Dci - New Orleans East

“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: 14442 Based on record review and interview, the dialysis facility failed to ensure total chlorine testing was performed at least every 4 hours to verify that total chlorine levels were less than 0.1 mg/L. This deficient practice had the potential to negatively impact the 56 in-center hemodialysis patients on census. Findings: Review of AAMI 5.2.5 Carbon adsorption revealed, in part: Carbon adsorption systems, often referred to as carbon filters, are the principal means of removing both free chlorine and chloramine. Removal of free chlorine to a maximum level of 0.5 mg/L and chloramine to a maximum level of <0.1 mg/L is necessary to protect hemodialysis patients from red cell hemolysis. Review of AAMI 6.2.5 Carbon adsorption revealed, in part: Intensive monitoring of carbon adsorption beds is recommended because of the long history of adverse events related to chloramine contamination of dialysate. Chloramine concentrations in municipal water may change from day to day and the capacity of carbon adsorption beds to remove chloramine can vary with the pH and temperature of the water, the nature of the chloramine compounds present, and the presence of other substances in the water. The dependence of chloramine removal on multiple factors makes the performance of carbon adsorption beds unpredictable. Patient safety can only be ensured by intensively monitoring the performance of the carbon adsorption bed. Review of the facility “Procedure No: 141.2, Daily Water Treatment Monitoring”, with no date issued, revealed, in part: “Purpose: Ensure proper operation of the Water Treatment System and its components that will provide AAMI Standard Quality Water for Hemodialysis Treatments. Policy: 10. Chlorine/Chloramines testing: Testing for total chlorine is performed at the beginning of each treatment day prior to patients initiating treatment and again at least every four hours.” Review of the facility “Water System Log DCI” revealed, in part: 03/17/2025: Total Chlorine-Time of test 5:40 AM and 10:20 AM (4 hours, 40 minutes between tests). 04/25/2025: Total Chlorine-Time of test 9:05 AM and 1:15 PM (4 hours, 10 minutes between tests). 05/09/2025: Total Chlorine-Time of test 5:30 AM and 9:45 AM (4 hours, 15 minutes between tests). 05/17/2025: Total Chlorine-Time of test 5:35 AM and 9:40 AM (4 hours, 5 minutes between tests). In an interview on 05/20/2025 at 11:12 AM, S2NM confirmed staff failed to perform total chlorine testing within the required 4 hour time frame on 03/17/2025, 04/25/2025, 05/09/2025, and 05/17/2025.”

“MICROB MONITOR-SAMPLE BEFORE DISINFECT CFR(s): 494.40(a) 7.2 Microbial monitoring methods 7.2.1 General: samples before disinfect Samples should always be collected before sanitization/disinfection of the water treatment system and dialysis machines. This Standard is not met as evidenced by: 14442 Based on record review and interview, the dialysis facility failed to ensure that samples were collected before disinfection of the water treatment system for 3 of 6 months reviewed. This deficient practice had the potential to negatively impact the 56 in-center hemodialysis patients on census. Findings: Review of the facility “Procedure No: 122.2, Storage Tank and Loop Disinfection with Bleach”, with no date issued, revealed, in part: “Purpose: Inhibit colonization of bacteria in the pure water distribution system and to ensure that bacteria and endotoxin levels in the fluid paths are controlled. Policy: 2. Ensure monthly scheduled non-patient labs have been drawn (within 72 hours) prior to initiating scheduled disinfection.” Review of the facility water sample and disinfection records from December 2024 to May 2025 revealed, in part: January 2025, samples were collected 01/15/2025 and water treatment system disinfected 01/29/2025. February 2025, samples collected 02/05/2025 and water treatment system disinfected 02/13/2025. March 2025, samples collected 03/18/2025 and water treatment system disinfected 03/17/2025. In an interview on 05/20/2025 at 10:16 AM, S3ET confirmed water and dialysate samples were not collected before disinfection of the water treatment system.”

