Emory Dialysis Saint Joseph’s

“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 interview, a review of the Food and Drug Administration (FDA) recommendations, and a review of facility Policy, it was determined that the facility failed to ensure expired medications in one of one Medication cabinet, in one of one Emergency Crash Cart (a rolling set of trays or drawers that carries equipment, medications, and other medical supplies, to transport and dispense emergency medication and equipment at the site of a medical emergency for life support protocols to potentially save someone’s life), and supplies in one of one Laboratory Supply Cabinet, in one of two Supply Shelves, and in one of one Eyewash Station (a station with a flushing device required by Occupational Safety and Health Administration (OSHA), suitable for quick drenching or flushing of the eyes for immediate emergency use), were removed and not made available for use. This deficient practice had the potential to negatively affect the health and safety of all five Peritoneal Dialysis (PD) patients who were under the care of this facility. Findings include: During a tour of the PD facility with the Facility Administrator on 12/27/23 at 2:10 p.m., the following medications and supplies had expired, thus these were not suitable for immediate use. In the Medication Cabinet: - 10 vials of Vancomycin 1 gram injections (antibiotic), expired 11/2023. In the Crash Cart (Emergency cart): - Two Calcium Chloride 10% injections (for treatment of hypocalcemia in those conditions requiring a prompt increase in blood plasma calcium levels), expired 12/1/23. - One box of Even Care G3 Blood Glucose Strips (used for testing blood sugar levels), expired 9/15/22. - One box of safety lancets expired 2/2018. - Three bags of Normal Saline Solution (used for the management and treatment of dehydration, such as hypovolemia, shock, metabolic alkalosis in the presence of fluid loss, and mild sodium depletion), 1000 mL per bag, expired 12/2022. In the Supply Shelf: - Seven bags of Peritoneal Dialysis Solution with 2000 mL (milliliters) per bag, expired 12/2022. - 34 bottles of Alcavis 50 (high level disinfectant), expired 8/2020. - 1 bottle of Disinfectant hand soap, expired 2/2020. - Three bottles of 70% Isopropyl Alcohol (Antiseptic) expired 8/2021. In Laboratory Supply Cabinet: - 10 Gold top tubes expired 12/5/23 - Two solid dark red top tubes expired 11/30/23 - 10 bright red top tubes expired 11/1/23 - 10 green top tubes expired 10/11/23 - 10 swabs for exit site cultures expired 2/2023 - Five swabs for exit site cultures expired 9/2023 In the Eyewash Station: - One bottle of Eye Saline (for eyewash) expired 7/2021. - According to FDA recommendation dated 2/8/21, drug and supplies’ 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 medications or using expired supplies. Once the expiration date has passed there is no guarantee that the medicine or supplies will be safe and effective. When asked for Medication Expiration Policy, the Home Program Manager only provided Policy (No number), titled, “Expiration Date Policy”, developed 8/2019, which stated: Policy: The following medical supplies should be discarded after the appointed expiration date. Supplies: - Alcavis 50 - Expiration date - six months after opening. - 70% isopropyl alcohol - Expiration date 30 days after opening. - Multi-dose vials - Expiration date - 28 days unless specified by the manufacturer... The Home Program Manager stated on 12/27/23 at 2:30 p.m., that this facility had not been opened for patients since 2020 during the Covid-19 outbreak. The patients for this facility had been seen in their sister facility in North Decatur, since 2020.”

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 33921 Based on record review and staff interview, it was determined that the facility failed to ensure that the Governing Body conducted an annual review of administrative rules and regulations and facility policies and procedures in accordance with accepted standards of practice to safeguard the health and safety of patients. This failure had the potential to negatively affect the health and safety of five Peritoneal Dialysis (PD) patients who were under the care of this facility. Findings include: During a review of facility records, it was revealed that the Governing Body had not had a meeting since 2021, which was confirmed by the Home Program Manager on 12/28/23 at 12:20 p.m. The Home Program Manager also stated on 12/27/23 at 2:30 p.m., that this facility had not been opened for patients since 2020. The five PD patients under the care of this facility had been seen at the North Decatur facility since 2020. In addition, the Home Program Manager also stated that the State or Department had not been notified that this facility was not opened for patients since 2020.”

“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 all passageways were free from obstacles to ensure safety and easy passage for patients and staff, ensuring lights were maintained and functioning, as well as ensuring facility readiness when patients will be seen at this facility. This deficient practice had the potential to negatively affect the health and safety of five of five Peritoneal Dialysis (PD) patients and potential future PD patients who will be under the care of this facility. Findings include: During a tour of the facility with the Home Program Manager on 12/27/23 at 2:10 p.m., the following was observed: There were: - Seven large boxes and a red dolly (used to transport heavy items), blocking two of two supply storage shelves, as well as partially blocking the pathway to the PD patient’s dialysis chair. - Five trash cans stacked up together next to one of the storage shelves (left side). - There were three large boxes with 27 plastic bins stacked up on top of the large boxes (with some trash bags on the top bin), located between the Nurse’s desk and the left storage shelf. - There were three rolling carts/trays in front of the clean and dirty sinks. In addition, two of three ceiling lights were not functioning. The Home Program Manager stated on 12/27/23 at 2:30 p.m., that the boxes, bins, carts, and dolly were from the other offices in the building and seemed to be using this facility as a storage room.”