Schererville Dialysis Center

“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: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure staff removed gloves and performed hand hygiene between patients and stations, and after glove removal in 1 of 1 observations of discontinuation of hemodialysis [HD] (a process to filter the blood of a patient whose kidneys do not work normally) with a central venous catheter [CVC] (catheter into large vein), 1 of 2 observations of access of an arteriovenous fistula [AVF] (dialysis access) for initiation of HD, and 2 of 2 observations of discontinuation of HD and post dialysis access care for AVF. Findings include: 1. A revised policy, dated 11/29/2022, titled “G40 Infection Control” indicated hands should be washed after gloves are removed, between patient contact, and after touching blood, body fluids, and contaminated items. The policy indicated antiseptic hand cleaners may be used in place of soap and water if hands are not soiled, during emergencies, or if there has been no exposure to or contact with blood or potentially infectious materials. 2. During an observation on 05/07/2025, beginning at 1:54 PM, at station 17, PCT 5 discontinued HD treatment for Patient 12. PCT 5 reinfused the HD machine and failed to remove gloves, perform hand hygiene, and don new gloves prior to disconnecting Patient 12 from the HD machine. 3. During an observation on 05/05/2025, beginning at 10:44 AM, at station 6, PCT 4 accessed Patient 7’s AVF. PCT 4 located and palpated the cannulation sites, and failed to perform hand hygiene and don clean gloves prior to disinfecting the cannulation sites. 4. During an observation on 05/05/2025, beginning at 10:58 AM, at station 3, PCT 4 discontinued HD for Patient 6. PCT 4 reinfused the HD machine and failed to remove gloves, perform hand hygiene, and don clean gloves prior to removing the needles from the patient. 5. During an observation on 05/05/2025, beginning at 9:04 AM, at station 11, PCT 1 discontinued HD for Patient 4. PCT 1 removed the needles from Patient 4 and failed to perform hand hygiene prior to donning new gloves and placing bandage on needle sites. 6. During an interview on 05/06/2025, beginning at 11:10 AM, PCT 2 indicated that hand hygiene and glove change should occur before patient contact and using the HD machine.”

