Usrc Hickory Hills Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that the Facility failed to comply with the Condition for Coverage 42 CFR 494.30, Infection Control. Findings include: 1. The Facility failed to ensure that patients susceptible (non-immune) to the Hepatitis B virus were either offered, received, or declined the Hepatitis B vaccine, as required. See deficiency at V-124. 2. The Facility failed to ensure that Hepatitis B antigen labs (to determine if negative or positive for Hepatitis B) were collected and monitored monthly, as required. See deficiency at V-127.”

“IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT CFR(s): 494.30(a)(1)(i) Routine Testing for Hepatitis B The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit. Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results. This Standard is not met as evidenced by: 34411 Based on document review and interview, it was determined that for 27 of 30 (Pt #2-6,Pt #9- 13, Pt #15, Pt #16, Pt #18, Pt #19, Pt #22, Pt #25, Pt #26, Pt #28-30, Pt #32, Pt #33-38) clinical records reviewed for patients susceptible (non-immune) to the Hepatitis B virus, the Facility failed to ensure that Hepatitis B antigen labs (to determine if negative or positive for Hepatitis B) were collected and monitored monthly, as required. Findings include: 1. The Facility’s policy titled, “Patient Hepatitis B Testing/Vaccination/Seroconversion” (dated 11/2022), was reviewed, and required, “...Schedule for Routine Testing for Hepatitis B (HBV) Infections...Obtain HBaAg [hepatitis B surface antigen] monthly for all HBV-susceptible patients. Susceptible patients include any patient: In a vaccine series; Anti-HBs [immunity to virus] <10 mlU/mL [milliunits per milliliter]; non-responders to the vaccine after 2 series; and or anti-HBs <10 mlU/mL and refusing the vaccine...” 2. The Facility’s “Vaccination” report indicated that 30 of the 42 patients on census, were non-immune/susceptible to the Hepatitis B virus. 3. On 5/30/2024, the Facility Administrator (E #1) presented a list (dated 5/29/2024) of the patients’ monthly HBsAG (antigen) results obtained. The list included 3 of the 30 susceptible/non-immune patient’s monthly Hepatitis B antigen results from 5/2024. Twenty-seven of the 30 (Pt #2-6, Pt #9- 13, Pt #15, Pt #16, Pt #18, Pt #19, Pt #22, Pt #25, Pt #26, Pt #28-30, Pt #32, Pt #33-38) susceptible patient’s Hepatitis B antigen labs were not drawn in 5/2024. The previous month (4/2024) included only 4 of the 30 susceptible patient’s monthly antigen results. 4. On 5/29/2024 at 11:45 AM, an interview was conducted with the Facility Administrator (E #1). E #1 stated that monthly Hepatitis B antigen labs are required for patients that are non-immune. E #1 stated that the process has changed with entering the orders for the monthly labs. E #1 stated that either the nurse or the secretary could enter the laboratory orders for the monthly draws. E #1 acknowledged that there were missing monthly Hepatitis B antigen draws.”

“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: 34411 Based on document review and interview, it was determined that for 24 of 30 (Pt #2, Pt #4, Pt #5-Pt #6, Pt #9-13, Pt #15-16, Pt #18-19, Pt #22, Pt #25-26, Pt #28-30, Pt #32-Pt #34) vaccination records reviewed for patients susceptible (non-immune) to the Hepatitis B virus, the Facility failed to ensure that the patients were either offered, received, or declined the Hepatitis B vaccine, as required. Findings include: 1. The Facility’s policy titled, “Patient Hepatitis B Testing/Vaccination/Seroconversion” (dated 11/2022), was reviewed, and required, “Purpose: To prevent the transmission of Hepatitis B virus (HBV) infection with timely testing, assessment and vaccination...Vaccination: 1. Obtain physician order and offer vaccine to all susceptible patients within 3 days of receiving lab result...Vaccination Testing and Actions: 1. Initial Vaccine Series ...If anti-HBs [indicator for immunity] is <10 mlU/mL [milliunit per millimeter], consider the patient susceptible [non-immune to