Iroquois Kidney Center

“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: 45565 Rutherford, Donna J. Based on document review and staff interview it was determined the Facility failed to ensure training and testing based on the emergency plan was updated at least every 2 years had been completed. This has the potential to affect all patients, staff, visitors, and community persons. Findings include: 1. The Emergency Preparedness Plan (EPP) and employee files were reviewed on 2/7/24 at approximately 10:30 AM. The EPP and employee files lacked training and testing documentation on the following staff: a) Social Worker Employee (E#2) Date of Hire (DOH)- 8/30/23 b) Registered Nurse E#3, DOH 9/25/22 c) Dietician E#4, DOH 7/19/19 2.The EPP manual was reviewed on 2/7/24 and lacked a current update. The EPP manual noted last updated on 10/19/2020. 3. An interview was conducted with E#1 (Nurse Manager) on 2/7/24 at approximately 12:30 PM. E#1 verbally confirmed the lack of the Emergency Preparedness training and updating documentation.”

“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: 45565 Rutherford, Donna J. Based on observation,and interview, it was determined that the Facility failed to ensure outdated supplies and medications were not available for use in the Facility. This has to the potential to affect all patients that receive care at the Facility. Findings include: 1. During a tour of the treatment area conducted on 2/7/24 at approximately 10:15 AM, the following items were noted to be outdated: a) 17 Ultraset Disposable Disconnect Y-sets- expiration date of 8/2/23 located in the supply room were available for patient use b) 1 Cathflo Activase 2 mg’s- expiration date of 12/23 located in the lab refrigerator and was available for patient use. 2. An interview was conducted during the tour on 2/7/24 at approximately 10:15 AM with E#1 (Nurse Manager). E#4 verbally confirmed the items were outdated and outdated medications and supplies are to be removed.”