“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, interview, and record review the dialysis facility failed to ensure patient safety by ensuring the hemodialysis [HD] (a process to filter the blood of a patient whose kidneys do not work normally) access site was visible during HD treatment in 1 of 3 observation periods of in-center HD treatment. Findings include: 1. A revised policy, dated 11/29/2022, titled “IC08 Monitoring & Documentation of Patient Care During Treatment” indicated that a patient’s vascular access should remain uncovered and visible throughout the course of the patient’s treatment. 2. During an observation on 05/07/2025, beginning at 12:50 PM, at Station #11, Patient 9’s left thigh arteriovenous graft [AVG] (dialysis access) was covered with a blanket. The blanket covered the patient from the neck to the toes through the observation period (12:50 PM - 14:03). 3. During an interview on 05/06/2025, beginning at 11:10 AM, PCT 2 indicated that patient access sites need to visible to staff at all times while receiving HD treatment.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility failed to ensure patient hemodialysis [HD] (a process to filter the blood of a patient whose kidneys do not work normally) prescription orders were adhered to in order to achieve and sustain the prescribed dose of dialysis to manage patients’ fluid volume in 2 of 5 in-center hemodialysis clinical records reviewed and 1 of 5 in-center observations of verification of dialysis treatment prescription delivery. Findings include: 1. A revised policy, dated 11/29/2022, titled, “IC08 Monitoring and Documentation of Patient Care During Treatment” indicated two signatures were required before starting the patient’s prescription in the electronic documentation system. The policy indicated data that would be documented at least every 30 minutes would include dialysate flow rate (DFR). Additionally, the policy indicated if the patient’s prescription was not met for any reason, a detailed progress note should be entered explaining why the prescription was not met and actions taken to address the situation. 2. During an in-center observation on 05/07/2025, beginning at 8:57 AM, at station #15, Patient 10 had a DFR running at 600 and a dialysate solution of 2K+ 2.5Ca+. A Treatment Flow Sheet, dated 05/07/2025, for Patient 10, indicated that the prescribed DFR was 800 and the prescribed dialysate was 2K+2Ca+. The Treatment Flow Sheet additionally indicated that the HD treatment was initiated by PCT 5 and was verified by PCT 4. During an interview on 05/07/2025, beginning at 8:58 AM, PCT 5 indicated that the reason for Patient 10 having the wrong DFR and dialysate was because Patient 10 was going to be discharged soon. During an interview on 05/07/2025, beginning at 10:10 AM, Administrative Staff 2 indicated that the DFR and dialysate prescription should match what is running on the HD Machine. Additionally, Administrative Staff 2 indicated that the prescribed dialysate is administered from a gallon jug, and the dialysate that was running is administered from the wall box. Administration 2 indicated that a patient should not be hooked up to an incorrect dialysate solution via the wall box in lieu of opening a new jug of prescribed dialysate. 3. A Clinical Record Review on 05/06/2025, for Patient 4, indicated that the prescribed DFR was 600. The HD Treatment Flowsheets indicated the following: A. On 04/14/2025, the DFR was run at 800 from 6:30 AM until treatment ended (9:00 AM). B.On 04/18/2025, the DFR was run at 500 when treatment was initiated at 5:27 until 5:32 AM. C.On 04/21/2025, the DFR was run at 500 when the treatment was initiated (5:35 AM) until the time treatment ended (9:07 AM). D.On 04/25/2025, the DFR was run at 500 from the time treatment was initiated (5:30 AM) until the time treatment was terminated (9:06 AM) E.On 05/02/2025, the DFR was run at 500 from the time treatment was initiated (5:30 AM) until the time treatment was terminated (9:00 AM) 4. A Clinical Record Review on 05/06/2025, for Patient 5, indicated that the prescribed DFR was 600. The HD Treatment Flowsheets indicated the following: A.On 04/10/2025, the DFR was run at 800 from the time the treatment was initiated (9:36 AM) until the time the treatment was terminated (12:04 PM). It was noted that PCT 2 indicated the change in DFR was per RN 2. No new physician order was made for this change, nor was it noted that the MD was contacted. B. On 04/15/2025, the DFR was run at 500 from the time the treatment was initiated (10:18 AM) until 10:32 AM. C. On 04/22/2025, the DFR was run at 800 from the time treatment was initiated (10:00 AM) until 10:31 AM. D. On 4/26/2025, the DFR was run at 500 from the time treatment was initiated (9:39 AM) until 10:00 AM. 5. During an interview on 05/07/2025, beginning at 10:10 AM, Administrative Staff 2 indicated that there should be no discrepancy between the dialysis prescription and what is administered unless there is a new MD order.”

“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: 51199 Based on observation, record review, and interview, the dialysis facility failed to ensure appropriate vascular access care when PCT 1 disinfected the arteriovenous fistula [AVF] (entry into the blood vessel for hemodialysis [HD])(a process to clean the blood of a patient whose kidneys do not work normally), then repalpated the disinfected area prior to cannulation (needle insertion) in 1 of 2 AVF cannulations observed. Findings include: 1. A revised policy, dated 06/20/2024, titled “IC04A AVF/AVG Cannulation, Treatment Initiation and Termination” indicates that the needle insertion site should be disinfected and allowed to dry, and if the access is touched after being disinfected, it must be disinfected again before needle insertion. 2. During an observation on 05/05/2025, beginning at 10:39AM, at Station #10, PCT 1 disinfected the cannulation site of Patient 8, allowed it to dry, and then palpated the cannulation site and inserted the needle. PCT 1 then palpated the second cannulation site and inserted the needle without disinfecting between palpation and needle insertion. PCT 1 failed to disinfect both cannulation sites after palpating the sites prior to cannulation. 3. During an interview on 05/06/2025, beginning at 11:10AM, PCT 2 indicated that after disinfecting the cannulation site, needle insertion should occur next without repalpating site.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 51199 Based on record review and interview, the dialysis facility’s Quality Assessment and Performance Improvement [QAPI] Program failed to measure, analyze and track quality indicators for patient outcomes related to fluid and blood pressure management in 1 of 1 facility. Findings include: 1. A revised policy, dated 01/13/2025, titled, “G09 Quality Assurance and Performance Improvement (QAPI),” indicated the QAPI program would look at indicators for patients and trend outcomes to identify commonalities among patients who do not reach expected targets. Additionally, the policy indicated that the dialysis facility should regularly review data to identify areas for improvement and take appropriate action to improve outcomes and processes. 2. A Dialysis Facility Report, for 2023, indicated the dialysis facility ultrafiltration rate (removal of fluid from a patient) for hemodialysis [HD] (a process to filter the blood of a patient whose kidneys do not work normally) was 11.8% which was above the national average of 7.8%. 3. During QAPI Program review on 05/07/2025, the QAPI program failed to evidence an indicator for tracking fluid and blood pressure management. 4. During an interview, on 05/07/2025, beginning at 10:10 AM, the Acting Clinical Manager, Administrative Staff 2, indicated the dialysis facility’s QAPI Program does not monitor fluid and blood pressure management.”

