Davita Comprehensive Renal Care - East Chicago

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 47022 Based on observation, record review and interview, the dialysis facility failed to evidence they have a process for cooperation with local, tribal, regional, state, and federal emergency preparedness officials to maintain an integrated response during a disaster or emergency situation in 1 of 1 dialysis facilities. Findings include: A revised policy dated April 2024, titled, “Facility Emergency Management Plan,” indicated the Facility Administrator would have communication at least on an annual basis with the following local agencies regarding emergency preparedness, communication, needs of the dialysis patients and facility and reviewing the agency’s emergency plan, the policy indicated documentation of contact information would include local emergency management agency, hospital, transportation providers, electric and water utility provider and fire department (if the facility had unique circumstances that would require additional planning, such as located on second floor). During an observation beginning on 09/25/2024, beginning at 10:00 AM, the dialysis facility was located on the 4th floor of a professional building attached to a hospital. A review of emergency management documents provided failed to evidence coordination with local and federal emergency management officials and their local fire department. The clinic provided for review copies of planning letters, sent on June 25, 2024 to local utility companies. During an interview on 09/30/2024, beginning at 10:30 AM, the Facility Administrator indicated emergency management letters were sent in June 2024 to the electric and water utility provider but were not send to local or federal emergency officials or the local fire department.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 47022 Based on record review and interview, the dialysis facility failed to evidence exercises were conducted to test the emergency plan, annually at minimum, in 1 of 1 dialysis facility. Findings include: A revised policy dated April 2024, titled, “Facility Emergency Management Plan,” indicated the Facility Administrator would maintain the emergency preparedness training and testing and would include the facility would conduct or participate in one exercise at least annually, conducted on opposite years, one year full scale exercise, next year facility based exercise that could include a tabletop exercise that included a group discussion led by the Facility Administrator, actions taken would be simulated, and documentation required would include event that occurred, plan and policies activated, evaluation of the plan and governing body review. Clinic documents provided for review included a Fire Inside the facility scenario with an Exercise Checklist, dated 03/13/2024 and 06/17/2024. The documents incictaed all required tasks would be demonstrated during exercise and included the actions required. The document failed to evidence who or if the tasks were completed, and included: the Facility Administrator, or designee, would assume command of the emergency events, teammates assume assignments, implement incident management tool, communicate this was a drill, assess immediate threat to patients, simulated call to 911, activate the fire alarm system, communication with team, patients and visitors regarding situation, patient emergency take off procedures performed and evaluation of patients who would be unable to perform procedure, assist patients that required assistance, determine level of evacuation, move patients to safe area, close all doors to contain fire, identify location of fire extinguishers, take emergency supply box to evacuation area, provide necessary medical care to patients, account for and assess teammates and patients, notify the Medical Director and local leadership, communicate facility status with patients and families, follow the directions of emergency response personnel, establish transportation for patients, implement patient temporary transfer and relocation, verify communication with the medical director, patients, teammates, area risk manager, state survey agency and dialysis network, transfer patients in electronic medical records system, and change answering machine message. During an interview on 09/26/2024, beginning at 11:00 AM, the Facility Administrator indicated fire drills are conducted quarterly, the March and June 2024 did not have documentation of actions performed and during the June 2024 the Facility Administrator was not present for the testing. The Facility Administrator indicated for 2023 fire drills were conducted quarterly but no other exercise related to annual testing was completed. During an interview on 09/30/2024, beginning at 10:40 AM, the Facility Administrator indicated annual emergency preparedness testing should have been completed and was not.”

