Davita Lafayette Home Dialysis

“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: 44230 Based on observation, record review, and interview, the facility failed to ensure infection control practices were maintained for 1 of 1 peritoneal dialysis initiations observed. (Patient #5) Findings Include: A policy titled, “Infection Control for Dialysis Facilities” (April 2023) indicated hand hygiene is to be performed prior to entering/exiting the patient treatment area, prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, and before touching clean areas. A policy titled, “Baxter Home Choice Claria Cycler” (March 2024) indicated materials required for initiating therapy to include a mask for everyone in the room. When initiating treatment, wash hands and apply personal protective equipment (PPE). During an observation on 07/16/2025 at 8:05 PM, RN 8 was observed initiating the PD treatment for Patient #5 in the SNF. She failed to complete a 1-minute hand wash prior to initiating treatment, failed to provide a face mask for the patient during bag connection, and failed to change gloves and perform hand hygiene after inserting the cycler drain line into the toilet. RN 8 then secured her hair away from her face twice during the dressing change with gloves on and failed to remove the contaminated gloves, perform hand hygiene and apply new gloves. During an interview on 07/17/2025 at 9:09 PM, RN 1 indicated that SNF staff are taught to complete a one-minute hand wash using soap and water prior to initiating treatment. Everyone in the room is required to wear a mask during cycler set-up. After touching the toilet and securing her hair RN 8 should have removed her gloves, completed hand hygiene, and redonned new gloves. Hand sanitation is required before and after glove removal.”

“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: 51751 Based on observation, record review and interview, the facility failed to ensure adequate documentation of the CVC (dialysis access) dressing change for 1 of 2 HHD patient records reviewed (Patient #7) and adequate disinfection of the CVC catheter limbs using an alcohol pad for 1 of 1 CVC initiations. (Patient #8) Findings include: 1. A policy titled “Central Venous Catheter (CVC) Care (April 2025), CVC dressing changes are performed prior to each dialysis treatment. 2. According to the “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” policy (April 2025), using aseptic technique, remove each cap and disinfect each CVC hub for 15 seconds including the sides, threads, and end of hub thoroughly with friction making sure to remove any residue. 3. A review of Patient #7 ’ s treatment records from 05/07/2025–07/09/2025 failed to evidence documentation for CVC dressing changes. 4. During an observation at the DEN on 07/16/2025 at 10:25 AM, RN 5 accessed Patient # 8’s CVC, did not disinfect the CVC hubs, then attached a syringe. 5. During an interview on 07/16/2025 at 10:50 AM, RN 5 indicated the CVC hubs are considered sterile when the caps are first removed, therefore, she did not need to disinfect prior to attaching the syringes, but once the initial syringes are removed the hubs are to be disinfected for 15 seconds. 6. During an interview on 07/17/2025 at 8:40 AM, RN 1 indicated that Patient#7’s wife completes dressing changes due to the patient’s vision failing. RN 1 also indicated that the dressing changes are done every other treatment due to the patient’s sensitive skin but could not provide a physician order to do so.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 44230 Based on observation, record review, and interview, the facility failed to ensure chlorine testing was performed per policy and procedure for 1 of 1 chlorine test observed. (PCT 2) Findings Include: A policy titled, “Total Chlorine Test Using RPC Ultra Low Total Chlorine Test Strip” (October 2023), indicated to dip the RPC strip in the water sample for 60 seconds. A policy titled, DSD Total Chlorine Monitoring of Portable Reverse Osmosis (RO) Water Treatment System” (October 2024), indicated if utilizing RPC Ultra Low Total Chlorine Test Strips and a water temperature is not available, teammates should use 60 second dip time. During an observation on 07/16/2025 at 9:15 AM, PCT 2 obtained a 100-milliliter sample of product water from the portable RO and submerged the RPC strip into the sample for 90 seconds to obtain a chlorine level. During an interview on 07/16/2025 at 9:15 AM, PCT 2 indicated the policy states the RPC testing strip should be submerged into the sample for a total of 60-90 seconds. She submerges it for 90 seconds each time to ensure saturation. During an interview on 07/16/2025, RN 5 indicated an RPC strip should be submerged into the product water sample for 60 seconds. During an interview on 07/16/2025 at 2:45 PM, the ROM indicated she completed chlorine testing education with PCT 2 last week and is unsure why she is not following policy to submerge the strip for 60 seconds.”