virus], revaccinate with an additional series and retest for anti-HBs...” 2. The Facility’s “Vaccinations” report was reviewed on 5/29/2024. The report included the Hepatitis B vaccination status of the patients on census. The facility’s census included 42 patients. Of the 42 patients, 30 of the patients ((Pt #2, Pt #4, Pt #5-Pt #6, Pt #9-13, Pt #15-16, Pt #18-19, Pt #22, Pt #25-26, Pt #28-30, Pt #32-Pt #34) were non-immune/susceptible. The clinical records of the 30 non-immune patients lacked documentation of either an initial vaccine series given, 2nd vaccination series given, or declination from the patient. These finding were acknowledged and confirmed with the Facility Administrator (E #1). 3. On 5/29/2024 at 11:45 AM, an interview was conducted with the Facility Administrator (E #1). E #1 stated that patients with Hepatitis B antibodies less than 10, should be offered the Hepatitis B vaccine. E #1 stated that patients who decline the vaccine, should sign the declination form. E #1 stated that the 2 charge nurses are responsible for overseeing the patient’s vaccination status. E #1 stated that there has been an oversight during the QAPI (quality meetings) in discussing the patient’s Hepatitis B vaccine status.”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that for 2 of 3 Patient Care Technicians (E #3, E #5), the Facility failed to ensure that staff demonstrated knowledge of the Facility’s infection control practices for the disinfection of AVF (arteriovenous fistula - used for dialysis access) sites, as required. Findings include: 1. The Facility’s policy titled, “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation” (dated 10/2023), was reviewed and required, “...Access preparation...Cleansing Agent: Alcohol Prep Pad: Cleaning Process and Contact Time. Utilizing a rubbing motion for at least 30 seconds...” 2. On 5/29/2024, between 9:30 AM and 11:15 AM, an observational tour of the dialysis treatment area was conducted, and the following was observed: - At Station #7, at 10:42 AM, a Patient Care Technician (PCT/ E #3), was observed initiating treatment on a patient with an AVF access. E #3 wiped both site (arterial and venous) for less than 10 seconds with alcohol prep pads (not the required 30 seconds). - At Station 10, at 10:50 AM #10, a PCT (E #5) was observed initiating treatment on a patient with an AVF access. E #5 wiped both site (arterial and venous) for less than 10 seconds with alcohol prep pads (not the required 30 seconds). - At Station #6, at 11:05 AM, the PCT (E #3) was observed initiating treatment on a patient with an AVF access. E #3 wiped both site (arterial and venous) for less than 10 seconds with alcohol prep pads (not the required 30 seconds). 3. On 5/30/2024 at 10:55 AM, an interview was conducted with the PCT E #3. E #3 stated that when disinfecting the AVF sites using alcohol pads, both sites should be wiped for 60 seconds each.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 34411 Based on document review, observation, and interview, it was determined that for 1 of 1 expired medication observed in the medication refrigerator, the Facility failed to ensure that an expired medication was discarded and not available for patient use. Findings include: 1. The Facility’s policy titled, “Guidelines for Administration of Medication” (dated 4/2024) was reviewed, and required, “...Multi-dose vials (MDV): a. Multi-dose vials will be discarded within 28 days of opening unless otherwise specified by manufacturer instructions...” 2. On 5/28/2024 between 9:05 AM and 11:00AM, an observational tour of the dialysis treatment area was conducted. During the tour, the medication refrigerator was observed for medication’s expiration dates. The medication refrigerator contained an opened tuberculin (TB) vial dated 4/18/2024 (greater than 28 days). 3. On 5/28/2024 at 10:30 AM an interview was conducted with the Registered Nurse (E #2). E #2 stated that the TB vial is good for 28 days once it is opened and should be discarded after expiration. E #2 acknowledged that TB vial was expired.”

