Provident Dialysis Center

“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: 32741 Based on document review, observation and interview, for 3 of 3 Patient Care Technicians (E #2, E #3 and E #4)) observed cleaning and disinfecting dialysis stations, the Facility failed to ensure the dialysis station was cleaned and disinfected in accordance with policy. Findings Include: 1. On 8/18/2025, the Facility’s policy titled, “Cleaning and Disinfecting Dialysis Surfaces & Equipment” (effective 12/21/2020) was reviewed and required, “...Correct cleaning and disinfection of environmental surfaces must be performed to prevent transmission of dangerous pathogens...Staff will thoroughly clean and disinfect the dialysis station, wipe down all non-disposable items and equipment...televisions...Wipe the front, top, back and sides of the hemodialysis machine...” 2. On 8/18/2025 between 9:30 AM and 11:30 AM, an observational tour was conducted in the dialysis treatment area. The following was observed: - At approximately 10:00 AM, the Patient Care Technician (E #3) was cleaning the dialysis station #9. E #3 did not clean/disinfect the dialysis machine. -At approximately 10:20 AM, the Patient Care Technician (E #2) was cleaning the dialysis station #6. E #2 did not clean/disinfect the TV monitor. -At approximately 10:30 AM, E #2 was cleaning the dialysis station #7. E #2 did not clean/disinfect the TV monitor. -At approximately 11:00 AM, the Patient Care Technician (E #4) was cleaning the dialysis station #4. E #4 did not clean/disinfect the TV monitor. 3. On 8/18/2025 at approximately 11:15 AM, an interview was conducted with the E#3. E # stated that the dialysis machine and TV monitor should be cleaned/disinfected.”

“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: 32741 Based on document review, observation, and interview, for 2 of 3 Patient Care Technicians - PCT (E #2 and E #3) observed for disinfecting AVF (arteriovenous fistula) cannulation sites, the Facility failed to ensure that staff followed infection control practices to disinfect and prevent contamination of AVF sites. Findings include: 1. On 8/18/2025, the Facility’s policy titled, “Preparation of the Vascular Access Sites” (dated March 8/2019) was reviewed and required, “Follow the steps in the table below to prepare the selected access sites for cannulation...If using alcohol to prep the cannulation sites - clean each site for one minute using multiple alcohol pads immediately prior to cannulation...” 2. An observational tour of the dialysis treatment area was conducted on 8/18/2025, between approximately 9:30 AM and 11:30 AM. The following was observed: - At approximately 10:10 AM, the Patient Care Technician (E #3) was observed at station #11, preparing to initiate dialysis for a patient with an AVF. E#3 wiped the first access site with alcohol for a total of 5 seconds (not the required one minute). E#3 then wiped the second access site with alcohol for a total of 5 seconds (not the required one minute). -At approximately 10:35 AM, E #3 was observed at station #12, preparing to initiate dialysis for a patient with an AVF. E #3 wiped the first access site with alcohol for a total of 10 seconds (not the required one minute). E #3 then wiped the second access site with alcohol for a total of 10 seconds (not the required one minute). -At approximately 10:40 AM, E #3 was observed at station #10, preparing to initiate dialysis for a patient with an AVF. E #3 wiped the first access site with alcohol for a total of 8 seconds (not the required one minute). E #3 then wiped the second access site with alcohol for a total of 10 seconds (not the required one minute). -At approximately 11:05 AM, the Patient Care Technician (E #2) was observed at station #6, preparing to initiate dialysis for a patient with an AVF. E #2 wiped the first access site with alcohol for a total of 20 seconds (not the required one minute). E #2 then wiped the second access site with alcohol for a total of 20 seconds (not the required one minute). 3. On 8/18/2025 at 11:20 AM, an interview was conducted with E #3. E #3 stated that each site for AVF site should be disinfected for 30 seconds prior to cannulation.”

