Usrc North Muncie

“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: 45607 Based on observation, policy review, and interview, the dialysis facility failed to ensure bleach solution for disinfection was stored with the lid closed for two of four 1:100 bleach solution containers on the treatment floor. Findings include: 1. Review of the Disinfection and Cleaning of Dialysis Equipment policy, revised 07/2023, indicated “ ... A 1:100 dilution bleach solution will be made daily ... Both container and lid must be opaque to prevent weakening of the bleach solution ... Container will remain covered at all times ...” 2. During an ICHD treatment floor observation on 08/05/2025 at 10:59 AM, observed one bleach container with the lid partially off on the “clean” sink near the patient entrance to the treatment floor and another bleach container holding used clamps with the lid partially off on the “dirty” sink near Station 25. At 11:13 AM and 12:38 AM, observed the lids of both bleach containers were still partially uncovered. 3. During an ICHD treatment floor observation on 08/06/2025 at 10:06 AM, observed one bleach container with the lid partially off on the “clean” sink near the patient entrance to the treatment floor and another bleach container holding used clamps with the lid partially off on the “dirty” sink near Station 25. At 10:22 AM, observed the lids of both bleach containers were still partially uncovered. 4. During an interview on 08/05/2025 at 11:24 AM, PCT 4 indicated they didn’t know if there was a time limit for how long bleach container lids can remain open, but indicated they were usually always on.”

“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: 45607 Based on observation, policy review, and interview, the dialysis facility failed to ensure staff performed hand hygiene per policy for 1 of 8 PCTs observed on the ICHD treatment floor (PCT 4). Findings include: 1. Review of the Hand Hygiene policy, revised 08/2020, indicated “ ... Hand Hygiene will be performed ... Before clean/aseptic procedure ... eg. vascular access cannulation/decannulation ... After gloves are removed ...” 2. During an ICHD treatment floor observation on 08/05/2025 beginning at 10:41 AM, PCT 4 discontinued dialysis for Patient #5, who had an arteriovenous fistula. Prior to removing the first needle, PCT 4 changed gloves without performing hand hygiene after glove removal. Prior to changing the gauze on the first needle site, PCT 4 again changed gloves without performing hand hygiene after glove removal. 3. During an interview on 08/05/2025 at 10:57 AM, PCT 4 indicated hand hygiene should be performed each time you touch the machine, touch the patient, touch dirty material, and after removing gloves.”

“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: 45607 Based on observation, policy review, and interview, the dialysis facility failed to ensure staff followed infection control procedure related to CVC exit site care for 1 of 2 CVC exit site care observations (RN 1). Findings include: 1. Review of the Dialysis Catheter Dressing Change Procedure policy, revised 02/2023, indicated “ ... Using aseptic technique, cleanse the skin surrounding the exit site with the appropriate skin antiseptic ... Acceptable cleansing agents include ... ChloraPrep (chlorhexidine 2% with 70% alcohol) ... Use gentle back and forth strokes, progressing from the catheter exit site outwards for 30 seconds ...” 2. During an ICHD treatment floor observation on 08/05/2025 beginning at 9:18 AM, observed RN 1 provided CVC exit site care for Patient #4. RN 1 cleansed the area around the exit site with ChloraPrep for 25 seconds. RN 1 failed to cleanse the area around the exit site for 30 seconds. 3. During an interview on 08/05/2025 at 12:36 PM, RN 1 indicated the area around a CVC exit site should be cleansed for a minute using ChloraPrep and then allowed to dry. 4. During an interview on 08/05/2025 at 12:35 PM, PCT 1 indicated the area around a CVC exit site should be cleansed with two ChloraPrep swabs, cleansing for 10 to 15 seconds per swab.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 48224 Based on observation and interview, the dialysis center failed to ensure staff did not eat or drink while working on the dialysis treatment floor for 1 of 1 flash tour observation period. Findings include: During the flash tour observation on 7/07/25 beginning at 8:44 AM, a cup of coffee was observed sitting on the east counter in the treatment area and a cup of coffee was observed sitting on the nurse’s station desk in the middle aisleway of the treatment area. During an interview on 7/08/25 at 10:30 AM, the Administrator relayed drinks are not allowed on the treatment floor.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 48224 Based on record review and interview, the dialysis facility failed to ensure the POC was reviewed and signed by the patient for 2 of 2 unstable ICHD patient records reviewed (Patient #4 and 5) and 1 of 2 ICHD patient records reviewed who have been on treatment greater than a year (Patient #2). Findings include: 1. The facility policy “Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA/POC)”, last revised 4/2024, indicated the CIPA/POC will be signed by the IDT members including the patient or the patient’s legal representative. If the patient chooses to not sign the plan of care, this will be documented on the plan of care, along the reason the signature was not provided. 