“H-TRAIN CONTENT INCLUDES ER PREP HOME PTS CFR(s): 494.100(a)(3) The training must- (3) Be conducted for each home dialysis patient and address the specific needs of the patient, in the following areas: (i) The nature and management of ESRD. (ii) The full range of techniques associated with the treatment modality selected, including effective use of dialysis supplies and equipment in achieving and delivering the physician’s prescription of Kt/V or URR, and effective administration of erythropoiesis-stimulating agent(s) (if prescribed) to achieve and maintain a target level hemoglobin or hematocrit as written in patient’s plan of care. (iii) How to detect, report, and manage potential dialysis complications, including water treatment problems. (iv) Availability of support resources and how to access and use resources. (v) How to self-monitor health status and record and report health status information. (vi) How to handle medical and non-medical emergencies. (vii) Infection control precautions. (viii) Proper waste storage and disposal procedures. This Standard is not met as evidenced by: 44230 Based on record review, and interview, the facility failed to ensure the DEN (dialysis extension in nursing home) provided contact information for the physician and/or RN for 1 of 1 Den’s observed. Findings Include: A document titled, “”Home Hemodialysis Coordination Agreement” indicated the facility will communicate with the SNF as urgent patient-care issues arise and take action where appropriate. The facility will collaborate with the SNF as necessary to provide dialysis care coordination to each patient admitted to the facility. Communication procedures will allow for 24/7 communication between the facility and SNF. The facility will provide the SNF a telephone support and list of names and contact information of Nephrologist and/or RN to be called for emergencies. During an interview on 07/16/2025 at 10:10 AM RN 8 indicated she had created her own list of ESRD contacts if needed. She was unaware of the requirement of the ESRD to provide this information. If she needs to contact the on-call ESRD physician, she calls the hospital to obtain the on-call physician. During an interview on 07/16/2025 at 10:14 AM, the Regional Operations Manager indicated SNF management was provided contact information for the physician and/or RN and was unsure why SNF staff do not have access to the information. She further indicated being aware of this requirement. 51751 During an interview on 07/16/2025 at 10:15 AM Entity 2 / RN 9 indicated that she was not provided with contact information for the nephrologists and/or the dialysis RN. She would call the DEN if they were open to obtain the physicians’ phone numbers if needed.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 51751 Based on record review and interview, the facility failed to ensure that HHD records were reviewed, and concerns addressed for 1 of 1 HHD patients reviewed. (Patient #7) Findings include: The clinical record for Patient #7 was reviewed and evidenced the following: A document titled “Patient Summary Report” evidenced an order for HHD using NxStage five times a week for 7 hours. Treatment records dated 05/07/2025 - 07/09/2025 evidenced the following: Shortened treatment times on 05/07/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/17/2025, 05/19/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/25/2025,05/27/2025, 05/28/2025, 05/30/2025, 06/01/2025, 06/03/2025, 06/04/2025, 06/05/2025, 06/08/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/18/2025, 06/19/2025, 06/21/2025, 06/23/2025, 06/24/2025, 06/26/2025, 06/27/2025, 06/29/2025, 06/30/2025, 07/03/2025, 07/05/2025, 07/07/2025, 07/08/2025, and 07/09/2025. Incomplete pre-intra-post blood pressures/pulse rates/ temperature on 05/07/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/17/2025, 05/19/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/25/2025,05/27/2025, 05/28/2025, 05/30/2025, 06/01/2025, 06/03/2025, 06/04/2025, 06/05/2025, 06/08/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/18/2025, 06/19/2025, 06/21/2025, 