Usrc Coffee Creek Dialysis

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility failed to notify the State Agency of an incident that disrupted normal operations and delayed/impacted patient care in 1 of 1 dialysis facility. Findings include: 1. During a review of Emergency Preparedness procedures on 06/20/2025, a document, titled “Network Reporting Information”, indicated that the network should be notified if there are any changes to operation hours if patient services will be impacted. 2. During a review of Adverse Events on 06/19/2025, the Facility Administrator [FA] provided an Event Report that was not located in the Adverse Events Log initially provided to surveyors. The Event Report, dated 06/09/2025, indicated that there was an interruption in operations involving the water supply beginning at 4:05 AM. The form continued to detail that the final water check alarm was elevated. The Biomed Technician was notified by opening staff, and informed staff that hemodialysis [HD] (a process to filter the blood in a patient whose kidneys do not work normally) treatments would not be able to begin until the problem was identified and corrections could be made. 3. During an interview on 06/20/2025, beginning at 12:32 PM, the FA indicated that the facility did not notify the State Agency of the disruption of operations and delay in HD treatments on 06/09/2025. 4. During an interview on 06/20/2025, beginning at 12:12 PM, the Biomed Technician indicated that she was able to report to facility at 5:18 AM and perfomed chlorine level checks at various ports of the RO system and spoke with the RO manufacturer Tech Line before facility was cleared to resume normal operations, approximately 1 hour later.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure staff removed gloves, performed hand hygiene, and donned new gloves in 3 of 5 observations of discontinuation of hendiadys (HD, a process to filter the blood on a patient whose kidneys do not work normally) and post dialysis access care for an arteriovenous fistula (AVF, dialysis access) or arteriovenous graft (AVG, dialysis access) (Patient #14, 17), in 1 of 4 discontinuations of HD from a central venous catheter (CVC, dialysis access) (Patient #20), and in 1 of 2 observations of an intravenous (IV, into a vein) medication administration (Patient #9). Findings include: 1. A revised policy, dated 07/2023, titled “Infection Control and Precautions for All Patients”, indicated that staff will perform hand hygiene before/after all patient contact and after contact with the keyboard or chair-side computer. 2. During an observation on 06/18/2025, beginning at 2:44 PM, PCT 1, at station #14, was discontinuing HD from Patient 17. PCT 1 disconnected the bloodlines and failed to remove gloves, perform hand hygiene, and don clean gloves before removing the needles from Patient 17. PCT 1 then failed to remove gloves, perform hand hygiene, and don new gloves prior to bandaging AVF cannulation site. 3. During an observation on 06/18/2025, beginning at 2:58 PM, PCT 1, at station #15, was discontinuing HD from Patient 14. PCT 1 removed the needles from Patient 14 and failed to remove gloves, perform hand hygiene, and don clean gloves prior to bandaging AVF cannulation sites. 4. During an interview on 06/20/2025, beginning at 10:10 AM, RN 3 indicated that hand hygiene should be performed before accessing and deaccessing HD sites. 41135 5. During an observation on 06/18/2025, beginning at 2:36 PM, PCT 1 was observed clamping the bloodlines running from the HD machine to Patient #20’s AVF and then removing the needles from the AVF site after touching the chair-side computer screen and computer keyboard without first changing gloves and performing hand hygiene. 6. During an observation on 06/18/2025, beginning at 2:25 PM, the FA was observed clamping the bloodlines running from the HD machine to Patient #7’s CVC and closing the clamps at the CVC access site after touching the chair-side computer screen and keyboard without first changing gloves and performing hand hygiene. 7. During an observation on 06/18/2025, beginning at 9:58 AM, RN 2 was observed wiping the injection port and injecting a medication into the blood lines for Patient # 9 after touching the chair-side computer screen and computer keyboard without first changing gloves and performing hand hygiene. 8. During an interview on 06/18/2025, beginning at 5:00 PM, the FA indicated no hand hygiene was needed after touching the computer before clamping bloodlines and would check the agency policy if hand hygiene was needed before administration of a IV medication after touching the computer. No additional information was provided regarding hand hygiene prior to IV administration before survey exit on 06/20/2025.”

