Davita Portage Dialysis

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 47022 Based on observation, and interview, the dialysis facility failed to ensure PCT 2 followed standard infection control precautions in 1 of 1 observations of supplies dropped on floor (Patient #17). Findings include: During an observation on 01/22/2025, beginning at 10:40 AM, PCT 2, at station #4, was accessing Patient #17 left arm arteriovenous fistula (AVF) (access for hemodialysis) [HD] [a process to filter the blood of a patient whose kidneys do not work normally]. During the observation, station #4 had medical supplies on a barrier on the side tray table of the chair. During the observation, a wrapped gauze package fell to the floor, PCT 2 picked up the gauze package and placed the gauze package on the barrier with other medical supplies that included but not limited to gauze packages, and the dropped gauze package touched other gauze packages on the barrier. PCT 2 then cannulated (inserted needles) the AVF with 2 lines and opened a gauze package and placed the gauze on the lower part of the AVF. During an interview on 01/22/2025, beginning at 11:00 AM, PCT 2 indicated the gauze that dropped on the floor was picked up and placed on the side tray table due to the gauze remained in the wrapper and it would be ok to use. During an interview on 01/22/2025, beginning at 4:30 PM, the Administrator indicated that medical supplies that are dropped on the floor should be placed in the garbage.”

“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: 47022 Based on observation, record review, and interview, the dialysis facility failed to ensure PCT 3 and PCT 5 performed hand hygiene (hand sanitizing with an alcohol based antiseptic or hand washing) after glove removal, when moving between patients or stations, and during arteriovenous fistula [AVF](access for hemodialysis)[HD](a process to filter the blood of a patient whose kidneys do not work normally) care in 3 of 5 observations of PCT 5 and in 1 of 1 observations of PCT 3 AVF site care. Findings include: 1.A center for disease control internet webpage CDC.gov indicated hand hygiene should be performed immediately before touching a patient, after touching a patient or patient’s surroundings, after contact with blood, body fluids, or contaminated surfaces and immediately after glove removal. 2. During an observation on 01/22/2025, beginning at 9:45 AM, PCT 5, at station #7, was discontinuing the right arteriovenous fistula for Patient #13. During the observation, PCT 5 discontinued the 1st line of the AVF and placed gauze on the site, PCT 5 removed her gloves and applied new gloves without performing hand hygiene. 3. During an observation on 01/22/2025, beginning at 9:58 AM, PCT 5, at station #7, was discontinuing Patient #13 2nd line of the AVF. During the observation, PCT 5 removed Patient #13’s 2nd AVF line, removed her gloves and applied new gloves without performing hand hygiene. 4. During an observation on 01/22/2025, beginning at 9:58 AM, PCT 5, at station #7, was cleaning the HD station, PCT 5 removed her gloves and applied new gloves without performing hand hygiene and entered station #6 and typed on the keyboard. 5. During an interview on 01/22/2025, beginning at 11:20 AM, PCT 5 indicated hand hygiene should be performed between patients and stations, and when gloves are changed. 51199 6. During an observation on 01/22/2025, beginning at 11:37AM, PCT 3, at station #11, was accessing Patient #22’s AVF for HD. During the observation, PCT 3 palpated the AVF site, cleaned and cannulated (needle insertion) the AVF site. PCT 3 failed to change gloves and perform hand hygiene before the AVF site cleaning. During an interview on 01/22/25, beginning at 11:55AM, PCT 3 indicated that hand hygiene and donning clean gloves was not necessary after locating and palpating the cannulation site and applying antiseptic. PCT 3 indicated that hand hygiene and donning new gloves was to be performed prior to cannulation.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html 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) standard infection control precautions were implemented by PCT 2 and PCT 5 to prevent catheter related infections in 2 of 3 CVC initiations (Patient #14, Patient #18) and 1 of 3 CVC discontinuations observed (Patient #6). Findings include: 1. A revised policy dated 10/2024, titled, “Central Venous Catheter [CVC] .... Procedure” indicated a 15 second hub scrub of the CVC should be performed during the process of connecting or disconnecting from the blood lines. The policy indicated that each CVC limb/cap should be cleaned with an alcohol prep pad starting close to the exit site and finishing with the cap. 2. During an observation on 01/22/2025, beginning at 10:35 AM, PCT 2, at Station #1, was initiating hemodialysis [HD](process to filter the blood of a patient whose kidneys do not work normally) access of Patient #14’s CVC. During the observation, PCT 2 cleaned the 1st hub (access site) with an alcohol pad for 4 seconds, cleaned the 2nd hub with an alcohol pad for 2 seconds and inserted syringes into the hubs. PCT 2 failed to clean the 1st or 2nd lines of the CVC prior to insertion of the syringes. 3. During an observation on 01/22/2025, beginning at 11:15 AM, PCT 5, at Station #7, was initiating HD access of Patient #18’s CVC. During the observation, PCT 5 cleaned the 1st hub and 2nd hub with an alcohol pad for 10 seconds and inserted syringes into the hubs. PCT 5 failed to clean the 1st and 2nd lines of the CVC prior to inserting the syringes. 4. During an observation on 01/22/2025, beginning at 10:40 AM, PCT 5, at station #8, discontinued HD access of Patient #6’s CVC. During the observation, PCT 5 cleaned the 1st and 2nd hubs for 5 seconds with an alcohol pad and applied the caps (hub covers). PCT 5 failed to clean the 1st and 2nd lines of the CVC prior to applying caps. 5. During an interview on 01/22/2025, beginning at 11:00 AM, PCT 5 indicated a CVC hub should be cleaned with an alcohol swab for 60 seconds and the lines should be cleaned prior to the insertion of the syringes. 6. During an interview on 01/22/2025, beginning at 4:30 PM, the Administrator indicated CVC hubs should be cleaned for 15 seconds, and the lines and threads should be cleaned.”