“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: 34411 Based on document review, observation, and interview, it was determined that the Facility failed to ensure that the Phoenix (pH/conductivity meter) solution was not expired, according to the manufacturer’s instructions and policy. This deficient practice has the potential to affect all 42 patients on census. Findings include: 1. The Facility’s policy titled, “Phoenix XL Meter Cleaning and Calibration” (dated 8/2020), was reviewed, and required, “...Tri-Station Maintenance: Verify expiration dates on all calibration and cleaning solutions...” 2. The Manufacturer’s Instructions for the Tri-Station Solutions (used for Phoenix meters), included, “Tri-Station Maintenance ...Replace your standard solutions: Conductivity solutions-30 days after opening. pH solutions-Any solutions-if the bottle expiration date is past, or if color, turbidity, or visible microbial growth develops ...” 3. On 5/28/2024 between 9:05 AM and 11:00 AM, a tour on the hemodialysis treatment floor was conducted. In the treatment area, at the Tri-Station where the Phoenix meter solutions are stored, there was an expired opened conductivity solution (used to check Phoenix meter). The conductivity solution (1 m/s) had a written expiration date of 4/19/2024 (more than 30 days after expiration). The solution was still available for use and not discarded after expiration date. 4. On 5/28/2024 at 9:50 AM, an interview was conducted with a Patient Care Technician (E #4). E #4 stated that the conductivity solutions should be discarded after 30 days of opening. E # stated that the pH and conductivity solutions are needed to check and calibrate the Phoenix meters to make sure they are working accurately.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 32741 Based on document review and interview, it was determined that for 3 of 4 (Pt.#2, Pt. #3 and Pt. #4) in-center hemodialysis clinical records reviewed, the Facility failed to monitor the BFR (Blood Flow Rate) and DFR (Dialysis Flow Rate) to ensure that the prescribed BFR was maintained for adequate hemodialysis. Findings include: 1. On 5/29/2024, the Facility’s policy titled, “Initiation of Dialysis Treatment” (dated 8/2020) was reviewed and indicated, “Purpose - to provide guidance to prevent complications related to initiation of the hemodialysis procedure...Prescription orders and safety measures include, but are not limited to the following - blood flow is at prescribed rate and correct dialysis flow rate...” 2. On 5/29/2024, Pt. #2’s clinical record (dated 5/30/2023 thru current) was reviewed and indicated: -Pt. #2 was admitted to the Facility on 5/30/2023 with the diagnosis of end stage renal disease. -Pt. #2’s physician orders dated 1/4/2024 noted BFR 350. -Pt. #2’s treatment record dated 5/9/2024 thru 5/25/2024 noted the following: -Pt. #2’s treatment record dated 5/21/2024 documented BFR 300 (not the prescribed 350). 3. On 5/29/2024, Pt #3’s clinical record (dated 7/25/2023 thru current) was reviewed and indicated: -Pt. #3 was admitted to the Facility on 7/25/2023 with the diagnosis of end stage renal disease. -Pt. #3’s physician orders dated 1/4/2024 noted BFR 400 and DFR 600. -Pt. #3’s treatment records dated 5/16/2024 thru 5/28/2024 noted the following: -Pt. #3’s treatment record dated 5/16/2024 documented BFR 450 (not the prescribed BFR 400). -Pt. #3’s treatment record dated 5/23/2024 documented BFR 450 (not the prescribed BFR 400). 4. On 5/29/2024, Pt. #4’s clinical record (dated 1/11/2022 thru current) was reviewed and indicated: -Pt. #4 was admitted to the Facility on 1/11/2022 with the diagnosis of end stage renal disease. -Pt. #4’s physician orders dated 1/4/2024 noted BFR 350 and DFR 600. -Pt. #4’s treatment records dated 5/14/2024 thru 5/25/2024 noted the following: -Pt. #4’s treatment record dated 5/14/2024 documented DFR 700 (not the prescribed 600). -Pt. #4’s treatment record dated 5/23/2024 documented BFR 400 (not the prescribed 350). 5. On 5/29/2024 at 11:45 AM, an interview was conducted with the Facility Administrator (E #1). E #1 stated that the dialysis prescription should be followed for each patient.”

“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: 32741 Based on document review and interview, it was determined that for 42 out of 42 patients (Pt. #1 thru Pt. #42), the Facility failed to track Hepatitis B vaccination status. Findings include: 1. On 5/29/2024, the Facility’s policy titled, “Introduction to Quality Assessment and Performance Improvement -QAPI” (date- 1/2020) was reviewed and indicated, “Quality Assessment and Performance Improvement Solves Real or Potential Problems...Integral components of QAPI include the following accurate, accessible data upon which to base decisions and actions...” 2. On 5/29/2024, the Hospital’s Quality Meeting Minutes (dated 2024) was reviewed. There was no documentation of Hepatitis B vaccination information. 3. On 5/29/2024 at 12:15 PM, an interview was conducted with the Facility Administrator (E #1). E #1 stated that E #1 needs to begin documenting Hepatitis B information and present at the Quality Meetings.”