Davita Irish at Home

“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: 51751 Based on observation, record review, and interview, the facility failed to follow adequate hand hygiene and glove changes to prevent the spread of communicable diseases during 2 of 2 PCT observations. (PCT 2, 5) Findings include: 1. According to the “Infection Control for Dialysis Facilities” policy (04/2023), all teammates, Physicians and Non-Physician will perform hand hygiene prior to gloving and immediately after removal of gloves. 2. During an observation on 04/07/2025 at 12:46 PM, PCT 2 disconnected the bloodlines from Patient #14 but failed to sanitize her hands after removing the contaminated gloves and putting on new gloves. 3. During an observation on 04/08/2025 at 10:08 AM, PCT 5 initiated Patient #15’s dialysis treatment, removed gloves, and began charting on the computer without performing hand hygiene. 4. During an interview on 04/09/2025 at 12:51 PM, RN 3 indicated that anytime gloves are removed staff should perform hand hygiene. 5. During an interview on 04/09/2025 at 1:14 PM, PCT 2 indicated that the computer area is considered a clean area and hand hygiene should be performed prior to using.”

“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: 51751 Based on observation, record review, and interview, the facility failed to ensure staff and visitors wore appropriate personal protective equipment (PPE) while in the treatment area during 1 of 2 observation days. (04/07/2025) Findings include: 1. According to the “Infection Control for Dialysis Facilities” policy (04/2023), appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physicians, and visitors when in the treatment area. 2. During an observation on 04/07/2025 at 12:30 PM, Patient #3 was receiving his/her dialysis treatment. Patient #3’s spouse was sitting next to him and failed to wear a protective gown on the treatment floor. 3. During an observation on 04/07/2025 at 12:47 PM, PCT 2 was observed on the treatment floor assisting with patients’ dialysis treatments. Her PPE, gown, was cut at the bottom, shortening the length. 4. During an interview on 04/07/2025 at 12:30 PM, Patient #3’s spouse indicated that he/she sits with Patient #3 during each treatment and PPE has not offered or provided for use when on the treatment floor. 5. During an interview on 04/07/2025 at 1:14 PM, PCT 2 indicated she had altered her PPE, gown, by cutting the bottom. Tape became adhered to her gown, so the PPE was cut. She indicated that PPE should not be altered in any way and does not normally alter it. 6. During an interview on 04/07/2025 at 4:34 PM, the Administrator indicated that all visitors should wear PPE on the treatment floor per facility policy. She has been educating the staff regarding this requirement but acknowledged that some staff have been advised while others have not. The Administrator indicated that staff should not be altering PPE in any way. 7. During an interview on 04/09/2025 at 12:51 PM, RN 3 indicated that visitors are expected to wear PPE when on the treatment floor and staff should not be altering PPE. 8. During an interview on 04/09/2025 at 1:14 PM, PCT 2 indicated visitors are required to wear PPE while on the treatment floor.”

“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: 51751 Based on observation, record review, and interview, the facility failed to maintain procedures in cleaning and disinfection of contaminated surfaces, medical devices, and equipment during 2 of 2 observations of dialysis station disinfections. (Station #3, #7) Findings include: 1. According to the “Infection Control for Dialysis Facilities” policy (04/2023), at the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include all surfaces in contact with the patient or their belongings and frequently contacted by healthcare personnel. 2. During an observation on 04/07/2025 at 12:30 PM, PCT 6 disinfected Station #3, but failed to disinfect the TV and the inside of the prime container on the dialysis machine after the previous patient vacated the station. 3. During an observation on 04/07/2025 at 1:05 PM, PCT 3 failed to disinfect the inside of the prime container, and the counter located behind the dialysis chair at Station #7. 4. During an interview on 04/08/2025 at 9:27 AM, PCT 6 indicated she forgot to disinfect the TV after the previous patient vacated Station #3 and further indicated the TV should be included when disinfecting a dialysis station, she just forgot to disinfect it. 5. During an interview on 04/09/2025 at 1:14 PM, PCT 2 indicated that station disinfection included the inside of the prime container and TV.”

