Dci Ball Square

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 37700 Based on observations, policy reviews, and interviews, the facility failed to ensure 5 of 7 direct care staff (Registered Nurse [RN] #3, RN #10, Certified Clinical Hemodialysis Technician [CCHT] #1, CCHT #2 and CCHT #3) observed, consistently implemented infection control standards to prevent infection within the dialysis unit. 1. The facility failed to consistently provide a sanitary environment to minimize the transmission of infectious agents within the patient treatment area. Please refer to V111. 2. The facility failed to ensure the separation of clean and dirty items related to the storage of staff personal protective equipment (PPE) and patient personal items, increasing the risk of cross contamination. Please refer to V117. 3. The facility failed to ensure that 1.) 2 of 2 staff members (CCHT #1 and CCHT #3) observed, adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, increasing the risk for cross contamination of blood borne pathogens, and 2.) bleach containers were covered with a secure lid in between use to maintain the efficacy of the solution to clean and disinfect contaminated surfaces, medical devices and equipment. Please refer to V122. 4. The facility failed to ensure 1 of 2 staff members (CCHT] #2) observed, adhered to adequate infection control practice while preparing 1 of 2 patients ( #12) observed, for initiation of dialysis with an arteriovenous fistula. Please refer to V142. 5. The facility failed to ensure 1 of 2 staff members (RN #10) observed, maintained aseptic technique when administering intravenous medication. Please refer to V 143. 6. The facility failed to ensure 2 of 2 staff members (CCHT #3 and RN #3) observed, adequate infection control practices to minimize the risk of infection during exit site care and initiation of treatment for 2 of 2 patients (#13, #11) with a central venous catheter (CVC). Please refer to V147.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 37349 Based on observation, review of Centers for Disease Control and Prevention (CDC) Guidance and staff interviews, the facility failed to consistently provide a sanitary environment to minimize the transmission of infectious agents within the patient treatment area. Findings Include: The CDC defines a “sanitary environment” as an environment that meets “Standard Precautions” for an in-patient hospital setting plus the more stringent precautions which are recommended for hemodialysis units because of the increased potential for contamination with blood and pathogenic microorganisms. On 3/12/24 at 8:45 A.M., during the flash tour of the dialysis treatment area, the surveyor observed patients receiving dialysis treatment. Between patients, when the dialysis chairs were vacant, the surveyor observed the following: *At stations 2, 5, and 15, the hemodialysis chair had a rip in the material on the right arm of the chair, exposing cloth, preventing staff from being able to adequately disinfect the area. *At stations 1, 3, and 12, the hemodialysis chair had a rip in the material on the chair where the patient’s back would be, exposing cloth, preventing the staff from being able to adequately disinfect the area. *At the clean sink area, laminate was missing, exposing particle board, preventing staff from being able to adequately disinfect the area. *At the dirty sink area, laminate was missing, exposing particle board, preventing staff from being able to adequately disinfect the area. *At station 2, behind the dialysis chair, approximately 6 feet of baseboard was missing, exposing a porous wooden surface. During an interview on 3/14/24 at 1:50 P.M., the Area Operations Director said there were plans for new chairs and cabinets in the dirty and clean sink areas, but in the meantime they need to make repairs so the chairs and cabinets can be properly disinfected. During an interview on 3/14/24 at 2:50 P.M., Registered Nurse #3 said she would let the Clinic Manager know about the missing baseboard.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 37349 The facility failed to ensure the separation of clean and dirty items related to storage of staff personal protective equipment (PPE) and patient personal items, increasing the risk of cross contamination. Findings include: Review of the facility policy entitled, General Facility Infection Control, dated 1/16/19, included the following: *Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. On 3/13/24 at 1:15 P.M., the surveyor observed staff PPE and a patient jacket stored on hooks at the entrance of the treatment area. The items were overlapping. During an interview on 3/13/24 at 1:15 P.M., the Regional Educator said that staff PPE and patient personal items should not be stored together. On 3/14/24 at 7:00 A.M., the surveyor observed staff PPE and a patient sweatshirt stored on hooks at the entrance of the treatment area. The items were overlapping. On 3/14/24 at 7:15 A.M., the surveyor observed Registered Nurse (RN) #10 administer medications to a patient. Upon completion, she removed her gown and hung it up on the hooks at the entrance of the treatment area, overlapping with a patient sweatshirt. During an interview on 3/14/24 at 1:50 P.M., the Area Operations Director said that patient personal items should not be stored with staff PPE. On 3/14/24 at 2:50 P.M., the surveyor observed staff PPE (1 gowns and 4 face shields) hanging from hooks at the entrance to the treatment area. The 4 shields were stacked and all hanging from one hook. During an interview on 3/14/24 at 2:55 P.M., RN #3 said they made some changes yesterday to correct the problem, but don’t have enough space to hang all PPE.”

