Fmc - Salina

“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: 28297 Based on observation, interview, and policy review, the facility failed to ensure patients washed or sanitized hands after holding access sites (A vascular access is created so that blood can be drawn from the body and run through a dialysis machine, where excess fluid and toxins are removed from the blood. (i) The filtered blood then flows back through the access into the body) for two of three survey days. The failure for patients to wash or sanitize hands after holding access site had the potential for cross contamination and could affect 87 in-center patients. Findings Include: Review of the facility policy titled, “Hand Hygiene,” revised 11/06/23, indicated, “ ...Patients should perform hand hygiene, if able, prior to and after treatment. Glove must be provided to patients when perform procedures that risk exposure to blood or body fluids, such as self-cannulating and holding access sites post treatment to achieve hemostasis. To help to ensure the prevention of cross contamination to their family members and other patients, hand hygiene must be performed ...” Observation on 03/11/24 at 2:45 PM revealed Patient (P) 13 at Station 12 applied pressure to the left arm access site until bleeding had stopped. When finished, the patient removed his/her glove and Patient Care Technician (PCT) 8 assisted the patient to the scale to retrieve his/her weight. The patient did not wash or sanitize hands and PCT 8 did not instruct or encourage the patient to wash or sanitize hands. During an interview on 03/11/24 at 3:15 PM PCT 8 confirmed P13 did not wash or sanitize hands after holding access site, however he/she should have to prevent contamination of surfaces and others. Observation on 03/12/24 at 9:15 AM P15 at Station 16 held pressure to his/her left upper arm access site. After the bleeding had stopped, the Registered Nurse (RN) 9 taped up the access site. The patient removed his/her glove, gathered belongings and RN9 walked with the patient to the scale to retrieve the patient’s weight. The patient left the unit without washing or sanitizing hands and RN9 did not instruct or encourage the patient to wash or sanitize hands. During an interview on 03/12/24 at 9:45 AM RN9 acknowledged the patient at Station 16 did not wash or sanitize hands after holding access sites but should have to prevent cross contamination. During an interview on 03/13/24 at 12:00 PM the Facility Administrator stated patients should wash or sanitize hands after holding access sites at the end of treatment to prevent cross contamination of blood borne pathogens.”

“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: 28297 Based on observation, interview and policy review, the facility failed to ensure the counter tops behind the dialysis stations were cleaned for one of three survey days. The failure to clean the counter tops behind the dialysis stations had the potential for contamination of surfaces and could affect 87 in-center patients. Findings Include: Review of the facility policy titled, “Clean and Disinfection of the Dialysis Station,” revised 09/05/23, indicated, “ ...The Center for Medicare and Medicaid Services (CMS) has regulations that in order to prevent cross contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment day and it is critical that these items be thoroughly cleaned and disinfected between use ...” Observation on 03/12/24 at 10:55 AM revealed behind Station 23 there was tape residue on the countertop. Behind Station 22 on the countertop there was a white substance residue. Behind Station 2 on the countertop was a sticky substance. Behind Station 13 there was a white substance on the countertop. Observation on 03/12/24 at 3:45 PM revealed the same observations at 03/12/24 at 10:55 AM regarding substances on the counter tops. During an interview on 03/12/24 at 3:55 PM Registered Nurse (RN) 5 confirmed the observation of dirty counter-tops behind the dialysis stations. RN5 confirmed that counter-tops were not cleaned after each patient treatment but just whenever they were visibly soiled. RN5 confirmed they needed cleaning. During an interview on 03/13/24 at 12:00 PM the Facility Administrator stated that the counter tops behind the dialysis stations should be cleaned if the staff notice the counters needed to be wiped.”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 37913 Based on review of personnel files, interview, and policy review, the facility failed to ensure that all staff members were trained in infection control training on an annual basis for one of 19 (Personal Care Technician (PCT) 8) files reviewed. This deficient practice had the potential to affect 87 in-center patients receiving dialysis treatments. Findings Include: Review of the facility’s policy titled “Bloodborne Pathogen and Infection Control Training”, published 11/02/20, indicated, “ ...Requirements for staff training are: At least annually. Within one year of the previous year’s training ...” Review of personnel files revealed that PCT8, hired on 09/20/21, received annual infection control training on 10/22/21 and 11/03/22; however, did not receive annual infection control training in 2023. During an interview on 03/13/24 at 9:30 AM, the Facility Administrator confirmed that PCT8 did not receive infection control training in 2023.”