“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: 47022 Based on observation, record review and interview, the dialysis facility failed to ensure the dialysis station’s blood pressure cuffs and Patients’ dialysis chairs cleaning were completed per policy in 2 of 4 observations of decontamination of the dialysis station post patient care (Patient Care Technician (PCT) 4). Findings include: 1. A revised policy dated April 2023, titled, “Infection Control For Dialysis Facilities,” indicated at the end of each treatment, the dialysis station would be cleaned and disinfected to include but not limited to blood pressure cuffs and dialysis chairs. 2. During an observation on 09/30/2024, beginning at 9:30 AM Patient #14 completed dialysis treatment and left Station #4; PCT 4 wiped the dialysis chair with wipes soaked with a 1:100 bleach solution, though failed to recline the chair and cleanse all surfaces of the chair. PCT 4 failed to clean the reuseable blood pressure cuff; the cuff remained hanging on the intravenous pole and was not decontaminated. PCT 4 then moved to Station #3. Beginning at 9:45 AM, at Station #3 PCT 4 cleaned the dialysis chair with wipes wet with bleach solution, thought failed to recline the chair. PCT 4 failed to clean the reuseable blood pressure cuff; the cuff remained hanging on the intravenous pole and was not decontaminated. PCT 4 then began to set up the dialysis machine with new dialyzer and tubing for the next patient. 3. During an interview on 09/30/2024, beginning at 9:55 AM, PCT 4 indicated he/she should have reclined the dialysis chairs to clean at Station #3 and Station #4 and did not. PCT 4 indicated he/she did not clean the blood pressure cuff at Station #3 and Station #4 and should have cleaned the cuffs with the bleach solution wipes.”

“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: 47022 Based on record review and interview, the dialysis facility failed to ensure Hepatitis B (liver infection) susceptible Patients were educated and offered a vaccine or a booster for Hepatitis B in 6 of 6 surveillance and vaccine reports reviewed with a Hepatitis B Surface Antibody of less than 10 (susceptible to Hepatitis B) (Patients #1, 2, 3, 4, 5, and 16). Findings include: 1. A revised policy dated April 2024, titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance,” indicated all Patients vaccinated for Hepatitis B should have a Hepatitis B antibody test one to two months after the last dose of the full vaccine series, if the Hepatitis B antibody was less than 10 the patient would be considered susceptible and should be vaccinated with an additional full series and retest in one to two months after the last dose of the series, no additional doses of vaccine are warranted for patients who do not respond to a full second series due to the patients would be considered vaccine non-responders and monthly Hepatitis B antigen testing would be required. The policy indicated if the Hepatitis B surface antibody was greater than or equal to 10 the patient would be considered immune, and the Hepatitis B surface antibody should be tested annually. The policy indicated on annual retesting of immune patients due to vaccination if the Hepatitis B surface antibody was less than 10 a booster dose should be administered with a nephrologist order. 2. A Vaccination and Surveillance Report received on 09/25/2024 for Patient #1, admission date of 01/31/2024, indicated a 05/09/2024 Hepatitis B surface antibody at 10, a 07/24/2024 Hepatitis B surface antibody at 8 and indicated the patient had no current Hepatitis B vaccinations documented. The Report failed to evidence documentation the Patient was offered a Hepatitis B vaccination/booster or that the Hepatitis B surface antibody, less than 10, was addressed. 3. A Vaccination and Surveillance Report received on 09/25/2024 for Patient #2, admission date of 03/10/2021, indicated a 06/07/2023 Hepatitis B surface antibody less than 3, a 06/05/2024 Hepatitis B surface antibody of less than 3 and last date of a Hepatitis B vaccination was administered 09/17/2021. The Report failed to evidence documentation the Patient was offered a Hepatitis B vaccination/booster or that the Hepatitis B surface antibody, less than 10, was addressed. 4. A Vaccination and Surveillance Report received on 09/25/2024 for Patient #3, admission date of 02/12/2016, indicated a 05/03/2024 Hepatitis B surface antibody of 5, a 06/07/2023 Hepatitis B surface antibody of 5, a 06/12/2024 Hepatitis B surface antibody of 5 and last date of a Hepatitis B vaccination of 10/25/2017. The Report failed to evidence documentation the Patient was offered a Hepatitis B vaccination/booster or that the Hepatitis B surface antibody, less than 10, was addressed. 