“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: 10249 Based on observations, interview, and policy review, the facility failed to 1.) ensure that 2 of 2 staff members observed (Certified Clinical Hemodialysis Technician [CCHT] #1 and #3) for 2 of 2 observations, adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, increasing the risk for cross contamination of blood borne pathogens; and 2.) ensure that bleach containers were covered with a secure lid in between use to maintain the efficacy of the solution to clean and disinfect contaminated surfaces, medical devices and equipment. Findings include: 1. The facility failed to ensure that 2 of 2 staff members (CCHT #1 and CCHT #3) observed adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, increasing the risk for cross contamination of blood borne pathogens. Review of the facility policy titled, Routine Disinfection in the Hemodialysis Unit, date issued 1/16/2001, indicated the following, but not limited to: Proper cleaning and disinfection of environmental surfaces (including patient chairs or bed surfaces, dialysis equipment surfaces, adjacent tables, and work surfaces) must be performed between patient use to prevent transmission of dangerous pathogens. *Obtain cloth/towels soaked in appropriate disinfectant. *To clean the dialysis machine start at the top of the machine. Ensure that all items from top to bottom are cleaned, including but not limited to: IV poles, stethoscope, if left on machine, all components of the machine (i.e. air detector, heparin pump, blood pump door, Hanson connector, and tubing), blood pressure cuff and tubing, any concentrator containers, and bottom, sides, shelves and back of the machine. *With a new cloth/towel saturated with approved disinfectant, move to the dialysis chair. Ensure all components of the chair are cleaned top to bottom including, but not limited to: Chair, foot rest, head rest, any pillows, side tables, remote/call light, pull out foot rest, wheels, and inside arms of the chair. *Ensure any ancillary equipments cleaned with a new cloth/towel that has been saturated with approved disinfectant. Items include but not limited to: Television monitors, remote controls, oxygen concentrators, oxygen tanks, and any other ancillary equipment. A. On 3/12/24 at 10:30 A.M. the surveyor observed CCHT #1 cleaning and disinfecting station 10 for the next patient. She was observed disinfecting using 1:100 bleached soaked pads. CCHT #1 was observed first to wipe down the TV remote and the blood pressure cuff, then placed them on the contaminated counter, behind the dialysis chair. She then proceeded to wipe down the dialysis machine, but failed to wipe the back of the machine. She failed to wipe the counter and wall behind the dialysis chair. During an interview on 3/12/24 at 10:45 A.M., CCHT #1 said, “Yes, I know when I put them down on the counter, I should not have done that”. She also said she does not wipe down the back of the machine because of the electrical wires, and does not want to get them wet. CCHT #1 further said she was not aware of the policy for cleaning the back of the dialysis machine when cleaning the station. 38141 B. On 3/13/24 at 9:10 A.M., during observation of the treatment area, the surveyor observed CCHT #3 disinfecting the dialysis machine at station 2 for the next patient. She was observed disinfecting the dialysis machine using the 1:100 bleach-soaked pads. CCHT #3 failed to disinfect the arms of the intravenous (IV) pole. CCHT #3 was observed disinfecting the stethoscope, then placed it on the arms of the dirty IV pole that had not been disinfected. CCHT #3 also failed to disinfect the countertop behind the dialysis chair. During an interview on 3/13/24 at 9:20 A.M., CCHT #3 said she didn’t realize she missed areas identified by the surveyor. 