Fmc - Winchester

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 30271 Based on observation, interview, and facility policy review, the facility failed to maintain the wall boxes that contained the plumbing for the dialysis machine behind each station in a serviceable condition for 15 out of 15 stations observed. This had the potential to affect all 60 in-center hemodialysis patients. The findings include: Review of the facility’s policy titled, “Equipment Installation - Operation - Maintenance - Repair - and Disposal,” dated 07/06/2021, revealed, “This Policy applies to all equipment that: Is essential to the safe operation of the facility. This includes but is not limited to: the Physical Plant (ceilings, floors etc. [et cetera]).” During an observation on 05/13/2024 at 11:30 AM with Clinic Manager (CM) 1 and BioMed (BM) 10, the top edges of the wall boxes behind each station had been damaged, and exposed wood was now observed. Further, it was observed that the front panels of the same wall boxes also had exposed wood along the lower edge where chairs had impacted the edge. CM1 and BM10 confirmed these findings at the time of the observation. During an interview on 05/14/2024 at 4:15 PM, CM1 stated that it was her responsibility and expectation to oversee the condition of the physical plant. CM1 stated that the wall boxes were not maintained to ensure that adequate disinfection of the surfaces could be done. During an observation and interview on 05/14/2024 at 11:20 AM, the Medical Director entered the treatment area and introduced himself. At that time, it was pointed out to the Medical Director that it was discovered during an observation that the wall boxes behind the dialysis stations were in disrepair and needed repair. The Medical Director confirmed the findings at that time.”

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 30271 Based on observation, interview, and facility policy review, the facility failed to protect medical record files from the potential of moisture damage in 1 of 1 medical record storage room. The findings include: Review of the facility’s policy titled, “Storage, Filing, Thinning, and Retrieving of Medical Records,” dated 02/07/2022, revealed, “The medical record rooms must be constructed so at [sic] to prevent damage due to adverse environmental conditions (ex.[example] moisture).” The policy revealed, “It is acceptable to use storage boxes to store records in the medical record room; however, metal files or cabinets are preferable.” An observation of the medical records room on 05/13/2024 at 11:34 AM, revealed the facility had a fire sprinkler system. The medical records were stored on an open cart and were not protected if the sprinkler head was activated by fire or any other means. Also, medical files were stored in cardboard storage boxes on open shelving. Clinic Manager (CM) 1 confirmed these findings at the time of the observation. During an interview on 05/14/2024 at 4:15 PM, CM1 stated that it was her responsibility and expectation to oversee the condition of the physical plant. CM1 confirmed that the medical record room was not equipped to protect the medical records from moisture damage.”