2. Patient #2’s clinical record evidenced an admission on 8/01/19 and included a POC, last revised 5/19/25. The clinical record failed to evidence the POC was reviewed and signed by Patient #2. During an interview on 7/7/25 at 2:45 PM, the Administrator verified the POC for Patient #2 had not been signed. During an interview on 7/9/25 at 9:27 AM, the CM verified the POC for Patient #2 was not signed and relayed the clinical record failed to evidence documentation of the 5/19/25 POC had been reviewed with Patient #2 yet. She also relayed they were planning to have Patient #2 sign the care plan during treatment on 7/09/25. 3. Patient #4’s clinical record evidenced an admission on 10/02/23 and included a POC, last revised 6/16/25. The clinical record failed to evidence the POC was reviewed and signed by Patient #4. During an interview on 7/7/25 at 2:45 PM, the Administrator verified the POC for Patient #4 had not been signed. During an interview on 7/09/25 at 9:27 AM, the CM verified the clinical record failed to evidence documentation of the 6/16/25 POC had been reviewed with Patient #4 due to him being in and out of the hospital. 4. Patient #5’s clinical record evidenced an admission on 10/02/22 and included a POC, last revised 6/16/25. The clinical record failed to evidence the POC was reviewed and signed by Patient #5. During an interview on 7/7/25 at 2:45 PM, the Administrator verified the POC for Patient #5 had not been signed. During an interview on 7/09/25 at 9:27 AM, the CM verified the clinical record failed to evidence documentation of the 6/16/25 POC had been reviewed with Patient #5 due to him being in and out of the hospital.”

“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: 51751 Based on observation, record review, and interview, the facility failed to provide and monitor a sanitary environment within the dialysis facility unit during 1 of 2 station disinfections. (Station 12) Findings include: 1. A policy titled “Disinfection and Cleaning of Dialysis Machine Equipment” indicated but was not limited to “empty prime container into a designated dirty sink”. 2. During an observation on 03/17/2025 at 10:45 AM, PCT 1 was observed emptying the prime container into a clean sink. The facility failed to provide and monitor a sanitary environment within the unit. 3. During an interview on 03/17/2025 at 10:56 AM, PCT 1 indicated that she should have emptied prime container in the dirty sink and admitted she made a mistake.”

“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, staff failed to appropriately disinfect the AVF site prior to cannulating (inserting dialysis needles) for 1 of 2 AVF initiations observations (Patient #8) and failed to remove gloves and complete hand hygiene after removing a CVC dressing for 1 of 2 CVC exit site observations. (Patient #11) Findings Include: 1. A policy titled, “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation” indicated site disinfection for at least 30 seconds using an alcohol prep pad prior to inserting the dialysis needles. 2. A policy titled, “Dialysis Catheter Dressing Change Procedure” indicated after removal of the old CVC dressing, gloves should be removed, hand hygiene performed, and new gloves donned. 3. A policy titled, “Hand Hygiene” indicated hand hygiene is to be performed when moving from a contaminated body site to a clean body site of the same patient. 4. During an observation on 03/17/2025 at 10:41 AM, PCT 4 disinfected Patient #8’s cannulation site using an alcohol pad for 15 seconds prior to inserting the dialysis needles. During an interview on 03/19/2025 at 12:30 PM, PCT 4 indicated disinfection using an alcohol pad prior to inserting the needles is 15 seconds. During an interview on 03/19/2025 at 12:354 PM, RN 2 indicated disinfection using an alcohol pad prior to inserting the needles is 30 seconds. 51751 5. During an observation on 03/18/2025 at 10:22 AM, PCT 7 performed care for Patient #11’s CVC exit site. PCT 7 removed the old CVC dressing but failed to remove her soiled gloves and perform hand hygiene before disinfecting the CVC site. PCT 7 failed to remove gloves, perform hand hygiene, and apply clean gloves after removing dirty dressing. During an interview on 03/18/2025 at 10:34 AM, PCT 7 indicated that staff must remove gloves and complete hand hygiene after removing a dirty dressing and before applying clean gloves.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 44230 Based on observation, record review, and interview, the facility failed to ensure hand soap/sanitizer was available and not expired for 1 of 1 facility reviewed. Findings Include: 1. A policy titled, “Facility Space/Design and Safety Requirements” indicated all supplies are checked at least monthly for expiration. Expired items will be discarded appropriately prior to or on the day of expiration. 2. During an observation on 03/19/2025 at 10:25 AM, three clean sinks located in training room #1 and #2 housed wall-mounted hand soap that had expired on 09/2024. A clean sink located in the home lab area also housed a wall-mounted soap dispenser that had expired on 09/2024. Three wall-mounted hand sanitizers located in the home department hallway had expired on 06/2024. The back hallway of the dialysis center housed a wall-mounted hand sanitizer dispense near the staff restrooms that had expired on 06/2024. 3. During an interview on 03/19/2025 at 10:42 AM, RN 5 indicated all soap and hand sanitizers dispensers are to be checked for expiration and discarded & replaced appropriately. She indicated that this was the responsibility of Biomed. 4. During an interview on 03/19/2025 at 2:31 PM, the Area Home Manager indicated that it is not BioMed’s responsibility to check for expired hand soap and hand sanitizer, it is the responsibility of all staff.”