06/23/2025, 06/24/2025, 06/26/2025, 06/27/2025, 06/29/2025, 06/30/2025, 07/03/2025, 07/05/2025, 07/07/2025, 07/08/2025, and 07/09/2025. Incomplete bloodline connector clip use on 05/07/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/17/2025, 05/19/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/25/2025,05/27/2025, 05/28/2025, 05/30/2025, 06/01/2025, 06/03/2025, 06/04/2025, 06/05/2025, 06/08/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/18/2025, 06/19/2025, 06/21/2025, 06/23/2025, 06/24/2025, 06/26/2025, 06/27/2025, 06/29/2025, 06/30/2025, 07/03/2025, 07/05/2025, 07/07/2025, 07/08/2025, and 07/09/2025. Incomplete vascular access leak detector use on 05/07/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/17/2025, 05/19/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/25/2025,05/27/2025, 05/28/2025, 05/30/2025, 06/01/2025, 06/03/2025, 06/04/2025, 06/05/2025, 06/08/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/18/2025, 06/19/2025, 06/21/2025, 06/23/2025, 06/24/2025, 06/26/2025, 06/27/2025, 06/29/2025, 06/30/2025, 07/03/2025, 07/05/2025, 07/07/2025, 07/08/2025, and 07/09/2025. Incomplete CVC assessment documentation on 05/07/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/17/2025, 05/19/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/25/2025,05/27/2025, 05/28/2025, 05/30/2025, 06/01/2025, 06/03/2025, 06/04/2025, 06/05/2025, 06/08/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/18/2025, 06/19/2025, 06/21/2025, 06/23/2025, 06/24/2025, 06/26/2025, 06/27/2025, 06/29/2025, 06/30/2025, 07/03/2025, 07/05/2025, 07/07/2025, 07/08/2025, and 07/09/2025. Incomplete dialysate rate/volume and/or ultrafiltration rate/volume on 05/07/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/17/2025, 05/19/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/25/2025,05/27/2025, 05/28/2025, 05/30/2025, 06/01/2025, 06/03/2025, 06/04/2025, 06/05/2025, 06/08/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/18/2025, 06/19/2025, 06/21/2025, 06/23/2025, 06/24/2025, 06/26/2025, 06/27/2025, 06/29/2025, 06/30/2025, 07/03/2025, 07/05/2025, 07/07/2025, 07/08/2025, and 07/09/2025. Incomplete HHD maintenance on 05/07/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/17/2025, 05/19/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/25/2025,05/27/2025, 05/28/2025, 05/30/2025, 06/01/2025, 06/03/2025, 06/04/2025, 06/05/2025, 06/08/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/18/2025, 06/19/2025, 06/21/2025, 06/23/2025, 06/24/2025, 06/26/2025, 06/27/2025, 06/29/2025, 06/30/2025, 07/03/2025, 07/05/2025, 07/07/2025, 07/08/2025, and 07/09/2025. Incomplete chlorine testing on 05/07/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/17/2025, 05/19/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/25/2025,05/27/2025, 05/28/2025, 05/30/2025, 06/01/2025, 06/03/2025, 06/04/2025, 06/05/2025, 06/08/2025, 06/09/2025, 06/11/2025, 06/13/2025, 06/15/2025, 06/16/2025, 06/18/2025, 06/19/2025, 06/21/2025, 06/23/2025, 06/24/2025, 06/26/2025, 06/27/2025, 06/29/2025, 06/30/2025, 07/03/2025, 07/05/2025, 07/07/2025, 07/08/2025, and 07/09/2025. A document titled “Patient Summary Report” for Patient #7 indicated an order for HHD using NxStage five times a week for 7 hours. During an interview on 07/17/2025 at 8:40 AM, RN 1 indicated Patient #7 does not report missed treatments. She prints a monthly treatment report and reviews it with physician and patient at monthly appointments. She indicated that there is not a policy for nocturnal HHD vital signs frequency and does not have a physician order indicating the patient expectation. She is aware of the documentation not being completed by the patient but is not the only staff member responsible for reviewing Patient #7’s treatment sheets, sometimes RN 2 reviews them. Patient #7 does not document the use of the bloodline connector clip but indicated it is attached to the cartridge and has been trained to use them. Patient #7 has gastrointestinal issues and often stops treatment due to this. She has educated the patient verbally several times but is unable to provide any documentation.”