“BACT CONTROL-SUPPLY LINE DISINFECTED CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: machine supply line disinfected Users should establish a procedure for regular disinfection of [the line between the outlet from the water distribution system and the back of the dialysis machine]. This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility failed to document weekly disinfection of the reverse osmosis [RO] system in 2 of 10 weeks of daily water logs reviewed (week of 11/24/2024, and week of 01/13/2025) and failed to perform chemical residual checks the day after the disinfection in 3 of 10 weeks of daily water logs reviewed (week of 12/22/2024, week of 01/06/2025, and week of 01/20/2025). Findings include: A revised policy, dated 10/2021, titled, “Water Treatment System Disinfection” indicated that the RO system was to be disinfected at least weekly, the distribution system was to be disinfected weekly, and that independent residual chemical testing was to be performed prior to the beginning of the daily activities on the first treatment day following a water treatment system or membrane chemical disinfection. A review of Daily Water Logs, received on 01/22/2025, for dates 11/18/2024 to 01/22/2025, indicated weekly disinfection of the reverse osmosis system were not documented for the week of 11/24/2024 and 01/13/2025. A review of Daily Water Logs, received on 01/22/2025, for dates 11/18/2024 to 01/22/2025, indicated on 12/23/2024, 01/07/2025 and 01/21/2025 the RO system was disinfected. A review of Daily Water Logs, received on 01/22/2025, for dates 11/18/2024 to 01/22/2025, indicated that follow up disinfection residual were not documented 12/24/24, 01/08/2025, and 01/22/25 prior to the start of daily activities. During an interview on 01/22/2025, beginning at 3:20 PM, the Facility Administrator [FA], indicated the Daily Water Logs did not have documentation the chemical disinfection of the reverse osmosis system was completed on 11/25/2024 and 01/14/2025. The FA indicated the Daily Water Logs did not have documentation the chemical residual test after disinfection were performed on 12/24/24, 01/08/2025, and 01/22/25.”