“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: 48224 Based on observation and record review, the dialysis facility failed to ensure employees cleaned and disinfected the entire station prior to setting up the machine for 1 of 2 machine set-up observations performed (PCT 8). Findings include: 1. The facility policy “Infection Control”, last updated 7/2023, indicated cleaning and disinfection of the dialysis station (e.g., chairs, beds, tables, integrated keyboards, dialysis machines, ancillary equipment) after patient has vacated the station. 2. During an observation on 3/17/25 at 10:20 AM, PCT 8 was observed setting up the dialysis machine in Station #16. After the machine set-up was complete, PCT 8 changed their gloves, obtained bleach wipes and then cleaned the chair, remote, blood pressure cuff, and cords in Station #16. PCT 8 failed to cleanse the entire station prior to setting up the dialysis machine. 3. During an interview on 3/20/24 at 9:40 AM, PCT 8 relayed the machine in Station #16 was acting up and they wanted to get it set up to ensure it was working properly. PCT 8 verified the entire station should have been cleaned prior to setting up the machine. 4. During an interview on 3/20/25 at 10:25 AM, the CM relayed the entire station should be cleaned before setting up the machine for the next patient.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 48224 Based on record review and interview, the dialysis facility failed to ensure the plan of care (POC) was reviewed and signed by the patient for 1 of 1 unstable ICHD patient record reviewed (Patient #4) and 1 of 2 ICHD patient records reviewed who have been on treatment more than two years (Patient #5). Findings include: 1. The facility policy “Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA/POC)”, last revised 4/2024, indicated the CIPA/POC will be signed by the IDT members including the patient or the patient’s legal representative. If the patient chooses to not sign the plan of care, this will be documented on the plan of care, along the reason the signature was not provided. 2. Patient #5’s clinical record evidenced an admission on 4/14/22 and included a POC, last revised 5/20/24. The clinical record failed to evidence the POC was reviewed and signed by Patient #5. During an interview on 3/18/25 at 12:08 PM, Corporate Person 1 verified the POC for Patient #5 was not signed and relayed the clinical record failed to evidence documentation of the 5/20/24 POC was reviewed with Patient #5. 51751 3. A document titled “CIPA” indicated that Patient #4 did not attend the Plan of Care meeting scheduled for 02/13/2025. The facility could not provide a signed document confirming that Patient #4 acknowledged the POC. The facility failed to review the care plan with the patient and provide a signed document indicating the patient’s acknowledgement of the POC. A document titled “CIPA” indicated that Patient #4 did not attend the Plan of Care meeting scheduled for 01/23/2025. The facility could not provide a signed document confirming that Patient #4 acknowledged the POC. The facility failed to review the care plan with the patient and provide a signed document indicating the patient’s acknowledgement of the POC. A document titled “CIPA” indicated that Patient #4 did not attend the Plan of Care meeting scheduled for 11/14/24. The facility could not provide signed documentation confirming that Patient #4 acknowledged the POC. The facility failed to review the care plan with the patient and provide a signed document indicating the patient’s acknowledgement of the POC. A document titled “CIPA” indicated that Patient #4 did not attend the Plan of Care meeting scheduled for 10/17/24. The facility could not provide signed documentation confirming that Patient #4 acknowledged the POC. The facility failed to review the care plan with the patient and provide a signed document indicating the patient’s acknowledgement of the POC. During an interview on 03/18/2025 at 12:20 PM, Corporate Person 1 indicated there was not documentation to support the Plan of Care was reviewed with Patient #4.”