37349 2. The facility failed to ensure bleach solution was stored in a closed container to maintain efficacy. Review of the facility policy titled, Surface Disinfection - Dilution of 1:100 Bleach Solutions, dated 1/16/19, failed to include guidance on storage of 1:100 bleach. During an observation on 3/12/24 at 10:00 A.M., the surveyor observed the 1:100 bleach solution containers, located in both the clean sink area and dirty sink area, were open. During an observation on 3/13/24 at 9:45 A.M., the surveyor observed the 1:100 bleach solutions containers, in both the clean sink area and dirty sink area, were open. During an interview on 3/14/24 at 10:20 A.M., the Area Operations Director said that bleach containers should be covered when not in use.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 37349 Based on observation, policy review, and interview, 1 of 2 facility staff (Certified Clinical Hemodialysis Technician [CCHT] #2) failed to ensure adequate infection control practices while preparing the patient for initiation of dialysis with an arteriovenous fistula for 1 of 2 patients (#12) with fistulas/grafts observed, out of a total sample of 13 patients. Findings include: Review of the facility policy titled, Cannulation of Established Arteriovenous Fistula (AVF) with Safety Needles, dated 9/15/23, included the following: *Patients that are physically able should be encouraged to wash hands and vascular access site prior to entering the treatment area; if patient is physically unable, staff should complete this step chairside. During an observation on 3/12/24 at 10:25 A.M., the surveyor observed CCHT #2 initiate treatment for Patient #12 via an AVF. Patient #12 had a clear dressing over his/her AVF. Blood and a white lotion were visible under the dressing. Patient #12 said that he/she had applied Lidocaine to his/her access site to help with discomfort during cannulation and although it doesn’t happen often, today his/her site was leaking blood. CCHT #2 removed the clear dressing and wiped away the blood and Lidocaine with a dry 4 x 4 gauze. Without washing the access, she proceeded to move forward with the initiation of treatment. During an interview on 3/12/24 at 10:40 A.M., CCHT #2 said she should have washed the access for Patient #12, and not just wipe it with a dry gauze.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 37349 Based on observation, interview, and policy review, the facility failed to ensure that 1 of 2 Registered Nurses (RN) (#10) observed, maintained aseptic technique when administering intravenous medications. Findings include: Review of the facility policy titled, General Facility Infection Control, dated 1/16/19, included the following: *Staff preparing medications should clean the septum of any multi-use vial with alcohol before inserting the needle and injection port before using the port to administer a medication. During an observation on 3/14/24 at 7:15 A.M., the surveyor observed RN #10 prepare and administer Retacrit (to treat anemia) 10,000 units for a patient in station 4. RN #10 used alcohol to disinfect the septum of a multidose vial of Retacrit 20,000 units per milliliter. RN #10 drew up what was available in the vial into the first syringe. The vial contained only enough medication for 5,000 units of Retacrit. RN #10 obtained a new vial of Retacrit 20,000 units per milliliter, disinfected the septum and drew up the additional 5,000 units of Retacrit in a second syringe. RN #10 brought the two syringes to station#4, used an alcohol wipe to disinfect the port and administered one of the syringes of Retacrit 5,000 units. RN #10 and the patient had a conversation related to the medication. Without disinfecting the port, RN #10 then administered the second syringe of Retacrit 5,000 units. During an interview on 3/14/24 at 7:20 A.M., RN #10 said she should have disinfected the port before administering the second syringe of Retacrit.”