“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 infection control procedures were performed to prevent CVC infections on 2 of the 2 CVCs observed. (Patient #16, 17) Findings include: 1. According to the “Central Venous Catheter (CVC) with ClearGuard HD Antimicrobial End Caps” policy (10/2024), staff should perform a 15 second disinfect of the CVC during the process of connecting or disconnecting for the blood lines using an alcohol pad. 2. During an observation of a CVC initiation on 04/08/2025 at 9:56 AM, PCT 6 accessed Patient #17’s CVC and failed to disinfect the venous hub using an alcohol pad for 15 seconds. 3. During an observation on 04/08/2025 at 10:07 AM, PCT 5 accessed Patient #16’s CVC but failed to disinfect the hubs of the CVC lines using an alcohol pad for 15 seconds. 4. During an interview on 04/08/2025 at 10:17 AM, PCT 7 indicated that CVC hubs are to be disinfected using an alcohol pad for 15 seconds. 5. During an interview on 04/09/2025 at 12:51 PM, RN 3 indicated that CVC hubs should be disinfected with an alcohol pad for 5-10 seconds each line.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 51751 Based on observation, record review, and interview, the facility failed to follow the preventative maintenance schedules for 1 of 1 facility observed. Findings include: 1. According to the “Preventative Maintenance Schedules for Equipment” policy (10/2023), all miscellaneous equipment will receive preventative maintenance performed by trained Biomed teammate or outside vendors per manufacturer’s recommendations. 2. During an observation on 04/07/2025, 2 intravenous (IV) pumps located in the medication area were found to not have inspection dates. 3. During an interview on 04/09/2025 at 11:11 AM, the Biomed indicated that sometimes the bleach used to disinfect takes the service stickers off the equipment, he is reviewing the service logs to determine if the pumps were serviced. 4. During an interview on 04/10/2025 at 9:46 AM, the Biomed indicated that the pumps were not serviced and have been removed from the treatment floor. The Biomed further indicated that the IV pumps were to be maintained annually by an outside vendor.”

“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: 51751 Based on observation, record review, and interview, the facility failed to assess the Arterial Venous Fistula (AVF) prior to cannulation (inserting the dialysis needles) on 2 of 2 patients observed. (Patient # 11, 12) Findings include: 1. According to the “AV Fistula or Graft Cannulation with JMS Sysloc Mini Safety Fistula Needles and Administration of Heparin Loading Dose” policy (04/2025), staff are to perform inspection, auscultation with a stethoscope, and palpation on the entire length of access to determine presence of bruit and thrill. 2. During an observation on 04/08/2025 at 10:25 AM, PCT 6 initiated Patient #11’s dialysis treatment and failed to listen to the AVF prior to cannulation. 3. During an observation on 04/08/2025 at 10:15 AM, PCT 8 initiated Patient #12’s dialysis treatment and failed to assess the AVF access site prior to cannulation. 4. During an interview on 04/09/2025 at 12:51 PM, RN 3 indicated that staff are expected to assess the AVF access site before cannulation, including listening to the site with a stethoscope. 5. During an interview on 04/09/2025 at 1:14 PM, PCT 2 indicated that AVF access sites are to be checked prior to cannulation by looking at the site, feeling the site and listening to the site with a stethoscope.”