“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: 48224 Based on record review and interview, the medical director failed to ensure staff monitored ICHD patients every 30 minutes for 3 of 8 ICHD records reviewed (Patient #2, 5 and 8); failed to ensure the RN was notified of low blood pressures (BP) for 2 of 8 ICHD patient records reviewed (Patient #2 and 5) and failed to ensure prescribed medications were administered during treatment for 2 of 8 ICHD patient records reviewed (Patient #3 and 8). Findings include: 1. The facility policy “Intradialytic Monitoring of Patient”, last updated 7/2024, indicated vitals signs must be obtained and documented at least every 30 minutes and reported to charge nurse if outside of standing orders and/or reportable parameters; Delivery of dialysis prescription: review prescribed treatment orders against actual machine settings and Blood Flow Rate and Dialysate flow rate: any variance from prescribed order requires documentation of reason. 2. The facility policy “Reportable Parameters to CN”, last updated 1/2020, indicated the Charge Nurse should be notified when Systolic >200 or <90 and Diastolic >100 intra-dialysis blood pressure parameters are out of parameters. 3. The facility policy “Guidelines for Administration of Medication” indicated medications should be administered in accordance with a physician’s order. 4. Patient #2’s ICHD treatment sheets, dated 3/05/25 to 3/17/25, were reviewed and evidenced the following: a. On 3/12/25, the ICHD treatment began at 9:40 AM. A routine BP check was conducted at 10:32 AM with a follow-up BP check at 12:07 PM, 1 hour and 35 minutes later. During an interview on 3/17/25 at 10:50 AM, PCT 4 relayed BP checks should have been performed every 30 minutes. 5. A document titled “Patient Summary” indicated Patient #3 had a physician order for Venofer (iron replacement medication) 100 milligrams (mg) every treatment. A treatment sheet dated 03/06/2025 for Patient #3 indicated Venofer was not administered as ordered. A treatment sheet dated 03/11/2025 for Patient #3 indicated Venofer was not administered as ordered. During an interview on 03/20/2025 at 11:23 AM, RN 1 indicated that an error led to the missed Venofer medications on 03/06/2025 and 03/11/2025 for Patient #3. The medication was accidentally discontinued and rescheduled for a future date. 6. A treatment sheet dated 03/10/2025 for Patient #8 indicated a BP & pulse check completed at 12:32 PM with a subsequent BP & pulse check completed at 1:32 PM. A treatment sheet dated 03/17/2025 for Patient #8 indicated a BP & pulse check completed at 1:31 PM with a subsequent BP & pulse check completed at 2:31 PM. During an interview on 03/20/2025 at 9:40 AM, PCT 8 indicated that blood pressure checks should be completed at least every 30 minutes and more frequently if BP is out of parameters. During an interview on 03/20/2025 at 11:43 AM, RN 2 indicated blood pressures are normally checked every 30 minutes unless the reading is unstable, then every 15 minutes. A document titled “Patient Summary” indicated Patient #8 was ordered Epogen (a drug that helps the body produce red blood cells) 9100 units every treatment. A treatment sheet dated 03/14/2025 for Patient #8 indicated that staff did not document the administration of the prescribed 9100 unit dose of Epogen during treatment During an interview on 03/20/2025 at 11:23 AM, RN 1 indicated that an error led to the missed Epogen medication to be administered on 03/14/2025 for Patient #8. The medication was accidentally discontinued instead of the dosage changed. 7. During an interview on 3/20/25 at 10:25 AM, the CM relayed the patients should have been monitored every 30 minutes; reassessed anytime the BP is out of parameters and the RN should have been notified. 51751 8. Patient #5’s ICHD treatment sheets, dated 3/03/25 to 3/17/25, were reviewed and evidenced the following: a. On 3/14/25, the ICHD treatment began at 10:18 AM. A routine BP check conducted at 10:32 AM indicated a BP of 90/72. The clinical record failed to evidence the PCT notified the RN regarding the low BP and failed to evidence the PCT reassess Patient #5’s blood pressure until 11:47 AM, 1 hour and 15 minutes later. The BP check at 2:27 PM indicated a BP of 85/50. The clinical record failed to evidence the PCT notified the RN regarding the low BP and failed to evidence the PCT reassess Patient #5’s blood pressure until 2:52 PM, 25 minutes later. b. On 3/17/25, the ICHD treatment began at 10:42 AM. A routine BP check was conducted at 11:01 AM with a follow-up BP check at 12:42 PM, 1 hour and 41 minutes later. A routine BP check conducted at 1:32 PM indicated a BP of 92/56. The clinical record failed to evidence the PCT notified the RN regarding the low BP. A routine BP check conducted at 2:55 PM indicated a BP of 93/59. A BP recheck at 2:59 PM indicated a BP of 94/52. The clinical record failed to evidence the PCT notified the RN regarding the low BP. During an interview on 3/20/25 at 9:40 AM, PCT 8 relayed BP checks should have been performed every 30 minutes and anytime the systolic is below 100, should recheck BP and notify the RN.”