“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, for 3 of 6 (Pt. #1, Pt. #3, 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 and DFR was maintained for adequate hemodialysis. Findings include: 1. On 8/19/2025, the Facility’s policy titled, “Hemodialysis Vascular Access - Blood Flow Rate Standing Order” (dated 5/2022)) was reviewed and indicated, “Ensure that all current orders are being consistently followed, i.e., treatment time, blood flow rate (BFR), dialysis flow rate (DFR), and frequency of dialysis...” 2. On 8/19/2025, Pt #1’s dialysis treatment records (dated 8/4/2025 through 8/15/2025) were reviewed and indicated: -Pt #1 was admitted to hemodialysis center on 7/16/2025 with the diagnosis end stage renal disease. Pt. #1’s hemodialysis prescription treatment order (dated 7/22/205) noted “BFR 250 and DFR 400” -Pt #1’s treatment records noted the following: - 8/4/2025 treatment record noted BFR 350 and DFR 600. There was no documentation in Pt #1’s clinical record regarding the reason for not following the prescribed BFR and DFR. -8/6/2025 treatment record noted BFR 350 and DFR 600. There was no documentation in Pt. #1’s clinical record regarding the reason for not following the prescribed BFR and DFR. -8/8/2025 treatment record noted BFR 360. There was no documentation in Pt. #1’s clinical record regarding the reason for not following the prescribed BFR. -8/11/2025 treatment record noted BFR 350 and DFR 600. There was no documentation in Pt. #1’s clinical record regarding the reason for not following the prescribed BFR and DFR. -8/13/2025 treatment record noted BFR 365 and DFR 600. There was no documentation in Pt. #1’s clinical record regarding the reason for not following the prescribed BFR and DFR. -8/15/2025 treatment record noted BFR 355 and DFR 600. There was no documentation in Pt. #1’s clinical record regarding the reason for not following the prescribed BFR and DFR. 3. On 8/19/2025, Pt #3’s dialysis treatment records (dated 8/5/2025 through 8/16/2025 ) were reviewed and indicated: -Pt. #3 was admitted to the hemodialysis center on 1/2/23 with the diagnosis end stage renal disease. -Pt #3’s hemodialysis prescription treatment order (dated 6/19/2025) noted “BFR 400 and DFR 800...” -Pt #3’s treatment records noted the following: -8/5/2025 treatment record noted BFR 350 and DFR 600. There was no documentation in Pt #3’s record regarding the reason for not following the prescribed BFR and DFR. -8/7/2025 treatment record noted BFR 350 and DFR 300. There was no documentation in Pt. #3’s record regarding the reason for not following the prescribed BFR and DFR. -8/9/2025 treatment record noted DFR 600. There was no documentation in Pt. #3’s record regarding the reason for not following the prescribed DFR. -8/12/2025 treatment record noted DFR 600. There was no documentation in Pt. #3’s record regarding the reason for not following the prescribed DFR. 4. On 8/19/2025, Pt. #4’s dialysis treatment record (dated 8/5/2025 through 8/14/2025) were reviewed and indicated: -Pt. #4 was admitted to the hemodialysis center on 2/21/23 with the diagnosis end stage renal disease. -Pt. #4’s hemodialysis prescription treatment order (dated 7/30/2025) noted “DFR 800...” -Pt. #4’s treatment records noted the following: -8/9/2025 treatment record and 8/12/2025 treatment record noted DFR 600. There was no documentation in Pt. #4’s record regarding the reason for not following the prescribed DFR. 5. On 8/19/2025 at 11:00 AM, an interview was conducted with the Registered Nurse (E #5). E #1 stated that dialysis prescription order for BFR and DFR should be followed for each treatment.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 32741 Based on document review and interview, for 1 of 6 (Pt #6) clinical record reviewed for shortened treatments, the Medical Director failed to ensure that the staff adhered to patient care policies, by notifying the physician of shortened hemodialysis treatments and ensuring that an AMA (against medical advice) form was completed. Findings include: 1. On 8/19/2025, the Facility’s policy titled, “Early Termination of the Dialysis Treatment” (dated 10/3/2022) was reviewed and required, “The dialysis facility expects that patients will be available for their entire treatment and be on time if receiving their treatment in-center...Follow the steps in the table below for patients requesting to shorten their prescribed treatment time...The charge nurse will complete an AMA form. The AMA form will be signed by the patient and witnessed by the charge nurse. A new form will be signed each time a treatment is requested shortened/terminated...” 2. On 8/19/2025, Pt. #6’s treatment records (dated 8/7/2025 through 8/19/2025) were reviewed. Pt #6 was admitted to the Facility on 8/5/2025, with a diagnosis of ESRD (end stage renal disease). The Treatment Orders (dated 8/2/2025), included a treatment time 4 hours and 45 minutes). Pt #6’s treatment sheets, from 8/7/2025 through 8/19/2025 were reviewed and included the following days with shortened treatments: - On 8/9/2025: “Duration -3 hours and 57 minutes. Pt. #6 prerequested to discharge treatment early in an effort to take his children to a parade.” - On 8/16/2025: “Duration 1 hour and 51 minutes. Pt. #6 requested to end treatment early due to personal emergency.” Pt #6’s clinical record lacked completed AMA forms or notification to the physician of shortened treatments for these shortened treatment dates. 3. On 8/19/2025 at 10:30 AM, an interview was conducted with the Registered Nurse (E #5). E #5 stated that the patient should sign the AMA form if they are cutting their treatments short. E #5 stated that the risk of a shortened treatment is explained to the patient. E #5 stated that the patient’s physician is also notified when a patient shortens a treatment.”