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 14442 Based on observation and interview, the dialysis facility failed to ensure staff responsible for water treatment and dialysate systems were trained to monitor expiration dates. This deficient practice was evidenced by having expired test strips and calibration solutions available for use in the water treatment room. Findings: Observation of the facility water treatment room on 05/19/2025 at 10:18 AM revealed the following expired supplies: MINNCARE HD Residual Test Strips. One container with an expiration date 02/25/2022 and one container with an expiration date 03/30/2024. HACH SteriChek Residual Peroxide Reagent Strips. Six containers with an expiration date 02/2024. Myron L Calibration Buffer Solution pH 10.00. One container with an expiration date 02/22/2025. Myron L Calibration Buffer Solution pH 4.00. One container with an expiration date 02/26/2025. Myron L Conductivity Standard Solution 14.0 Millisiemens. One container with an expiration date 03/01/2025. Micro-X Residual Test Strips. Two containers with an expiration date 04/30/2025. In an interview on 05/19/2025 at 10:23 AM, S1AOD confirmed the supplies expired and should be discarded and not used. In an interview on 05/19/2025 at 10:32 AM, S3ET indicated the test strips were used during the water system disinfection process and solutions were used during calibration of hemodialysis machine testing equipment.”

“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: 14442 Based on observation, record review, and interview, the dialysis facility failed to maintain a safe environment. This deficient practice was evidenced by failing to secure nine oxygen tanks observed freestanding in the in-center hemodialysis treatment room. This deficient practice had the potential to impact the 56 in-center hemodialysis patients on census. Findings: Observation of the in-center hemodialysis treatment room on 05/19/2025 at 1:04 PM revealed nine freestanding and unsecured oxygen tanks in the patient wheel chair storage area. Review of the facility “Procedure No: 7.34, Use and Storage of Oxygen Tanks”, issued 01/31/2018, revealed, in part: “Purpose: Oxygen is a combustible gas. Employees must be able to safely use and store oxygen tanks. Procedure: Storage: 1. Oxygen tanks will be stored upright. They must be chained/strapped into a trolley or rack or chained to the wall so that they are stable upright and do not fall and cause the metal cylinder to strike objects and create sparks, and combustion occur.” In an interview on 05/19/2025 at 1:05 PM, S2NM confirmed the nine oxygen tanks were not securely stored.”

“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: 14442 Based on observation and interview, the dialysis facility failed to ensure all patient treatment equipment was maintained. This deficient practice was evidenced by failing to ensure in-center hemodialysis patient treatment chairs were maintained for patient comfort during treatment by having sunken cushions (treatment stations c, d, f) and to allow effective cleaning/disinfection by having tears and cracks in vinyl coverings (treatment stations a, b, e, g) for 7 (a, b, c, d, e, f, g) of 7 (a, b, c, d, e, f, g) treatment chairs inspected. The dialysis facility had 21 in-center hemodialysis patient treatment stations and 56 in-center hemodialysis patients on census. Findings: Observation of the in-center hemodialysis treatment room on 05/19/2025 from 1:00 PM to 1:34 PM revealed dialysis stations c, d, and f patient treatment chairs seat and back cushions moderately to severely sunken and dialysis stations a, b, e, and g patient treatment chairs had tears and cracks in the vinyl covering. In an interview on 05/19/2025 at 1:17 PM, Patient R1 indicated that her treatment chair seat cushion sunk down and was uncomfortable. Patient R1 indicated that she brought a pillow to treatment to sit on due to the condition of the chair. In an interview on 05/19/2025 at 1:21 PM, S2NM confirmed the facility had patient treatment chairs with sunken seat and back cushions and torn and cracked vinyl coverings. S2NM confirmed patients’ have complained about treatment chairs being uncomfortable due to sunken cushions. S2NM confirmed patient treatment chairs with torn and cracked vinyl coverings created an issue with chairs being adequately cleaned and disinfected.”

“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: 14442 Based on record review and interview, the dialysis facility failed to maintain accurate records. This deficient practice was evidenced by failing to ensure the time that total chlorine testing performed was accurately documented. Findings: Review of the facility “Procedure No: 141.2, Daily Water Treatment Monitoring”, with no date issued, revealed, in part: “Purpose: Ensure proper operation of the Water Treatment System and its components that will provide AAMI Standard Quality Water for Hemodialysis Treatments. Policy: 10. Chlorine/Chloramines testing: Testing for total chlorine is performed at the beginning of each treatment day prior to patients initiating treatment and again at least every four hours.” Review of the facility “Water System Log DCI” revealed, in part: 03/25/2025: Hour 4 and Hour 8 Time of test-Total Chlorine were both documented as performed at 1:30 PM. 03/27/2025: Hour 4 and Hour 8 Time of test-Total Chlorine were both documented as performed at 9:15 AM. 04/23/2025: Hour 4 and Hour 8 Time of test-Total Chlorine were both documented as performed at 1:45 PM. In an interview on 05/20/2025 at 11:36 AM, S2NM confirmed the time staff performed total chlorine test was not accurately documented on 03/25/2025, 03/27/2025, and 04/23/2025.”