Davita Creston Dialysis

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 51639 Based on review of facility policy, personal files, and staff interview the facility failed to ensure emergency preparedness training for all staff members. Failure to ensure staff training in emergency preparedness could result in the delay of providing the needed medical emergency services which could result in adverse patient outcomes. At the time of the survey the facility reported a census of 26 in-center hemodialysis patients. Findings for 3 staff providing patient care services at the dialysis facility include: Review of the policy titled, “Facility Emergency Management Plan (ICHD, Home),” policy 4-07-01, last revised April 2024 revealed, “The FA, or designee, is responsible to provide training of EMP (Emergency Management Plan) to teammates annually and upon hire.” It also revealed that training should be documented in teammate files. Review of the personnel files for Registered Nurse (RN) L, Patient Care Technician (PCT) M, and PCT N lacked documentation of emergency preparedness training specific to the facility. Interview on 2/11/2025 at 2:50 PM with Facility Administrator (FA) acknowledged that the 3 staff members lacked emergency training in their personnel files specific to the facility.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 44475 Based on policy review, observation and interview, the facility did not ensure a safe and sanitary environment by its failure to discard multiple expired and outdated supplies from facility circulation, which created risk for usage. The facility reported a census of 26 in center hemodialysis patients at the time of the survey. Failure to maintain an inventory of supplies used in a dialysis facility, in order to prevent the use of expired supplies, may place dialysis patients at risk for harm. Expired supplies can lose their potency, degrade in quality, packaging may become compromised, and supplies may become unsafe to use. Findings include: 1. The facility’s policy titled, “Infection Control for Dialysis Facilities” revised April 2023, directed in pertinent part, supplies will be stored in a manner that maintains their integrity and expiration date and package integrity will be verified prior to use. 2. Observation on 2/5/25 at 10:19 AM, revealed the following: a hand sanitizer bottle located in the supply room with an expiration date of March 2024, a hand sanitizer bottle located in the equipment maintenance area with an expiration date of May 2023, 71 gold colored vacutainers (used to collect blood samples for testing) with an expiration date of 1/31/25, 26 intravascular administration (IV) sets with an expiration date of 12/11/24, two Minncare HD (hemodialysis) 1% Indicator Strips with an expiration date of 12/23/24, and two suction instruments located in the crash cart (a cart stocked with emergency medical equipment) with an expiration date of 1/30/25. 3. In an interview on 2/11/25 at 10:57 AM, Staff J, Facility Administrator (FA), reported there should be no expired supplies in the facility.”

“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: 50072 Based on review of policy, observations and interview the facility failed to ensure staff performed infection control practices to minimize the spread of infections or bloodborne pathogens in the dialysis facility in accordance with the facility’s policy. The facility staff reported a hemodialysis patient census of 26 at the time of the survey. Failure to perform infection control practices according to policy can lead to cross contamination to other patients and surfaces, potentially placing all 26 patients receiving in center hemodialysis treatments at risk for infections or other adverse outcomes. Findings for observation of 2 of 2 staff (Staff C and Staff I) include: 1. Review of the facility policy # Policy: 1-05-01, titled INFECTION CONTROL FOR DIALYSIS FACILITIES, with the latest revision date of April 2023, reads in part: DISINFECTION 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops). i. The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system. Pressurized washers, spray bottles, or sprayers for cleaning purposes will not be used on wall boxes or the adjoining area. Teammates will monitor and address wall box residue/build up and patency issues. ii. Priming containers are to be emptied prior to disinfection. Drain line and water supply line should not be placed with ends in prime containers or in a position where they can drip into or contaminate the prime bucket. 2. Observations on 02/10/25 at 3:12 pm showed Staff C started the disinfection process at treatment station #2 by wiping down the front and left side of the machine prior to emptying the prime waste container (a container attached to the dialysis machine to catch fluids). Staff C failed to fully recline the treatment chair and wipe down the crack between the top and bottom seat cushions. Staff C removed the trash bag from the trash receptacle and replaced the bag without wiping down the trash receptacle. Staff C stacked a used sharps container inside the trash receptacle without wiping down the sharps container prior to placing it in the receptacle. Both items were replaced to station #2. 3. Observations on 02/10/25 at 3:20 pm showed Staff I started the disinfection process at treatment station #4 by wiping down the top of the dialysis machine, the left side then the front of the machine before emptying the prime bucket. Staff I failed to wipe down the trash receptacle before placing a new trash bag inside. 4. Additional observations on 02/10/25 at 3:39 pm showed Staff C started the disinfection process at treatment station #1 by wiping down the top, front and left sides of the machine prior to emptying the prime bucket. Staff C failed to fully recline the treatment chair and wipe down the crack between the top and bottom seat cushions. Staff C dropped the disinfectant towels on the floor, picked them up and continued to wipe down the right side of the treatment chair. Staff C did not wipe down the TV or the TV arm. Staff C removed the trash bag from the trash receptacle and replaced the bag without wiping down the trash receptacle. Staff C stacked the sharps container inside the trash receptacle without wiping down the sharps container 5. During an interview with Staff C on 2/13/2025 at 10:00, they reported the entire dialysis machine should be cleaned front and back including the hoses and wall ports. In addition, the chair should be opened and reclined so that all surfaces can be cleaned. They also stated that the back counter, TV, blood pressure cuff, sharps bin and trash bin should be wiped down as well. Staff C reported if disinfectant towels are dropped on the floor, the towels should be discarded immediately.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 44475 Based on policy review, facility documentation, and staff interview, the facility failed to ensure QAPI (Quality Assurance and Performance Improvement) documentation showed a comprehensive review and analysis of all patient deaths were available. Failure to review and analyze individual patient deaths and the relationship to the care received at the facility could potentially result in missed opportunities to ensure patient safety and prevent further threats to dialysis patients. The facility reported a census of 26 in center hemodialysis patients at the time of the survey. Findings for review of 6 patient deaths dated August 2024 to January 2025 include: 1. Review of facility policy titled “Continuous Quality Improvement Program” revised April 2021, directed in pertinent part, written documentation and plans of action will be documented within the FHM. The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include mortality, review of deaths. 2. Review of facility document titled: “Facility Health Meeting” (FHM), dated August 2024 to January 2025 lacked documentation to include a review and analysis of the 6 in center hemodialysis patient deaths that took place during this date range. 3. In an interview on 2/11/25 at 3:04 PM, Staff B, Facility Administrator (FA), reported that discussion occurs during FHM when a patient death occurs, however documentation of the discussion did not take place.”