“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: 51751 Based on record review and interview, the medical director failed to ensure staff followed policies and procedures regarding initial nursing assessments to be completed prior to start of treatment for 2 of 2 new patients reviewed. (Patients #2, 3), appropriate labeling and storage of medications, storage of supplies, and monitoring supplies for expiration and appropriately discarding for 1 of 1 facility observed. Findings include: Initial Assessment Prior to 1st Treatment 1. According to the “Initial Patient Nursing Assessment for New Patients” policy (04/2024), a registered nurse (RN) as required by federal regulations will perform an initial pretreatment evaluation of all patients prior to the initiation of their first treatment at the facility. 2. During a record review of Patient # 2 on 04/08/2025, the initial RN assessment was documented on 01/27/2025 at 7:17 AM. The patient’s treatment was initiated at 6:29 AM. The facility failed to document an initial nursing assessment prior to the start of the initial treatment. 3. During a record review of Patient #3 on 04/08/2025, the initial RN assessment was documented on 03/18/2025 at 6:09 AM. The patient’s treatment was initiated at 6:06 AM. The facility failed to document an initial nursing assessment prior to the start of the initial treatment. 4. During an interview on 04/09/2025 at 11:03 AM, the Administrator indicated that she did not know if the initial assessment had to be documented prior to start of first treatment. 5. During an interview on 04/09/2025 at 12:51 PM, RN 3 indicated that the RN must complete the initial assessment prior to the start of a new patient’s initial treatment. Meds drawn up with no time/initials & unsecured 1. According to the “Medication Policy” policy (10/2023), if the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient’s name, name of medication, date, time prepared, dose, and initials of teammate preparing the medication. All medications are to be locked if not under the supervision by a licensed teammate. 2. During an observation of the Home Department on 04/07/2025 at 2:00 PM, the medication drawers located outside of the nurse’s station were found unlocked with the key resting inside the lock of one of the drawers. 3. During an observation on 04/08/2025 at 9:47 AM, PCT 6 was observed drawing up three syringes of Heparin (medication used to prevent blood from clotting) for Patient #13. PCT 6 failed to label the medication with a prepared time and her initials. The Heparin syringes were then placed on a counter located in center of the treatment floor unsecured, covered with a blue clean pad. 4. During an observation of 04/09/2025 at 10:20 AM, seven pre-made packets used for incoming patients included pre-drawn Heparin laying on the counter in the middle of the treatment floor, unsecured. Authorized staff failed to ensure the medications were secure while initiating or terminating patient treatments. 5. During an interview on 04/08/2025 at 12:50, RN 2 indicated that the medication drawers are typically open in the morning and locked prior to leaving for the day. The key was left in the drawer on 04/07/2025 during the surveyor flash tour because she had accessed the medications approximately one hour prior. RN 2 indicated she typically keeps the keys on her. 6. During an interview on 04/09/2025 at 10:23 AM, RN 5 indicated that medications should be secured and/or monitored when not in use. 7. During an interview on 04/09/2025 at 1:14 PM, PCT 2 indicated that medications, including heparin, should be monitored or secured if not being administered immediately. Storage of Supplies 1. According to the “Physical Environment” policy (04/2018), supplies will not be stored directly on the floor but stored on shelves or pallets. 2. During an observation of the water room on 04/07/2025 at 1:25 PM, 1 case of bleach was found sitting on the floor in the water room. 3. During an observation of the stockroom on 04/07/2025 at 1:32 PM, 2 cases of laboratory shipping supplies were found sitting on the floor. 4. During an observation of the Home Department on 04/07/2025 at 1:34 PM, 3 cases of Baxter 1.5% solution (peritoneal dialysis solution) were found sitting on the stockroom floor. 5. During an interview on 04/09/2025 at 12:51 PM, RN 3 indicated that supplies are to be kept off the floor and stored on pallets. 6. During an interview on 04/09/2025 at 1:14 PM, PCT 2 indicated that all supplies are to be kept off the floor and rotated with the older supplies near the front. Expired Supplies 1. According to the “Infection Control for Dialysis Facilities” policy (04/2023), staff will check expiration dates and package integrity prior to use. 2. According to the “Residual Bleach Testing Using RPC E-Z Chek Residual Chlorine (Bleach) Test Strips” policy (09/2013), staff should verify that strips are in date. 3. During an observation of the water room on 04/07/2025 at 1:25 PM, 2 bottles of residual chlorine test strips were found to be expired on 02/19/2025 and 03/20/2025. 4. During an observation of the Home Department on 04/07/2025 at 1:35 PM, Training Room #4 had expired hand soap at the clean sink, expired 01/2025, sixteen BD Vacutainers (used to collect blood) with an expiration date of 12/31/2024, four sterile surgical gloves, expired on 03/23/2025, and one 60 milliliter syringe with an expiration date of 03/01/2025. 5. During an observation of the Home Department on 04/07/2025 at 1:50 PM, Exam Room 1 had a Baxter 12-inch extension set (adaptor used to connect the peritoneal dialysis catheter to Baxter supplies) that had expired on 04/05/2024 and hand soap located at the clean sink had expired on 06/2023. 6. During an observation of the Home Department on 04/07/2025 at 2:00 PM, an antimicrobial end cap (used to cap off a peritoneal dialysis catheter) located in the laboratory area had expired on 02/23/2025. 7. During an observation of the Isolation Room on 04/08/2025 at 9:27 AM, 5 mint top blood collection tubes expired on 09/30/2024, 5 yellow top blood collection tubes expired on 10/31/2024, and 5 lavender top blood collection tubes expired on 02/28/2025. 8. During an interview on 04/07/2025 at 1:29 PM, the Biomed indicated that the staff that do the chlorine checks are responsible for checking expiration date on test strips. 9. During an interview on 04/08/2025 at 9:51 AM, RN 3 indicated that all supplies should be discarded and is monitored by all staff prior to using.”