“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: 41135 Based on record review and interview, the facility failed to ensure the hendiadys (HD, the process to filter the blood when the kidneys do not function properly) machines provided preventative maintenance in accordance with the manufacturer’s recommendations in 1 of 3 HD machines maintenance records. The findings include: Review of a policy titled “Preventative Maintenance” revised 08/2020 indicated the facility would provide preventative maintenance for HD machines per the manufacturer’s recommendations. Review of the preventative maintenance logs for HD machine #1 failed to evidence an annual preventative maintenance from March 2024 to June 2025. During an interview on 06/18/2025, beginning at 11:40 AM, the Biomedical Technician indicated the manufacturer’s directions for use indicated the HD machines should have an annual preventative maintenance procedure and indicated there was not one done for HD machine #1.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility failed to provide necessary services, the prescribed treatment time, or offer an alternative time/location, for hemodialysis [HD] (a process to filter the blood of a patient whose kidneys do not work normally) to patients after an event that caused an interruption in operations in 5 of 5 record reviews of patients that had scheduled opening shift HD treatments on 06/09/2025. Findings include: 1. A revised policy, dated 02/2023, titled “Patient Rights and Responsibilities”, indicated that every patient has the right to receive the necessary services required by the regulations regarding the plan of care. 2. During a review of Adverse Events on 06/19/2025, the Facility Administrator [FA] provided an Event Report that was not located in the Adverse Events Log initially provided to surveyors. The Event Report, dated 06/09/2025, indicated that there was an interruption in operations involving the water supply beginning at 4:05 AM. The form continued to detail that the final water check alarm was elevated. The Biomed Technician was notified by opening staff, and informed staff that hemodialysis [HD] (a process to filter the blood in a patient whose kidneys do not work normally) treatments would not be able to begin until the problem was identified and corrections could be made. 3. A record review, on 06/20/2025, for Patient 19, indicated that on 06/09/2025, Patient 19 was instructed that there would be a delay of HD treatment by 30minutes - 1 hour due to a water room issue and that Patient 19 refused to stay for HD treatment. The absence report indicated that the reason for absence was Patient choice/Psychosocial Issue. During an interview on 06/20/2025, beginning at 1:15 PM, the Facility Administrator [FA] indicated that on 06/09/2025, Patient 19 was present in the dialysis facility and when notified that treatment time would be delayed, refused treatment and left the facility. The FA indicated that no alternate day/time/location was offered to Patient 19, because when leaving, the facility was willing to begin HD treatment and Patient 19 continued to refuse. The FA could not provide an Against Medical Advice Form for Patient 19 for this incident. During an interview on 06/20/2025, beginning at 9:40AM, Patient 19 indicated that he/she was contacted via phone at home and informed of water room situation that would be causing a delay in HD treatment by approximately 1 hour. Patient 19 informed staff that due to transportation arrangements, he/she would not be able to attend a treatment that was anticipated to begin 1 hour past the scheduled time. Patient 19 indicated that he/she never reported to the dialysis facility on 06/09/2025. Patient 19 indicated that no alternative time/day/location was offered to him/her. 4. A Hemodialysis Flowsheet, dated 06/09/2025, for Patient 18, indicated the following: A. The prescribed HD treatment time was 240 minutes (4 hours). B. The HD treatment started at 6:04 AM and ended at 9:48 AM for a total time of 224 minutes (3 hours 44 minutes). C. Post Dialysis Comments by RN 3 indicated that the treatment duration was signed off due to physician request. During an interview on 06/20/2025, beginning at 10:05 AM, Patient 18 indicated that his/her treatment was delayed but believed he/she received the full treatment time. 5. A Hemodialysis Flowsheet, dated 06/09/2025, for Patient 12, indicated the following: A. The prescribed HD treatment time was 240 minutes (4 hours). B. The HD treatment started at 5:57 AM and ended at 9:27 AM for a total time of 210 minutes (3 hours 30 minutes) C. Pre Dialysis Comments by RN 2 indicated that Patient 12 started late due to water room issue and that Patient 12 requested to get off treatment at scheduled time. D. Post Dialysis Comments by RN 2 indicated that the treatment duration was signed off due to physician request. During an interview on 06/20/2025, beginning at 9:45 AM, Patient 12 indicated that on 06/09/2025, treatment was started late and ended early due to a water room problem. Patient 12 indicated that he/she was not given the opportunity to complete his/her prescribed