“PE-ACCOMMODATE PT PRIVACY CFR(s): 494.60(c)(3) The dialysis facility must make accommodations to provide for patient privacy when patients are examined or treated and body exposure is required. This Standard is not met as evidenced by: 47022 Based on observation, and interview, the dialysis facility failed to ensure accommodations were made to provide for patient privacy when patients are examined or treatment was provided, and body exposure was required in 1 of 1 patients with a leg arteriovenous graft [AVG](access for hemodialysis) [HD] (a process to filter the blood of a patient whose kidneys do not work properly) (Patient #16). Findings include: 1. A Patient’s Rights document signed and dated 04/11/2022, by Patient #16, indicated a patient was entitled to the right to privacy and confidentiality in all aspects of treatment, the dialysis facility would make accommodations to provide for patient privacy when the patient’s examination would require body exposure, and the dialysis facility could use screens or curtains. 2. During an observation on 01/22/2025, beginning at 10:45 AM, RN 1 prepared Parsabiv (a medication given intravenously to lower parathyroid hormone, phosphorus and calcium levels) and entered station #12 with Patient #16 receiving HD. During the observation, Patient #16 was sitting in the HD chair with his/her pants pulled down to the knees and was wearing boxers (underwear) with his/her legs exposed and no covering/draping to cover Patient’s legs or boxers. During the observation, RN 1 administered the Parsabiv through the AVG site, exited the station and went to a sink to wash her hands. During the observation, 12 HD patients were present on the observation floor. 3. During an interview on 01/22/2025, beginning at 10:45 AM, RN 1 indicated Patient did not request any covering, Patient would wear breakaway pants and the dialysis facility did have screens and blankets to cover the patient but were not in use. 4. During an interview on 01/24/2025, beginning at 12:25 PM, the Administrator indicated the facility’s best practice [method generally accepted as standard] for HD leg access would include patients being asked to wear shorts or would drape patients to ensure the HD access was visible and protect patient’s privacy.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 51199 Based on observation and interview, the dialysis facility failed to ensure patients hemodialysis [HD] (a process to filter blood of a patient whose kidneys do not work normally) access sites were visible during HD treatment (Patient #16, Patient #20). Findings include: 1. During an observation on 01/22/25, beginning at 9:52 AM, Patient #20, at station #15, was receiving HD and was observed to have a blanket covering his/her body, including his/her right chest central venous catheter [CVC] (catheter into large vein). 2. During an observation on 01/22/2005, beginning at 9:45 AM, Patient #16, at station #12, was receiving HD and was observed with his/her left thigh Arteriovenous Graft [AVG] (access for hemodialysis) covered by a blanket. 3. During an interview on 01/22/2025, beginning at 9:46 AM, PCT 1 indicated that patients and their access should be in view of staff at all times.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 47022 Based on observation, record review, and interview, the dialysis facility failed to ensure PCT 2 auscultated (listened usually with a stethoscope) an arteriovenous fistula [AVF](access for hemodialysis)[HD] [process to clean the blood of a patient whose kidneys do not work normally] for a bruit (swishing sound caused by blood flow through an artery) in 1 of 3 AVF cannulations observed. (Patient #17). Findings include: A revised policy dated 10/2024, titled, “Arteriovenous Fistula and Arteriovenous Graft [AVG] Vascular Access Care,” indicated inspection of the AVF, AVG access would include presence/absence of a bruit. During an observation on 01/22/2025, beginning at 10:40 AM, PCT 2, at Station #4, cleaned Patient #17’s left arm AVF and cannulated (inserted needles) the AVF. PCT 2 failed to auscultate the AVF for a bruit prior to cannulation. During an interview on 01/22/2025, beginning at 11:00 AM, PCT 2 indicated she did not auscultate Patient #17’s AVF prior to cannulation. During an interview on 01/22/2025, beginning at 4:30 PM, the Administrator indicated an AVF/AVG should be auscultated prior to cannulation.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 47022 Based on observation, record review, and interview, the dialysis facility failed to ensure the accuracy of medical record documentation in 2 of 3 clinical records reviewed for observation documentation. (Patient #17, Patient #16). Findings include: 1. A revised policy dated October 2020, titled, “Vascular Access Monitoring and Surveillance,” indicated the arteriovenous fistula [AVF] and arteriovenous graft [AVG] [dialysis access] findings and interventions would be documented in the patients’ medical records. 2. A PCT Job Description dated 04/2023, indicated the PCT duties and responsibilities would include but not limited to data entry and maintaining of patients’ charts. 3. A Treatment Details Report, dated 01/22/2025, for Patient #17 indicated Patient’s AVF was assessed for continuous bruit (sound caused by blood flow through an artery) and thrill (vibration felt). During an observation on 01/22/2025, beginning at 10:40 AM, PCT 2, at Station #4, cleaned Patient #17’s left arm AVF and cannulated (inserted needles) the AVF. PCT 2 failed to auscultate the AVF for a bruit prior to cannulation. During an interview on 01/22/2025, beginning at 11:00 AM, PCT 2 indicated she did not auscultate Patient #17’s AVF prior to cannulation. 4. During an interview on 01/24/2025, beginning at 12:00 PM, the Administrator indicated PCT 2 should not have documented the AVF site was assessed for a bruit on 01/22/2025; and if a HD access was not visualized staff should not document access was visualized. 51199 5. During an observation on 01/22/2005, beginning at 9:45 AM, Patient #16, at station #12, was receiving HD and his/her left thigh Arteriovenous Graft [AVG] (access for hemodialysis) was covered by a blanket. At 10:09 AM, PCT 1 removed the blanket from Patient ‘s left thigh. A Treatment Sheet, dated 01/22/2025, indicated Patient #16 ‘s AVG was visible to staff at 9:45 AM and 10:00 AM.”