Fmc - Canal Dialysis

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 48224 Based on record review and interview, the dialysis facility failed to ensure the EP communication plan included a method for sharing information and medical documentation for patients under the agency’s care with other health providers to maintain continuity of care during an emergency for 1 of 1 facility. Findings include: 1. The review of the agency’s EP communication plan failed to evidence a method for sharing information and medical documentation with other health providers to maintain continuity of care. 2. During an interview on 12/03/25 at 3:45 PM, the Facility Administrator relayed the EP plan did not include a method for sharing information and medical documentation with other health care providers during an emergency.”

“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: 48224 Based on observation, policy review and interview, the dialysis facility failed to maintain a sanitary environment within the ICHD treatment area during 1 of 2 days of ICHD treatment area observations, which had the potential to affect 40 active ICHD patients. Findings include: 1. The policy “Cleaning and Disinfecting the Dialysis Station,” last updated 9/02/25, indicated bleach solution will be stored in labeled, covered opaque containers to prevent disintegration of the chemical (sodium hypochlorite) when exposed to sunlight and air. 2. During the flash tour observation on 12/01/25 beginning at 9:14 AM, one bleach container was observed with the lid unsecured, within the ICHD treatment floor at 9:40 AM and 10:08 AM. 3. During an observation on 12/01/25 at 2:53 PM, one bleach container was observed with the lid unsecured within the ICHD treatment floor. 4. During an interview on 12/02/25 at 9:02 AM, the Facility Administrator relayed the bleach containers should be closed when not in use.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 45607 Based on observation, record review, and interview, the dialysis facility failed to ensure patient accesses remained uncovered during treatment for 3 of 12 patients observed (Patient #1, 2, 12). Findings include: 1.Review of the Patient Assessment and Monitoring policy, revised 05/01/23, indicated “ ... During Treatment ... Observe connections are secure and visible ... Ensure access remains uncovered throughout the treatment ...” 2. A treatment floor observation was conducted on 12/01/25 from 9:19 AM to 10:08 AM with the following observed: At 9:19 AM, Patient #1 and #2 had their accesses covered with a blanket. At 9:26 AM, Patient #1 and #2 still had their accesses covered with a blanket. At 9:42 AM, Patient #1 and #2 still had their accesses covered with a blanket. At 10:01 AM Patient #2 still had their access covered with a blanket. At 10:01 AM, PCT 3 uncovered Patient #1’s access sites. 3. A treatment floor observation was conducted on 12/02/25 from 1:03 PM to 1:45 PM with the following observed: At 1:04 PM, Patient #12 had their access covered with a blanket. At 1:13 PM, Patient #12 still had their access covered with a blanket. At 1:17 PM, Patient #12 still had their access covered with a blanket. At 1:22 PM, Patient #12 still had their access covered with a blanket. At 1:23 PM, PCT 5 uncovered Patient #12’s access. 4. Review of Patient #2’s clinical record included a treatment sheet dated 12/01/25. The treatment sheet failed to evidence Patient #2 was asked to uncover their access during treatment. 5. Review of Patient #12’s clinical record included a treatment sheet dated 12/02/25. The treatment sheet failed to evidence Patient #12 was asked to uncover their access during treatment. 6. During an interview on 12/01/25 at 10:03 AM, PCT 3 relayed patient accesses should never be covered during treatment. 7. During an interview on 12/01/25 at 10:06 AM, RN 1 relayed patient accesses should not be covered but they have some patients who are adamantly opposed to leaving accesses uncovered so their accesses are checked during vital signs. 8. During an interview on 12/02/25 at 1:18 PM, RN 3 relayed patient accesses should not be covered and further relayed if a patient covers their access staff asks the patient to uncover it. 9. During an interview on 12/02/25 at 1:19 PM, PCT 5 relayed patient accesses should never be covered during treatment. 10. During an interview on 12/02/25 at 1:20 PM, PCT 4 relayed patient accesses should never be covered during treatment. 11. During an interview on 12/03/25 at 3:55 PM, the FA relayed if a patient was asked to uncover their access during treatment it should be documented in the treatment sheet. 48224”