“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: 44232 Based on observation, record review, and interview, the Patient Care Technicians (PCT) failed to ensure patients performed hand hygiene in 4 of 4 observations post-treatment. (Employees: PCT 1, 4, 5, and 7) (Patients: #11, 13, 18 and 19) Findings Include: 1. A review of a revised policy dated 08/2020, titled “Hand Hygiene” indicated but was not limited to, “ ... avoid the transmission of harmful germs and prevent healthcare-associated infections ... HAND HYGIENE will be performed: After gloves are removed ... After handling biohazardous waste ... “ 2. During a flash tour observation on 01/29/2025 at 7:50 AM, a sign posted on the paper towel dispenser above the clean sink at the entrance to the treatment area was reviewed. The sign stated, “Clean Hands Save. Protect patients, protect yourself.” 3. During an observation on 01/29/2025 at 11:16 AM, Patient #13 removed their glove from their right hand after holding pressure to the dressing on their left upper extremity access site. PCT 1 obtained the patient’s weight, and temperature at the scale and Patient #13 left the treatment area. PCT 1 failed to instruct the patient to perform hand hygiene or offer hand sanitizer prior to leaving the treatment area. During an interview on 01/29/2025 at 11:48 AM, PCT 9 confirmed the patients were to be offered or instructed to perform hand hygiene prior to leaving the treatment area. 4. During an observation on 01/29/2025 at 12:10 PM, Patient #11 removed their glove from their right hand after holding pressure to the dressing on their left upper extremity access site. PCT 7 obtained the patient’s weight, and temperature at the scale and Patient #11 left the treatment area. PCT 7 failed to instruct the patient to perform hand hygiene or offer hand sanitizer prior to leaving the treatment area. 5. During an observation on 01/29/2025 at 3:50 PM, Patient #18 removed their glove from their right hand after holding their pressure dressing on their left access site. PCT 4 obtained the patient’s weight, and temperature at the scale and Patient #18 left the treatment area. PCT 4 failed to instruct the patient to perform hand hygiene or offer hand sanitizer prior to leaving the treatment area. During an interview on 01/29/2025 at 3:50 PM, when queried regarding the process of patients performing hand hygiene after holding their access with a gloved hand, PCT 4 indicated the patients were to wash their hands they were unsure if they were to offer hand sanitizer. 6. During an observation on 01/30/2025 at 9:35 AM, Patient #19 removed their glove from their right hand after holding pressure to the dressing on their left upper extremity access site. PCT 5 obtained the patient’s weight, and temperature at the scale and Patient #19 left the treatment area. PCT 5 failed to instruct the patient to perform hand hygiene or offer hand sanitizer prior to leaving the treatment area. 7. A review of the personnel record for PCT 1 contained documentation PCT 1 completed annual infection control training on 01/05/2025. 8. A review of the personnel record for PCT 4 contained documentation PCT 4 completed annual infection control training on 01/13/2025. 9. A review of the personnel record for PCT 5 contained documentation PCT 5 completed annual infection control training on 02/03/2024. 10. A review of the personnel record for PCT 7 contained documentation PCT 7 completed annual infection control training on 11/13/2024. During an interview on 01/30/2025 at 4:50 PM, the Facility Administrator (FA) and the Corporate Clinical Specialist, (Corp 2) confirmed the staff were to offer hand hygiene and encourage the patients to wash their hands after holding a pressure dressing on their access with a gloved hand.