U-Mass Memorial Health Care Systems

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 31240 Based on record review and staff interview, the facility failed to complete necessary psychosocial status monitoring by failing to complete a standardized mental and physical assessment tool (KDQOL-36) chosen by the Social Worker (SW) within four months of initiating treatment (or first reassessment) and at least annually, at regular intervals for 1 patient (#1), out of a total sample of 1 patient. Findings include: For Patient #1 the facility failed to ensure an annual KDQOL-36 assessment had been completed. Patient #1 was admitted to the facility in July 2023 with a diagnosis of End Stage Renal Disease, requiring hemodialysis treatments 3 times a week. Review of the clinical record indicated an initial KDQOL-36 assessment had been completed on 11/6/23. Further review of the clinical record indicated no other KDQOL-36 had been completed. Additionally, there was no documentation to indicate the assessment had been provided to the patient and/or that the patient had refused to complete it. During an interview on 6/25/25 at 10:50 A.M., the Social Worker (SW) said the only KDQOL-36 assessment completed for Patient #1 was 11/6/23. She said she thought she had offered the assessment to the patient last year, but he/she did not have his/her glasses with him/her and did want to take it with him/her at that time. She said she would review her documentation in the clinical record. During a second interview on 6/25/25 at 11:10 A.M., the SW said she had not documented that she had attempted to complete a KDQOL-36 assessment with Patient #1 last year. She said the facility does not have a policy regarding the KDQOL-36 assessment process, but she would need to follow the federal regulation for it. She said she would have to establish a process to ensure KDQOL-36 assessments were completed timely for those patients requiring them.”

“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: 31240 Based on record review, policy review and interview, the Medical Director failed to ensure that staff adhered to the heparin administration policy and documented that they waited 3-5 minutes after administration of a heparin (blood thinning medication) bolus to initiate dialysis treatment for 1 patient (#1), out of a total sample of 1 patient. Findings include: Review of the facility’s policy, entitled, Heparinization for the Hemodialysis Procedure, effective date July 2022, indicated the following: *A bolus loading dose of heparin will be administered a minimum of 3 minutes prior to the initiation of the dialysis treatment. Patient #1 was admitted to the facility in July 2023 with a diagnosis of End Stage Renal Disease requiring hemodialysis treatments 3 times a week. Review of the physician’s orders dated 6/11/25, 6/13/25, 6/16/25, 6/20/25 and 6/23/25, indicated; administer Heparin 6000 units intravenous pre-hemodialysis. Review of 9 treatment sheets, dated 6/2/25 through 6/23/25, indicated that for 5 of 9 treatments staff failed to wait a minimum of 3 minutes after administration of a heparin bolus to initiate treatment including the following: *On 6/11/25 treatment started at 7:27 A.M., heparin was documented as administered at 7:28 A.M. 1 minute after the initiation of treatment, not a minimum of 3 minutes prior to the initiation of dialysis, per the facility policy. *On 6/13/25 treatment started at 7:25 A.M., heparin was documented as administered at 7:28 A.M., 3 minutes after the initiation of treatment, not the minimum of 3 minutes prior to the initiation of dialysis, per the facility policy. *On 6/16/25 treatment started at 7:35 A.M., heparin was documented as administered at 7:34 A.M., 1 minute before the initiation of treatment, not the minimum of 3 minutes prior to the initiation of dialysis, per the facility policy. *On 6/20/25 treatment started at 7:30 A.M., heparin was documented as administered at 7:48 A.M., 14 minutes after the initiation of treatment, not the minimum of 3 minutes prior to the initiation of dialysis, per the facility policy. *On 6/23/25 treatment started at 7:30 A.M., heparin was documented as administered at 7:42 A.M., 12 minutes after the initiation of treatment, not the minimum of 3 minutes prior to the initiation of dialysis, per the facility policy. During an interview on 6/24/25 at 11:55 A.M., the Nurse Manager said staff should wait a minimum of 3 minutes after infusing heparin, before treatment is initiated per the policy. She said staff did not follow this procedure for the 5 treatments noted above.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 31240 Based on observation, staff interview, and policy review, the facility failed to ensure that equipment used to dust the walls of the Isolation Room after the care of a Hepatitis B positive patient, was bagged/discarded and disinfected before staff (Housekeeper #1) exited the room. Findings include: Review of the facility’s policy titled, Dialysis and Hemo Dialysis Unit, dated 10/1/23, included, but not limited to, the following: -Purpose: to provide a safe, clean environment for all patients and staff of the dialysis facility and to prevent the spread of infection or blood borne pathogens. -Clean areas should be clearly separated from contaminated areas where supplies and equipment are handled. On 1/9/24 at 11:38 A.M., the surveyor observed Housekeeper #1 cleaning the Isolation Room that had been used to dialyze a Hepatitis B positive patient earlier in the morning. She was observed using a dusting wand to dust around the top parts of the walls and wall mounted television. The surveyor observed Housekeeper #1 return the dusting wand to the cleaning cart just outside the Isolation Room. The dusting head had not been removed and bagged or discarded, and the wand was not disinfected before being taken out of the Isolation Room and secured to the cleaning cart. During an interview on 1/10/24 at 12:00 P.M., the Clinical Manager said Housekeeper #1 should have bagged the duster prior to exiting the room. She said this cleaning process would need to be reviewed. During an interview on 1/10/24 at 1:30 P.M., Housekeeper #1 said the cleaning items used in the Isolation Room need to be thrown out or bagged before leaving the room. The surveyor reviewed the observations of her placing the used dusting wand back on the cleaning cart after she was done utilizing it. She said she must have forgotten to disinfect the wand and bag the dusting head. She said the cleaning cart is kept on the dialysis unit and is used to clean all areas of the unit. During an interview on 1/10/24 at 2:30 P.M., the Infection Control Nurse said the expectation would be for the head of the duster to be thrown out or bagged, and the handle be disinfected before Housekeeper #1 exited the Isolation Room.”