“H-MONITOR HOME ADAPT;HOME VISIT=POC CFR(s): 494.100(c)(1)(i) Services include, but are not limited to, the following: (i) Periodic monitoring of the patient’s home adaptation, including visits to the patient’s home by facility personnel in accordance with the patient’s plan of care. This Standard is not met as evidenced by: 51751 Based on record review and interview, the facility failed to ensure home visits were completed for 1 of 7 patients reviewed. (Patient #7) Findings include: According to the “Home Hemodialysis (HHD) Home Visit Policy” policy (February 2025), the ESRD Conditions for Coverage state an initial home visit is required to be completed when a patient starts home dialysis and when problems are identified as part of monitoring the patient’s home adaptation. A document titled “HHD Home Visit Evaluation” dated 06/27/2022, indicated that Patient #7 received a home visit on the last day of HHD training. During an interview on 07/17/2025 at 08:40 AM, RN 1 indicated that Patient #7 had not had a home visit since 06/27/2022 despite his/her history of non-compliance with treatments to include missed/shortened treatments, incomplete documentation of treatments and dialysis machine maintenance. 44230 During an interview on 07/16/2025 at 2:45 PM, RN 1 indicated the policy for home visits does not provide the minimum frequency of home visits to be completed for home hemodialysis patients. She verified that no other home visits were completed after 06/27/2022, start of home dialysis, despite the ongoing concerns of non-compliance. RN 1 indicated education has been provided to the Patient #7 regarding missing/short treatments and incomplete treatment documentation however this concern has not been documented in the patient’s medical record. RN 1 could not verbalize any other interventions completed to assist with patient compliance, including home visits. During an interview on 07/17/2025 at 8:41 AM, RN 1 indicated that Patient #7 frequently shortens and/or misses treatments. She pulls a report of his missed treatments and discusses them with him monthly at clinic visits. She indicated Patient #7 often reports his IPAD used to document treatments does not connect. She indicated the physician is aware of this concern. RN 1 was unaware Patient #7 has not run on the correct physician ordered blood flow rate and dialysate flow rate and plans to address this with him/her. Education is provided to the patient regarding his/her noncompliance, although it is not documented. Vital signs are to be completed pre and post treatment for nocturnal patients. Chlorine testing is to be completed with each new SAK (every other treatment) but did not realize he had not been documenting any results. She indicated the bloodline connector clip (used to prevent bleeding out during treatment) should be used and documented as on the treatment sheet. Patient #7 has been trained to use the blood leak detectors both for the dialysis machine and under the patient’s access (alarms when blood/fluid is detected while patient is sleeping) but does not know if this is being used as it is not documented. She indicated that Patient #7 and/or spouse are to complete CVC dressing change every other day despite the order indicating daily. RN 1 is aware Patient #7 fails to document any of his dressing changes. RN 1 further indicated Patient #7 has been noncompliant since starting HHD in 2022.”

“H-COORDINATION OF CARE BY MEMBER OF IDT CFR(s): 494.100(c)(1)(ii) Services include, but are not limited to, the following: (ii) Coordination of the home patient’s care by a member of the dialysis facility’s interdisciplinary team. This Standard is not met as evidenced by: 44230 Based on record review and interview, the facility failed to maintain coordination of care between the facility and SNF for 2 of 2 dialysis den patients reviewed. (Patient #3, 4) Findings Include: 1. A policy titled, “Incenter Hemodialysis Policies and Procedures DaVita Skilled Nursing Facility Dialysis (DSD) (April 2024) indicated the SNF Coordination Agreement will include how communication and responses will be coordinated and documented between the ESRD facility and nursing home staff. 2. A document titled, “Home Hemodialysis Coordination Agreement” indicated the facility and SNF will maintain communication regarding all required supportive care of the patient both during and after dialysis treatments. The facility will communicate with the SNF necessary post treatment monitoring required related to fluid overload/depletion, infection, and electrolyte imbalances. The facility and SNF will communicate, and document responses related to medication administration, physician and treatment orders, lab values, vital signs, changes in patient status, weights, compliance with food/fluid restrictions or provision of meals, dialysis treatments provided and patient response, and concerns with dialysis accesses. 3. The clinical record for Patient #3, admission date 05/20/2025, included 3 coordination notes from 05/20/2025 -- 07/15/2025. All three coordination notes failed to include the dates of treatments. 4. The clinical record for Patient #4, admission date 08/11/2023, included 4 coordination notes from 01/01/2025 - 07/15/2025. Two coordination notes were dated 06/04/2025 and 06/30/2025 while the other 2 coordination notes failed to include any date. 5. During an interview on 07/16/2025 at 9:54 AM, RN 5 indicated the SNF sends a communication document with each patient upon arrival to the DEN. The SNF and DEN use this document to communicate with the facility on each individual patient. Once the patient’s treatment is completed the form is filled out by the dialysis nurse, a copy is made for the DEN, and the original is sent back to the SNF staff with the patient. RN 5 indicated she gets busy and forgets to make copies of these communication documents prior to sending the original back with the patient, indicating this was the reason they were missing from the patient’s clinical records. RN 5 indicated she needs to ensure she is getting a copy for the facility’s records.”

