review of facility records revealed that P#6 was admitted to PD on 2/7/23. P#6 had peritonitis education as part of P#6’s initial PD training on 2/8/23. P#6 was diagnosed with Peritonitis on 3/29/24, caused by Gram Negative Bacilli (bacteria). There was no documented evidence that a home visit was conducted after P#6’s peritonitis infection and there was no evidence that P#6 was retrained to prevent future peritonitis infections since 3/29/24. - During an interview with PD Registered Nurse (RN AA) on 1/16/25 at approximately 1:00 p.m., she stated that she always taught her patients infection control and prevention of peritonitis. RN AA admitted that she had not conducted a home visit post P#6’s peritonitis infection. - A review of facility Policy # HT-PG-0061, titled, “Peritoneal Dialysis Training Program”, with latest revision date of 7/2024, stated: 4. Retraining (nonbillable) may also be provided for, but not limited to: a. Recent peritonitis... Home visits by the home training nurse should be included as part of initial patient training. The home assessment will be conducted prior to the initiation of performing treatments at home. There was no specific policy regarding other home visits, such as post peritonitis infection.”