“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: 28297 Based on observation, interview and policy review, the facility failed to ensure the patients’ mask was covering his/her nose during the initiation of dialysis via a Central Venous Catheter (CVC) (A hemodialysis central venous catheter is a type of access used for hemodialysis. CVCs are placed under the skin and into a large central vein, preferably the internal jugular veins. CVCs are meant to be used for a short period of time until a more permanent type of dialysis access has been established.) for one of two observations. The failure to ensure the mask was covering the nose as required had the potential for contamination of the CVC and increase the risk of infections and could affect 29 of 87 in-patients that have CVCs in the facility. Findings Include: Review of the facility policy titled, “Termination of Treatment Using a Central Venous Catheter and Optiflux Ebeam Single Use Dialyzer,” revised 02/07/22, indicated, “ ...place mask on patient, perform hand hygiene then don new gloves ...” Observation on 03/11/24 at 1:45 PM Registered Nurse (RN) 6 was at Station 25 discontinuing the treatment for P12 via a CVC. RN6 completed CVC discontinuation, however the patients mask remained below his/her nose during the entire discontinuation process. During an interview on 03/11/24 at 11:45 AM RN6 confirmed P12’s mask was not covering the nose as required to prevent contamination. During an interview on 03/13/24 at 12:00 PM the Facility Administrator confirmed it was part of the facility policy for the patient to wear a mask covering the mouth and nose during CVC discontinuation of dialysis via a CVC to prevent contamination of the CVC.”

“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: 28297 Based on observation, interview, and policy review, the facility failed to ensure the patient treatment area was secure from unauthorized access of the public for three of three days. The failure to secure the treatment area from unauthorized access had the potential for adverse events and could affect 87 in-center patients. Findings Include: Review of the facility policy titled, “Physical Security and Facility Access,” revised 09/05/23 indicated,” ...Doors from the waiting area to the treatment area should remain closed and locked at all times while still allowing emergency access/exit ...” Observation on 03/11/24 at 8:30 AM revealed a door to the Peritoneal Dialysis (PD) training area was unlocked. There is a bell on the outside that indicates to push bell for service, however the door was not locked or secured. Once through the door there is direct access to the treatment area. Observation on 03/12/24 at 8:15 AM revealed the door to the Peritoneal Dialysis training area was not locked or secured. There is direct access to the treatment area once inside the PD area hallway. Observation on 03/13/24 at 8:30 AM revealed the door to the Peritoneal Dialysis Training area was not locked or secured. Upon entrance to this area revealed direct access to patient treatment area. During an interview on 03/13/24 at 8:40 AM the Home Program Manager confirmed that the door from the lobby to the PD training area was not locked appropriately. The Home Program Manager stated the lock was broken and that it had been reported to Biomedical about a week prior. The Home Program Manager stated there was no documentation to support that it had been reported to biomedical.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 37913 Based on medical record reviews, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for four of seven sampled in-center patients (Patient (P) 2, P3, P4, and P5). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for 87 in-center patients receiving dialysis treatments at the facility. Findings Include: Review of the facility’s policy titled, “Unable to Achieve Prescribed Blood Flow Rate,” published 11/01/21, indicated, “Purpose: The purpose of this policy is to provide troubleshooting guidelines if unable to achieve prescribed blood flow rate (BFR). ... Background: Achieving prescribed BFR is a critical parameter in achieving adequate treatment Kt/V [a standard used to measure dialysis adequacy - K (represents clearance - can be improved with increased dialysate flow, increased blood flow, or increase surface area of dialyzer), t (time), and V (represents the volume of water in the patient’s body)]. Policy: Staff, patient and/or care partner will recognize and report to the nurse in charge the inability to achieve prescribed blood flow rate. ... Documentation: Document in patient’s treatment record what action was taken to address the inadequate blood flow and if unable to resolve. ...” 1. Review of P2’s medical record revealed a prescribed blood flow rate (BFR) of 400 milliliters per minute (mL/min). On 03/06/24 dialysis treatment started at 11:39 AM with the BFR documented at 425 mL/min. At 12:24 PM the BFR was increased to 450 mL/min. At 2:44 PM the BFR was changed to the prescribed BFR of 400 mL/min. There was no documented rationale for the change to the prescribed BFR. 2. Review of P3’s medical record revealed a prescribed BFR of mL/min. On 03/05/24 dialysis treatment started at 6:23 AM with the BFR documented at 400 mL/min. At 7:03 AM the BFR was decreased to 350 mL/min until end of treatment at 9:51 AM. There was no documented rationale for the change to the prescribed BF. 3. Review of P4’s medical record revealed a prescribed BFR of 450 mL/min. On 02/27/24 dialysis treatment started at 11:10 AM with the BFR documented at 450 mL/min. At 11:47 AM the BFR was decreased to 400 mL/min. At 2:00 PM the BFR was changed to the prescribed BFR of 450 mL/min. There was no documented rationale for the change to the prescribed BFR. 4. Review of P4’s medical record revealed a prescribed BFR of 450 mL/min. On 02/29/24 dialysis treatment started at 10:41 AM with the BFR documented at 400 mL/min. At 11:00 AM the BFR was decreased to 300 mL/min until end of treatment at 2:12 PM. There was no documented rationale for the change to the prescribed BFR. 5. Review of P4’s medical record revealed a prescribed BFR of mL/min. On 02/24/24 dialysis treatment started at 7:32 AM with the BFR documented at 350 mL/min. At 8:51 AM the BFR was decreased to 300 mL/min until end of treatment at 9:43 PM. There was no documented rationale for the change to the prescribed BFR. During an interview on 03/12/24 at 11:30 AM, the Facility Administrator confirmed the treatment sheets were reviewed and rationales were not documented.”

