Davita Sullivan 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: 38262 Based on record review and interview, the facility failed to ensure documentation on a color blindness test was complete for staff responsible for reading color tests to ensure safe water levels for 1 of 2 PCT personnel record reviews. (PCT 2) Findings include: A document titled Teammate Color Vision Test Results indicated, but was not limited to, “Test Kit: Pseudo-Isochromatic Plate by GOOD-LITE [color blindness test] ... Test teammate for plates 1-9. For each plate, write the teammate response and circle the correct response below ... Normal ... Color Vision Defect.” Personal Care Technician (PCT) 2’s personnel record was reviewed on 11/27/2023. The facility failed to ensure the color vision test dated 01/03/2023 was completed by circling either the “Normal” or “Color Vision Defect” response for each plate tested. During an interview on 11/27/2023 at 12:45 PM, the Facility Administrator (FA) stated he/she conducted the color vision test but did not circle a response for each plate tested. The FA stated the color vision test should indicate a response of normal or color vision defect for each plate tested.”

“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: 48387 Based on observation, record review, and interview, the facility failed to maintain a secure and safe environment for 2 of 2 dialysis facility treatment areas. Findings include: 1. A September 2008 policy titled Physical Environment was provided by the Facility Administrator on 11/27/2023 at 10:03 AM. The policy indicated, but was not limited to, “1. The dialysis facility will be ... maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment.” 2. Upon entrance to the facility on 11/27/2023 at 8:32 AM, the door to the home hemodialysis treatment room and the office area leading to the back entrance of the in-center treatment area were propped open and there was no receptionist at the front desk. The staff propped open the back in-center treatment door, which remained propped open throughout the day. The door was without a locking mechanism. The facility failed to ensure the treatment areas were safe and secure. 3. During an interview on 11/27/2023 at 9:33 AM, the Facility Administrator stated the outside cleaning agency came in late on Friday and left the doors propped open to the treatment areas. The Administrator stated the cleaning agency doesn’t know the facility policy and that staff are to ensure the doors are closed. At 10:03 AM, the Facility Administrator stated the back entrance to the in-center treatment area was usually propped open. 4. During an interview on 11/27/2023 at 9:41 AM, Patient Care Technician (PCT) 1 stated the doors that lead to the home treatment area and the office area that leads to the in-center treatment floor are not to be propped open. PCT 1 stated the RN should have ensured the doors were not propped open upon opening the outside door to let patients in.”

“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: 48387 Based on record review and interview the facility Medical Director (MD) failed to ensure employees followed policy and procedure regarding facility visitors with the potential to affect all patients when visitors are present for 1 of 1 facilities reviewed. Findings include: 1. An October 2023 policy titled Facility Visitation was provided by the Facility Administrator (FA) on 11/27/2023 at 9:35 AM. The policy indicated, but was not limited to, “ ... 5. Children under 12 years of age will not be allowed to stay in the waiting room area or lobby, unless supervised by an adult who is not being dialyzed ... 7. Visitors to the facility should be accompanied and supervised at all times by a DaVita teammate ...”. 2. During an interview on 11/27/2023 at 9:00 AM, Registered Nurse (RN) 1 indicated there was one incident where a child was walked from the waiting room down the office hallway to the exit door in the rear of the building. RN 1 indicated only one patient was in the facility waiting room during this time, no patients were receiving treatment. Two staff members were present, RN 1 and Patient Care Technician (PCT) 1. RN 1 indicated she walked the child from the waiting room to the exit door in the rear of the facility. 3. During an interview on 11/27/2023 at 9:41 AM, PCT 1 indicated kids were not allowed in the facility during treatment hours and not allowed in the treatment room. PCT 1 indicated his/her two-year-old child has been dropped off at the door at the end of the shift and is then walked to the breakroom if PCT 1 is not ready to leave for the day. PCT 1 normally leaves the trainee with the child in the breakroom but if the trainee is not available, he/she would give the child a snack to wait in the breakroom and watch television. PCT 1 indicated PCT 2’s child, who is nine years old, was in the facility before Halloween, during the 1st shift of patients. The child was waiting in the breakroom unattended before PCT 1 asked the child to pass out candy to patients entering the facility. The child was at the front door handing out candy to patients as they entered the facility. A past employee informed PCT 1 that due to HIPPA they were not allowed to let children pass candy out to patients. The child was returned to the breakroom to wait for a family member to arrive. 4. During an interview on 11/27/2023 at 9:53 AM, PCT 2 indicated before Halloween he/she had to bring the child to work before the child’s school start time. The child was unattended, waiting in the breakroom, PCT 1 asked the child to pass out candy to patients as they entered the facility for treatment. A former employee saw the child passing candy out to patients and instructed PCT that was against HIPPA policy. The child was returned to the breakroom to wait for a family member to arrive. PCT 2 indicated the child had only been at the facility one other time, during which PCT waited at the back door with the child. PCT is unaware if there is a policy to address kids being in the facility. PCT 2 indicated the Facility Administrator (FA) was not present during the incident and was not asked about having the child in the facility. 5. During an interview on 11/27/2023 at 10:03 AM, the FA indicated visitors are not routinely allowed outside of the waiting room. The FA indicated he/she was not aware of what facility policies are regarding kids in the facility but would not allow kids in the facility. He/she was aware of one staff member who has their kids dropped off at the facility, the staff member normally gathers personal items and leaves when the child arrives. The FA indicated no patients were present at the time of drop off. FA indicated he/she was aware of the child passing out candy to patients in the waiting room but was not notified child was present in the facility on the day of the incident. The FA indicated he/she has not had a complaint from the patient, current staff, or former employees concerning kids being in the facility. 6. During an interview on 11/27/2023 at 3:18 PM, The MD indicated he/she was unaware kids were being brought to the facility by staff and would expect kids not to be in the treatment area or have contact with patients. MD indicated he/she was unsure what policy was regarding kids in the facility but would expect staff to follow policies set by the facility.”