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 44232 Based on record review and interview, the facility failed to ensure grievances were documented when made by staff and patients for 2 of 2 patient (Patient: #6 and 7) and 4 of 4 staff complaints. (Employees: Facility Administrator (FA), Medical Social Worker (MSW), and Patient Care Technician (PCT) 3, and 4) Findings Include: 1. A review of a revised policy dated 09/2020, titled “Complaint/Grievance” indicated but was not limited to, “Complaints are verbal or written expressions of dissatisfaction ... The facility administrator will ensure proper documentation of the complaint and the actions taken to resolve the issue ... All complaints or grievances received by staff will be reported to the facility administrator ... All verbal complaints will be accurately and full documented on the Complaint/Grievance Form ... All complaints/grievances will be recorded on the Complaint/Grievance Log ... “ 2. A review of the complaint logs dated 01/05/2024 through 01/15/2025, evidenced the complaint logs contained complaints regarding climate control, wait times, staff behaviors being rude, inconsistent staffing, delay in chair time, thanksgiving schedule. failed to evidence complaint logged from staff and patients regarding a patient’s behaviors. A review of nine facility documents titled “Complaint/Grievance Form”, evidenced seven forms were left blank for the FA signature, five forms were blank for the person completing the form, and three forms were missing the Medical Director’s signature of review. Five of the complaint/grievance forms were missing documentation of follow-up. During an interview 01/29/2025 at 8:50 AM, when queried regarding the complaint/grievance forms missing information and signature, the MSW indicted the current ones for January will be reviewed next week during QAPI per policy. The others were missing FA signatures due to the interim management staff the facility has had from July 2024 through November 2024. The MSW confirmed the forms were missing documentation and signatures and staff were to report any patient complaints to the FA. 3. During an interview on 01/29/2025 at 12:50 AM, PCT 4 indicated inactive Patient #9, had stalked them on social media and messenger. PCT 4 further indicated the patients and staff complained about inactive Patient #9, “nosing into their business, spreading gossip, and always complaining about everything”. When questioned about a complaint being filed PCT 4 indicated they were unaware. The complaint log failed to evidence any complaints/grievances from staff or patients regarding the behavior concerns of inactive Patient #9. 4.During an interview on 01/29/2025 at 1:00 PM, Patient #6 indicated they had complained to the staff about a patient who is no longer treated by them. The patient was nosey and constantly interrupting them when they were on the phone and always complaining. The patient was moved to another chair. The complaint/grievance log failed to evidence a complaint regarding Patient #6 and another patient’s behavior. 5. During an interview on 01/30/2025 at 8:05 AM, when queried regarding the staff and patient’s complaints the FA had spoken of as the reason, they moved inactive Patient #9 from station #25 to Station #14, the FA confirmed there had been no complaints documented. The FA further indicated they were trying to not hurt the inactive patient’s feelings as they were sensitive, and the patients complained of the patient asking personal questions. The FA confirmed all complaints are to be documented and investigated. 6. During an interview on 01/30/2025 at 10:57 AM, PCT 3 indicated they had worked at the clinic for 7 years. The PCT indicated there were numerous complaints by patients regarding inactive Patient #9. PCT 3 further indicated they were unaware of complaints filed and they knew patients and staff complained of the inactive patient interrupting conversations, asking personal questions about their personal life, and posting on social media wrong information about people. 7. During an interview on 01/30/2025 at 1:30 PM, Patient #7, when queried if any patients had behavior towards them that were not appropriate, Patient #7 indicated they had complained to the staff, and the staff moved their chair and time, to get away from inactive Patient #9. Patient #7 further indicated the inactive patient kept calling them and stalking them on social media. and kept asking them if they could take them home since they had a car. Patient #7 indicated they were afraid the inactive patient would follow their transportation when they left. Patient #7 confirmed they were happy the inactive patient is no longer on the same day or chair time now. The complaint/grievance log failed to evidence a complaint from Patient #7.”