“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: 37913 Based on medical record review, interview, and policy review, the facility failed to conduct a monthly comprehensive assessment for one of one sampled patient (Patient (P) 1) deemed as unstable. Failure to conduct a comprehensive assessment by an interdisciplinary (IDT) consisting of a registered nurse (RN), a physician treating the patient for ESRD (end stage renal disease), a social worker, and a dietitian at least monthly for patients deemed as unstable, had the potential to miss opportunities to address a decline in a patients’ condition and negatively impact the well-being of 124 patients receiving dialysis treatments at the facility. Findings Include: Review of the facility’s policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care,” published 07/03/2023, indicated, “Purpose: The purpose of this policy is to provide guidance on the requirements for the Comprehensive Interdisciplinary Assessment {CIA} and the patient Plan of Care {POC}. Responsibility: Interdisciplinary Care Team (RN, Attending Physician, and physician extenders as applicable, Social Worker, Registered Dietician) ... The patient’s Plan of Care will be guided and developed based on the findings identified in the Comprehensive Interdisciplinary Assessment. ... Patient stability must be reviewed monthly. The interdisciplinary team will offer input to the attending physician who will determine whether the patient is stable or unstable on the criteria included in this policy. The frequency of the Comprehensive Interdisciplinary Assessment and Plan of Care are determined by the stability of the patient as determined by the physician, with input from the IDT. ... CIA/POC for Unstable Patients: Unstable patients must be reassessed by the IDT monthly. Monthly reassessment and any POC updates related to the reason the patient is considered “unstable” must be documented until the issues have been resolved or the IDT (including the patient if possible) determines that the condition is chronic ...” Review of P1’s medical record revealed on 11/06/23 the patient had been deemed unstable based on a comprehensive assessment provided by the IDT. There was lack of evidence of a subsequent monthly comprehensive assessment conducted and completed by the IDT. During an interview on 03/13/24 at 9:00 AM, the Facility Administrator confirmed a monthly comprehensive assessment for P1 was not completed by the IDT members within 30 days of the unstable assessment completed on 11/06/23.”

“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: 37913 Based on medical record review, policy review, and interview, the facility failed to review and evaluate the post dialysis weight for one of seven incenter patients sampled (Patient (P) 1). This deficient practice had the potential to affect all 87 in-center hemodialysis patients at the facility. Findings Include: Review of the facility’s policy titled, “Nursing Supervision and Delegation,” published 11/06/23 indicated “ ... The staff member who collects information pre, post and during treatment will document their findings. Any observed changes or abnormal findings in the patient’s condition or vascular access, changes reported by the patient recent hospitalization, or other medical procedures (ex. Dental procedures) must be reported to the registered nurse who will assess the patient. ...” Review of P1’s medical record revealed on 03/08/24 the post dialysis weight was 183.6 kilograms (kg) or 8.6 kg over the dry weight of 175 kg. There was no documentation that facility staff provided interventions for P1’s excessive post-weight. Review of the “Nursing Post Assessment,” dated 03/08/24 at 3:13 PM. stated, “pt [patient] denies sob [shortness of breath], dizziness, chest pain. No c/o [complaint] at this time. VSS [Vital Signs stable] . No changes from pre tx [treatment] assessment.” During an interview on 03/12/24 at 11:00 AM, the Facility Administrator confirmed that on 03/08/24 P1 completed treatment with a post weight 8.6 kg over his/her dry weight. The Facility Administrator stated “P1 should have been offered an extra treatment and the physician should have been notified of the excessive weight.””