“H-RECORDKEEPING SYSTEM CFR(s): 494.100(c)(2) (2) The dialysis facility must maintain a recordkeeping system that ensures continuity of care and patient privacy. This includes items and services furnished by durable medical equipment (DME) suppliers referred to in §414.330(a)(2) of this chapter. This Standard is not met as evidenced by: 44230 Based on record review and interview, the facility failed to ensure clinical records reflected trained SNF staff were completing PD (dialysis via catheter in abdomen) treatments for 1 of 1 SNF reviewed. (Entity 1) Findings Include: A document titled, “”Home Hemodialysis Coordination Agreement” indicated the facility will ensure SNF staff are trained prior to completing care/treatments. The PD treatment records for Patient #5, dated 04/29/2025 - 06/30/2025, failed to evidence the SNF staff member performing the dialysis initiation and discontinuation of treatments completed. During an interview on 07/16/2025 at 2:45 PM, RN 1 indicated she could not identify which SNF staff member were completing the PD treatments to determine their training status by the facility. All SNF staff performing dialysis treatments for Patient #5 are to be trained by the facility staff prior to completing patient treatments.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 44230 Based on record review and interview, the facility failed to ensure the health and safety of patients with identified medication allergies for 1 of 2 Home Hemodialysis DEN patients. (Patient #3) Findings Include: A policy titled, “Anticoagulation” (September 2024) indicated Heparin (medication used to prevent clotting of blood) is contraindicated when patients have documented allergies to pork heparin. A policy titled, “DSD Medication Policy” (April 2024) indicated prior to administration of medications, check for patient allergies when receiving or entering a medication order and prior to administering any medication. A document titled, “Patient Summary Report” for Patient #3 indicated an allergy to Heparin. The clinical record for Patient #3 was reviewed and evidenced the following Heparin administrations. A document titled, “Treatment Details Report” indicated RN 5 administered 2000 units of Heparin into both the arterial and venous lumens of the CVC (dialysis catheter) on 07/01/2025 at 11:00 AM. A document titled, “Treatment Details Report” indicated PCT 2 administered 2000 units of Heparin into both the arterial and venous lumens of the CVC on 07/03/2025 at 11:04 AM. A document titled, “Treatment Details Report” indicated RN 5 administered 2000 units of Heparin into both the arterial and venous lumens of the CVC on 07/05/2025 at 8:10 AM. A document titled, “Treatment Details Report” indicated RN 5 administered 2000 units of Heparin into both the arterial and venous lumens of the CVC on 07/08/2025 at 11:20 AM. A document titled, “Treatment Details Report” indicated RN 5 administered 2000 units of Heparin into both the arterial and venous lumens of the CVC on 07/10/2025 at 7:29 AM. A document titled, “Treatment Details Report” indicated RN 7 administered 2000 units of Heparin into both the arterial and venous lumens of the CVC on 07/12/2025 at 11:37 AM. During an interview on 07/15/2025 at 11:03 AM, RN 5 indicated Patient #3 reported Heparin as an allergy to her. The order for Heparin was discussed with Physician 1 and she was given approval to administer Heparin in the CVC lumens. RN 5 indicated there was no documentation in the patient ’ s clinical record of this discussion and/or the approval to administer. During an interview on 07/15/2025 at 10:37 AM, the FA indicated Patient #3 has a Heparin allergy listed in the clinical record and Heparin should not be administered without a physician order. During an interview on 07/15/2025 at 3:15 PM, the FA indicated that if a patient has an allergy listed for a medication, that medication should not be administered to the patient.”