“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: 51199 Based on record review and interview, the dialysis facility failed to ensure that all policies and procedures relative to patient admissions were adhered to in 1 of 1 clinical record reviews of new admission patients. Findings include: 1. A revised policy, dated 01/13/2025, titled “G04 Admission & Discharge of Patients” indicated that prior to the initiation of any patient’s first treatment at the facility, a Nursing Initial Assessment will be completed and documented in the patient’s medical record. 2. A clinical record review on 05/06/2025, for Patient 1, indicated that Patient 1’s first treatment was initiated on 04/29/2025, and the Nursing Initial Assessment was completed and documented on 05/05/2025. 3. During an interview on 05/07/2025, beginning at 10:10 AM, Administrative Staff 2 indicated that Patient 1’s Nursing Initial Assessment was not completed prior to the initiation of the first treatment, and was competed on 05/05/2025. Additionally Administrative Staff 2 indicated that it is the policy to complete this assessment prior to first treatment initiation and if it is not completed at that time, it is considered an adverse event.”

“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: 51199 Based on observation, record review, and interview, the dialysis facility failed to maintain accurate records in 1 of 1 in-center observation of incorrect dialysis prescription delivery. Findings include: 1. A revised policy, dated 11/29/2022, titled, “IC08 Monitoring and Documentation of Patient Care During Treatment” indicated two signatures were required before starting the patient’s prescription in the electronic documentation system. The policy indicated data that would be documented at least every 30 minutes would include dialysate flow rate (DFR). Additionally, the policy indicated if the patient’s prescription was not met for any reason, a detailed progress note should be entered explaining why the prescription was not met and actions taken to address the situation. 2. During an in-center observation period on 05/07/2025, beginning at 8:57 AM, at station #15, Patient 10 had a dialysate solution being administered of 2K+ 2.5Ca+. The prescription order for Patient 10 was for a dialysate solution of 2K+ 2Ca+. 3. A Treatment Flow Sheet, dated 05/07/2025, for Patient 10, indicated that the prescribed dialysate of 2K+ 2Ca+ was running from the time of treatment initiation (6:13 AM) until the time of treatment termination (9:24 AM). There was no notation of a different dialysate being administered for any length of time during the course of the treatment. 4. During an interview on 05/07/2025, beginning at 8:58 AM, PCT 5 indicated that the reason for Patient 10 having the wrong dialysate was because Patient 10 was going to be discharged soon. 5. During an interview on 05/07/2025, beginning at 10:10 AM, Administrative Staff 2 indicated that the dialysate prescription should match what is running on the HD Machine. Additionally, Administrative Staff 2 indicated that the prescribed dialysate is administered from a gallon jug, and the dialysate that was running is administered from the wall box. Administration 2 indicated that a patient should not be hooked up to an incorrect dialysate solution via the wall box in lieu of opening a new jug of prescribed dialysate.”