treatment time. 6. A Hemodialysis Flowsheet, dated 06/09/2025, for Patient 4, indicated the following: A. The prescribed HD treatment time was 240 minutes (4 hours). B. The HD treatment started at 6:23 AM and ended at 9:43 AM for a total time of 200 minutes (3 hours 20 minutes). C. Post Dialysis Comments by RN 3 indicated that the treatment duration was signed off due to physician request. During an interview on 06/20/2025, beginning at 10:03 AM, Patient 4 indicated that he/she remembers finishing treatment around 9:45 AM. 7. A Hemodialysis Flowsheet, dated 06/09/2025, for Patient 3, indicated the following: A. The prescribed HD treatment time was 240 minutes (4 hours). B. The HD treatment started at 5:59 AM and ended at 9:00 AM for a total time of 181 minutes (3 hours 1 minute). C.Post Dialysis Comments by RN 3 indicated that the treatment duration was signed off due to physician request and that treatment was shortened due to water malfunction. During an interview on 06/20/2025, beginning at 9:57 AM, Patient 3 indicated that he/she had to wait in the car for some time before treatment was able to be started and was under the impression that the full treatment had been received. 8. During an interview on 06/20/2025, beginning at 10:00 AM, RN 3 indicated that the water room incident only affected patients on the first shift, and that the first shift patient treatments were ended early in order to get the second shift patients started on time. 9. During an interview on 06/19/2025, beginning at 2:43 PM, Corporate 1 indicated that on 06/09/2025, there was an issue with the water room and the Medical Director ordered that all patients who had to start late needed to have their HD treatments ended at the normally scheduled end time. When asked if patients were given the option to complete their full treatments, Corporate 1 indicated patients were not given the option to complete their full treatments because the Medical Director ordered everyone to come off of treatment early. 10. During an interview on 06/20/2025, beginning at 10:16 AM, The Medical Director [MD] indicated that since the water room incident was due to no fault of the patient, patients should have been allowed to complete their full treatment times or should have been offered an alternate day/location. 11. During an interview on 06/20/2025, beginning at 12:32 PM, the FA indicated that due to the water room incident on 06/09/2025, HD treatments were delayed approximately 40 minutes and that no patients missed treatments due to the water room incident. The FA indicated that patients were offered their full treatment time, but all patients refused to stay past their scheduled end times. The FA was unable to provide any Against Medical Advice Forms for the date of 06/09/2025. The FA was unable to provide any MD orders for any of the reviewed patients that instructed staff to end treatments early on 06/09/2025.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility failed to ensure that RN 2 completed an initial assessment prior to the first in-center hemodialysis [HD] (a process to filter the blood of a patient whose kidneys do not work normally) treatment in 1 of 2 clinical record reviews of patients who had switched modalities. Findings include: A clinical record review on 06/19/2025, for Patient 4, showed an admission date of 05/02/2025. A Hemodialysis Flowsheet, dated 05/02/2025, for Patient 4, indicated that in-center HD treatment started at 5:38 AM and RN 2 verified treatment orders and reviewed Patient Plan of Care at 6:01 AM. During an interview on 06/19/2025, beginning at 1:50 PM, Corporate 1 indicated that she was unable to locate any Initial RN Assessment Form or any RN notes that contained an assessment prior to the start of HD treatment. During an interview on 06/20/2025, beginning at 9:17 AM, Corporate 1 indicated that Patient 4 was technically a transfer and not a new admission, and the requirements for a transfer patient do not require an initial RN assessment if it had been completed upon initial admission date, even if it was a different modality.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 41135 Based on record review and interview, the facility failed to provide the necessary care and services to achieve and sustain the appropriate hemoglobin (red blood cells) level to treat anemia (low blood cell count) in 1 of 3 clinical record reviews for in-center hendiadys (HD, the process to filter the blood when the kidneys do not function properly) patients. (Patient #3) The findings include: A clinical record review for Patient #3 evidenced a medication list dated 06/19/2025 which indicated the Patient was to receive Epogen (a medication to increase the production of red blood cells for treatment of anemia) 3 times a week effective 06/11/2025. A treatment sheet dated 06/13/2025 indicated Epogen was not given due to the Patient changed in-center HD shifts. On 06/18/2025, beginning at 12:00 PM, the FA indicated Epogen was not given on 06/13/2025, because the medication was missed since the medication label was printed for 2nd shift and the Patient had switched to 1st shift.”

