Davita Vincennes Home Dialysis

“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: 48387 Based on record review and interview, the facility failed to ensure documentation on a color blindness test was complete for staff responsible for reading colorimetric tests to ensure safe water levels for 1 of 2 RN record views (RN 1) and 1 of 2 home hemodialysis Patient. (Patient #5) Findings include: 1. A policy titled “Color Vision Evaluation” indicated that requires Teammates, patients, and helpers who use test kits or strips that depend on color differentiation for test results to undergo an evaluation of their color vision. 2. A document titled “Color Vision Test Results” indicates that the tester providing the color blind test will write the teammate/patient/helper’s response and circle the correct response (Normal / Color Vision Defect) on the document. 3. A review of RN 1’s personnel record included a 10/08/2018 Color Vision Test Result that failed to indicate whether RN 1 passed the color vision test. 4. A review of Patient #5’s record included Color Vision Test Results, dated 08/12/2024, for Patient #5 and Patient #5’s caregiver that failed to evidence whether they passed the color vision test. 5. During an interview on 07/24/2025 at 12:35 PM, the FA indicated that the staff member performing the color blindness test is supposed to complete the Color Vision Test Result document by circling if the answer given is normal.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 38262 Based on observation, record review, and interview, the facility failed to ensure the entrance leading to the patient treatment area and storage area was secured from unauthorized persons for 1 of 1 facility observations. Findings include: A 10/2023 policy titled “Dialysis Facility Physical Security Guidance” indicated that staff should ensure unauthorized persons do not enter the dialysis treatment area. On 07/23/2025 at 9:55 AM, the surveyor entered the building and found the door to the patient treatment area propped open. Several patients in the waiting area had access to the unsecured area. No employees were present in the home treatment zone, and a storage room key had been left in the lock. The home treatment area was unsecured and vulnerable to unauthorized access. On 07/23/2025 at 9:57 AM, the Administrative Assistant explained that in-center staff needed supplies from the storage room and likely forgot to close the door to the home treatment area. On 07/24/2025 at 11:41 AM, the Facility Administrator stated that staff should keep the home treatment area door closed and never leave the storage room key in the lock where anyone could access it.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 38262 Based on record review and interview the facility failed to complete the required monthly plan of care for an unstable patient for 1 of 1 unstable patient record reviewed. (Patient #4) Findings include: A 04/2023 policy titled “Failure to Comply with Home Dialysis Training Program Objectives” indicated that the plan of care will address non-compliance issues. A review of Patient #4’s record evidenced the patient was classified as unstable as of 12/2024 and continues to be unstable due to ongoing non-adherence and behavioral issues. The record did not show that a plan of care was completed for February 2025 or April 2025, as required by 42 CFR §494.90. During an interview on 07/24/2025 at 12:28 PM, the FA was unable to provide an explanation for why staff did not complete the monthly plans of care for Patient #4.”