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 37913 Based on grievance log review, interview, and policy review, the facility failed to document the resolution for one of six (Patient (P) 17) grievances reviewed. This deficient practice had the potential to affect all 124 patients receiving dialysis treatment at the facility. Findings Include: Review of the facility’s policy titled, “Clinical Services Patient Grievance,” published 01/02/14, indicated “Clinical Manager (CM) [is responsible for:] Reviewing the Patient Grievance Status Report daily. Meeting with the patient/representative within 5[sic] days to discuss the grievance, resolve it as quickly as possible, and provide periodic update to the patient. Documenting actions taken on the Patient Grievance Status Report and reporting this information to the Quality Assessment and Performance Improvement (QAI) Committee. Escalating unresolved grievances to the attention of the Director of Operations/Area Manager. Ensuring the facility is adhering to the Patient Grievance Policy.” Review of “Grievance Log” on 03/13/24 at 12:00 PM revealed that P17 filed a grievance on 01/19/24. P17 grievance was documented as being received on 01/19/24 and the grievance process was started but there was no resolution/corrective actions was documented. P17 was not available to interview on 03/13/24. During an interview on 03/13/24 at 12:30 PM, the Facility Administrator confirmed there was no documentation of the resolution to P17’s grievance.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 40633 Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the End Stage Renal Disease (ESRD) facility failed to develop and implement policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records for the Emergency Preparedness Program. During an interview on 03/12/23 between 9:30 AM and 3:00 PM, the Administrator stated that there were no policies and procedures for a system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records for the Emergency Preparedness Program.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 40633 Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the End Stage Renal Disease (ESRD) facility failed to develop and maintain an EPP training and testing program that is based on the emergency plan, its risk assessment and the communication plan. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the EPP failed to show a training and testing program that is based on the emergency plan, its risk assessment and the communication plan for the Emergency Preparedness Program. During an interview on 03/12/24 between 9:30 AM and 3:00 PM, the Administrator confirmed there was no training and testing program that is based on the emergency plan, its risk assessment and the communication plan for the Emergency Preparedness Program.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 40633 Based on review of the agency’s Emergency Preparedness Program (EPP) and interview the End Stage Renal Disease Facility (ESRD) facility failed to conduct or participate in exercises to test the EPP. This deficient practice has the potential to place patients at risk for harm or injury during an emergency situation. Findings Include: Review of the agencies Emergency Preparedness Program updated in 2023 failed to include a training and testing program which included a full-scale community-based emergency preparedness exercise. During an interview on 03/12/24 between 9:30 AM and 3:00 PM, the Administrator stated that there was no full-scale community-based emergency preparedness program or exercise which was conducted in the past year for the Emergency Preparedness Program. The last documented full scale drill was in 2018.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas must meet one of the following: *Contain 1 hour rated enclosure when non-sprinklered *Sprinkler protected with smoke resistive separation *Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7 This Standard is not met as evidenced by: 40633 Based on observation and staff interview the facility failed to ensure proper separation of hazardous areas from other spaces. This deficient practice would allow for the spread of smoke and fire to travel into the adjacent area, affecting 4 residents in 1 of 2 smoke zones. Findings Include: During the survey conducted on 03/12/24, the following is observed: 1) At 1:45 PM, it was observed that the soiled room on the basement level of the facility had an approximately 1/2 inch opening through and around piping into the room which was not properly sealed on both sides of the wall. The Biomed Tech was present and acknowledged the findings.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm Systems - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 40633 Based on observation and staff interview, the facility failed to maintain the fire alarm system as required by NFPA 72. This deficient practice fails to ensure reliability of the alarm system in the event of an emergency, affecting all patients, visitors and staff in 2 of 2 smoke zones. Findings Include: During the survey on 03/12/24 it is observed: 1. Fire alarm circuit located in the Mechanical room was not equipped with a breaker lock preventing tampering and disabling of the fire alarm system. The Administrator and Director of operations were present and acknowledged the findings.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 20.7.1.4 through 20.7.1.7 This Standard is not met as evidenced by: 40633 Based on fire alarm document review and staff interview, the facility failed to conduct fire drills as required and properly record the results and facts related to the fire drills. This deficient practice affects the ability of the staff to properly respond in the event of an actual emergency affecting all patients in 2 of 2 smoke zones. Findings Include: During document review on 03/12/24 between the hours of 10:00 AM and 12:00 PM the following was observed: 1. There were no fire drills documented for the only shift of the ESRD in the 3rd quarter of 2023. The Administrator and Director of operations were present and acknowledged the findings.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 20.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 40633 Based on interview and document review the facility failed to properly inspect and maintain the fire doors in accordance with NFPA 80. Failure to maintain fire rated doors creates a potential for heat, smoke and harmful gases to spread beyond the area of fire origin into other areas of the facility affecting all patients, visitors and staff in 2 of 2 smoke zones. Findings Include: During the survey on 03/12/24, the following observations were made: 1. There is no documentation of an annual fire door inspection for any of the fire rated doors. 2. The fire rated door at the bottom of the stairwell, was found to not self-close and latch when tested. The door also possessed damage and exposed interior where a non listed closure device was installed. The Administrator and Director of operations were present and acknowledged the findings. Review of the following NFPA Standard revealed: Fire door assemblies shall be visually inspected from both sides to assess the overall condition of door assembly. 2010 NFPA 80, 5.2.4.1 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 2010 NFPA 80, 2.4.2”