“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: 51199 Based on record review and interview, the dialysis facility failed to follow policies related to internally reporting an adverse patient event in 1 of 1 reviews of adverse events related to medication errors found in clinical record reviews, ending treatment early against medical advice (AMA) in 1 of 1 clinical records reviewed ending treatment AMA, and receiving treatments as ordered in 1 of 3 clinical records reviewed receiving in-center hendiadys (HD, the process to filter the blood when the kidneys do not function properly) (Patient #5). Findings include: 1. A revised policy, dated 07/2024, titled “Occurrence/Incident Reports Including Great Catch”, indicated that all incidents, including medication errors/omissions, will be documented on an incident report within 24 hours and reviewed by Facility Administrator [FA] and Medical Director [MD]. 2. A policy titled “Against Medical Advice” revised 01/2020 indicated an AMA form will be completed for any patient refusing to complete prescribed treatment for which the RN would review with the patient and have the patient sign. 3. During a clinical record review on 06/19/2025, it was noted that a medication (Epogen) had not been administered during the hemodialysis [HD] (a process to filter the blood of a patient whose kidneys do not work normally) treatment, as scheduled on 06/13/2025. During an interview on 06/19/2025, beginning at 12:00, the FA indicated that she was aware of the missed medication on 06/13/2025 and explained that since the patient had switched shifts recently, the label that the RN would normally use as a guide to administer medication was printed on the incorrect shift list and the medication was missed. The FA indicated that she was unsure if an incident report/adverse event was completed for the missed medication. The FA was unable to provide surveyors with any incident report of this event. 41135 4. A clinical record for Patient #3 evidenced a HD treatment order dated 06/04/2025 which indicated the treatment time was 4 hours. A treatment sheet dated 06/04/2025 indicated the Patient requested treatment stop AMA after 2 hours and 43 minutes. The clinical record failed to evidence an AMA form was completed and signed by the Patient. On 06/20/2025, at 9:17 AM, the Clinical Specialist indicated the facility did not have an AMA form. 5. A clinical record review for Patient #5 evidenced a HD order dated 05/30/2025 which indicated the facility was to administer 100 milliliters (ml) of normal saline (NS, a liquid to flush the vein) intravenously (IV, into the vein) every 30 minutes during HD. A treatment record dated 05/30/2025 indicated the facility staff flushed 50 ml of NS IV at 11:09 AM, 11:35 AM, 12:06 PM, 12:30 PM, 1:00 PM, 1:30 PM, and 2:01 PM and failed to administer 100 ml of NS per the order. The treatment sheet dated 06/16/2026 failed to evidence the facility staff flushed NS during treatment. On 06/18/2025, at 4:10 PM, the FA indicated she was not sure why the NS was not given at all during treatment on 06/16/2025 and why only 50 ml were given on 05/30/2025. No additional information or documentation was provided prior to survey exit on 06/20/2025.”