“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: 45607 Based on observation, record review, and interview, the dialysis facility failed to ensure hand hygiene was performed according to facility policy for 3 of 6 PCTs observed (PCT 1, 4, and 6). Findings include: 1. Review of the Hand Hygiene policy, revised 08/2020, indicated “ ...Hand Hygiene will be performed ... Prior to entering and on exiting station to provide care to patient ... Before clean/aseptic procedure ... After touching patient surroundings ... After gloves are removed...” 2. Review of the Personal Protective Equipment (PPE) policy, revised 07/2023, indicated “ ... Hand hygiene is performed before donning and after doffing PPE....” 3. An ICHD treatment floor observation was conducted on 12/09/2024 from 3:15 PM to 5:30 PM. At 4:21 PM, observed PCT 4 doff gloves and donn new gloves without first performing hand hygiene. At 4:27 PM, observed the PCT doff gloves and started pushing biohazard waste bin to another location. A machine alarmed in Station 16, and PCT 4 donned gloves without first performing hand hygiene and then touched the machine. During an interview on 12/09/2024 at 4:48 pm, PCT 4 indicated hand hygiene should be performed after everything, before everything, and between everything. PCT 4 further indicated hand hygiene should be performed after glove removal. 4. An ICHD treatment floor observation was conducted on 12/09/2024 from 3:15 PM to 5:30 PM. At 4:42 PM and 5:10 PM, observed PCT 1 doff gloves and entered supply drawer without first performing hand hygiene. At 4:57 PM, observed PCT 1 doff gloves and immediately donn new gloves without first performing hand hygiene. During an interview on 12/09/2024 at 5:28 PM, PCT 1 relayed HH should be performed anytime you change your gloves, in between patients, and when touching machines. 5. An ICHD treatment floor observation was conducted on 12/10/2024 from 11:20 AM to 12:45 PM. At 12:27 PM, observed PCT 6 doff gloves and donn new gloves without first performing hand hygiene. At 12:31 PM, observed PCT 6 doff gloves and performed hand hygiene. PCT 6 then typed on the computer with bare hands. PCT then donned gloves without first performing hand hygiene. During an interview on 12/10/2024 at 12:42 PM, PCT 6 relayed hand hygiene should be performed when entering or exiting the treatment floor, before touching the machine, between patients, before cannulation, after glove removal, and immediately before donning new gloves.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 45607 Based on observation, record review, and interview, the dialysis facility failed to ensure staff disinfected the fistula or graft access site for at least 30 seconds with an alcohol wipe for 2 of 2 PCTs observed accessing a fistula or graft (PCT 6 and 7). Findings include: 1. Review of the Assessment and Cannulation for AV [arteriovenous] Fistula/Graft and Patient Self Cannulation policy, revised 10/2023, indicated “ ...Access preparation ... Disinfect each access site separately with one of the below options ... Alcohol Prep Pad ... Utilize a rubbing motion for at least 30 seconds seconds ...” 2. On 12/10/2024 at 11:35 AM, PCT 7 was observed accessing Patient #15’s AV fistula or graft. PCT 7 wiped the patient’s skin at the access site for 10 seconds with an alcohol swab prior to cannulation. During an interview on 12/10/2024 at 12:35 PM, PCT 7 relayed the cannulation site should be wiped for 30 seconds when using alcohol wipes. 3. On 12/10/2024 at 12:20 PM, observed PCT 6 accessed Patient #16’s AV graft. PCT 6 wiped the patient’s skin at the access site for 10 seconds with an alcohol swab prior to the first cannulation and again for 10 seconds prior to the second cannulation. During an interview on 12/10/2024 at 12:42 PM, PCT 6 relayed she didn’t recall there being a certain time for wiping the site with alcohol. She indicated she wipes with alcohol from seconds to a minute.”

“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: 45607 Based on observation, record review, and interview, the dialysis facility failed to ensure the central venous catheter (CVC) exit site was disinfected per facility policy for 1 of 1 patient care technicians (PCTs) observed performing CVC exit site care (PCT 2). Findings include: 1. An agency document on The Dialysis Catheter Dressing Change Procedure indicated “Using aseptic technique, cleanse the skin surrounding the exit site with the appropriate skin antiseptic ... Povidone iodine ... Use the ‘bullseye’ technique, applying in a circular motion around the insertion site while progressing outward for 2-3 minutes.” 2. During an observation on 6/05/24 at 12:13 PM, PCT 2 was observed providing CVC exit site care for Patient #6. PCT 2 disinfected around the CVC exit site with povidone-iodine swabs for a total of 15 seconds. PCT 2 failed to disinfect the area around the CVC exit site for at least 2 to 3 minutes with povidone-iodine. During an interview on 6/05/24 at 12:24 PM, PCT 2 relayed she should disinfect the CVC exit site for 60 seconds. During an interview on 6/06/24 at 4:42 PM, the Administrator relayed the CVC exit site should be disinfected with povidone-iodine for 2 minutes and allowed to dry before placing the dressing.”