5. A Vaccination and Surveillance Report received on 09/25/2024 for Patient #4, admission date of 03/29/2023, indicated a 09/04/2024 Hepatitis B surface antibody of less than 3, a 08/07/2024 Hepatitis B surface antibody of 5 and last date of a Hepatitis B vaccination of 09/18/2023. The Report failed to evidence documentation the Patient was offered a Hepatitis B vaccination/booster or that the Hepatitis B surface antibody, less than 10, was addressed. 6. A Vaccination and Surveillance Report received on 09/25/2024 for Patient #5 indicated a 05/05/2023 Hepatitis B surface antibody of less than 3, a 06/14/2023 Hepatitis B surface antibody of less than 3, a 06/05/2024 Hepatitis B surface antibody of less than 3 and last date of a Hepatitis B vaccination of 09/23/2022. The Report failed to evidence documentation the Patient was offered a Hepatitis B vaccination/booster or that the Hepatitis B surface antibody, less than 10, was addressed. 7. A Vaccination and Surveillance Report received on 09/25/2024 for Patient #16 indicated a 07/15/2024 Hepatitis B surface antibody of less than 3, a 07/17/2024 Hepatitis B surface antibody of less than 3, a 09/18/2024 Hepatitis B surface antibody of less than 3 and last date of a Hepatitis B vaccination was 10/18/2022. The Report failed to evidence documentation the Patient was offered a Hepatitis B vaccination/booster or that the Hepatitis B surface antibody, less than 10, was addressed. 8. During an interview on 09/26/2024, beginning at 12:40 PM, the Medical Director indicated a Hepatitis B surface antigen should be completed every 3 months, if a Patient had immunity to Hepatitis B than a yearly Hepatitis B surface antibody should be completed and if falls below the 10 level should be offered a Hepatitis B vaccination booster. The Medical Director indicated Patient #2 should have had a Hepatitis B vaccination offered. 9. During an interview on 09/27/2024, beginning at 1:00 PM, RN 1 indicated Hepatitis B antigens were to be completed monthly, Hepatitis B surface antibodies were to be completed yearly, if a patient did not have surface antibodies a Hepatitis B vaccinations or booster would need to be administered. RN 1 indicated Patient #1, 2, 3, 4, 5, and 16 should have had a Hepatitis B booster. 10. During an interview on 09/27/2024, beginning at 2:00 PM, RN 1 indicated the Hepatitis B labs should have been monitored and had scheduled repeat labs to offer boosters if required.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 47022 Based on observation, record review, and interview, the dialysis facility failed to ensure central venous catheter (CVC) (catheter into large vein) exit site care was completed per policy and procedure when 70% alcohol was used as the cleansing agency in 1 of 1 exit site care observed with a Patient that required alcohol antiseptic (Patient #8). Findings include: A revised policy dated October 2023, titled, “Central Venous Catheter .... “ indicated when CVC access exit site care was completed utilizing a 70% alcohol pad the effective contact time was 30 seconds with a back-and-forth motion, and the air drying time would be 60 seconds. During an observation on 09/27/2024, beginning at 12:10 PM, Patient Care Technician (PCT) 2 was observed cleaning Patient #8’s CVC exit site using 70% alcohol swab; PCT 2 scrubbed the exit site for less than 10 seconds, and immediately applied a gauze pad to the exit site without the observation of the required dry time. During an interview on 09/27/2024, beginning at 12:25 PM, PCT 2 indicated when a Patient required alcohol antiseptic cleaning to the CVC site, there was not a required site cleaning time or a required dry time prior to a gauze pad being applied.”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 47022 Based on record review and interview, the dialysis facility failed to evidence their QAPI program included an action plan was developed to promote Hepatitis B immunizations in 1 of 1 dialysis facility. Findings include: An August 2024 Facility Health Meeting document indicated 32% of their active patients on hemodialysis were susceptible to Hepatitis B and 4% of the patients were missing their results or were late. The document failed to include documentation of an action plan to analyze and identify trends to identify lapses in surveillance in Hepatitis B vaccinations, investigate the problem or perform performance improvement plans. During an interview on 09/30/24, beginning at 3:00 PM, the Facility Administrator and RN 1 indicated there was not Hepatitis B surveillance of the vaccination program to identify trends in lapses or vaccinations to implement a performance improvement plan.”