“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: 44230 Based on observation, record review and interview, the medical director failed to ensure staff followed policy and procedure related to expired supply monitoring for 1 of 1 facility reviewed and failed to ensure staff followed policy and procedure related to disinfection of vascular accesses for 1 of 1 AVF (dialysis access) initiations. (Patient #3) Findings include: Expired Supplies A policy titled, “Infection Control for Dialysis Facilities” (April 2023), indicated supplies will be monitored for expiration date prior to use. During an observation of exam room 2 on 07/14/2025 at 1:27 PM, a bottle of ExSept (skin disinfectant) had a manufacturer’s expiration date of 05/06/2025. During an observation of exam room 3 on 07/14/2025 at 1:31 PM, a bottle of ExSept had a manufacturer’s expiration date of 05/06/2025. During an observation of the laboratory area on 07/14/2025 at 1:48 PM, 10 light blue lab tubes expired on 02/28/2025 and 10 Cobas PCR Media Uni Swab Sample Packet (used to test for COVID infection) expired on 04/30/2024. During an observation on 07/14/2025 at 1:59 PM, the wall hand sanitizer outside of exam room 3 expired 01/2025. 51751 During an observation of exam room 4 on 07/14/2025 at 1:36 PM, 1-1000 milliliter bag of 0.9% Sodium Chloride intravenous fluid (fluid used to rehydrate) expired 03/2025. During an observation of the medication preparation area on 07/14/2025 at 1:43 PM, 2 BD SafetyGlide 1milliliter syringes expired 04/30/2025 and 2 Acta Medical Intravenous Administration Sets (used to administer fluids into the vein) expired 04/19/2025. During an observation of the medication preparation area on 07/14/2025 at 1:46 PM, a bottle of hand soap found at the clean sink expired 03/2023. During an observation of the DEN on 07/16/2025 @ 8:42 AM, 73 recirculation connectors found in a cabinet of the medication preparation area, expired 03/31/2025 and 1 Microorganism collection and transport system (used to obtain cultures) expired 06/22/2025. During an observation of the DEN on 07/16/2025 at 8:52 AM, 2 bottles of E-Z Chek Blood Leak test strips (strips used to detect blood leaks) found in a cabinet of the medication preparation area expired 03/31/2025. During an observation of the DEN on 07/16/2025 at 8:56 AM, 100 yellow top laboratory tubes found in the laboratory cabinet expired 5/31/2025 along with 43 BD Vacutainer blood collection sets (used to collect blood samples) expired 06/30/2025. During an interview on 07/14/2025 at 2:35 PM, RN 1 indicated that all nurses are to take responsibility for checking for expired supplies when stocking every week and that a staff member is currently being trained to regularly complete supply checks. AVF Disinfection According to the “AV Fistula or Graft Cannulation with JMS Systolic Mini Safety Fistula Needles and Administration of Heparin Loading Dose” policy (April 2025), teammates are to apply alcohol to the access site using a circular rubbing motion, center out for 60 seconds and allow to dry for 15 seconds prior to cannulation. During an observation at the DEN on 07/17/2025 at 7:10 AM, RN 5 initiated Patient #3’s AVF (dialysis access) treatment. RN 5 disinfected the AVF with an alcohol prep pad using a swiping motion for 6 seconds and failing to allow the alcohol to dry prior to cannulation (inserting needle). During an interview on 07/17/2025 at 7:20 AM, RN 5 indicated that she was unsure of the amount of time needed to disinfect a AVF or what the policy stated. She usually does a couple swipes and sticks the patient.”