“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: 38141 Based on observations, interviews, and facility policy review, the facility failed to ensure that 2 of 2 staff (Certified Clinical Hemodialysis Technician [CCHT] #3, and Registered Nurse [RN] #3) observed adequate infection control practices to minimize the risk of infection during exit site care and initiation of treatment for 2 of 2 applicable patients (#13, #11) with a central venous catheter (CVC), out of a total sample of 13 patients. Findings include: Review of the facility policy titled, CVC Exit Site Disinfection and Dressing Change, dated 9/15/2023, indicated the following: * The use of central venous catheters for hemodialysis is the most common factor contributing to bacteremia inpatients on dialysis, and the relative risk for bacteremia in patients with dialysis catheters is seven times the risk than for patients with primary Arteriovenous fistulas. * Perform hand hygiene and don PPE, including new gloves. * Assist patient in donning face mask. (Wearing face mask decreases the risk of transmitting microorganisms from the respiratory tract of the staff member or patient, onto the catheter site itself, as well as potentially into the vascular system of the patient when the catheter ports are open to air). * Clean exit site: Option #3 ExSept Plus (sodium Hypochlorite 0.11% solution). * If not already completed, with clean, gloved hands, aseptically open sterile gauze packets, keeping gauze in their sterile wrappers. Saturate both gauze pads with an ample amount of ExSept Plus solution, approximately 3-5 ml each. Take one saturated ExSept gauze and disinfect CVC exit site starting at the center and moving in continuous circles outward to circumference of 2 inches. * Key points: ExSept is classified as an effective skin antiseptic. To be effective, the solution must have a 2 minute contact time and must be allowed to dry to achieve maximum results. 1. For Patient #13, the facility failed to ensure that CCHT #3 observed adequate infection control practices to minimize the risk of infection during exit site care. During an observation on 3/13/24 at 10:50 A.M., while on the treatment floor, the surveyor observed CCHT #3 in station#3 initiate exit site care for Patient #13. CCHT #3 failed to encourage Patient #13 to adjust their mask to cover their nose and mouth. While CCHT #3 was performing exit site care, including disinfection of the area around the catheter and initiation of treatment, Patient #13 wore a mask below his/her nose, only covering his/her mouth. Patient #13 was observed occasionally coughing throughout the procedure. During an interview on 3/13/24 at 11:05 A.M., CCHT #3 said she should have made sure that Patient #13’s mask was covering their nose and mouth. 10249 2. For Patient #11, the facility failed to ensure that RN #3 adhered to appropriate infection control practices to prevent intravascular infections, while performing a Central Venous Catheter (CVC) exit site dressing change. Patient #11 was admitted to the facility in February 2019 with a diagnosis of End Stage Renal Disease (ESRD), requiring dialysis treatment via a CVC. During an observation on 3/12/24 at 9:50 A.M., the surveyor observed RN #3 perform exit site care on Patient #11. RN #3 performed hand hygiene and donned gloves. RN #3 removed and discarded the dirty dressing, and performed hand hygiene. The surveyor observed RN #3 don new gloves and apply ExSept Plus solution to two 4 X 4 gauze pads. RN #3 took one gauze pad and in a circular motion disinfected the area around the catheter for 45 seconds. She then took the second gauze pad and continued to disinfect the area for an additional 40 seconds, for a total of 1 minute and 25 seconds, and not the 2 minutes per facility policy. During an interview on 3/12/24 at 10:50 A.M., RN #3 said,”We use ExSept as an antiseptic and I put a few drops on each gauze pad”. RN #3 said she should have wiped for 1 minute with each pad and said, “I bad”.”

“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: 37349 Based on observation, interview, and Manufacturers Recommendations for Use, the facility failed to ensure that 1 of 2 staff observed (Certified Clinical Hemodialysis Technician [CCHT] #1) waited 20 seconds before reading the results of chorine testing to ensure an accurate result was obtained. Findings include: Review of the Manufacturers Total Chlorine Test Strips Instructions for Use, undated, included the following: * Collect a fresh 100 milliliters(ml) sample of water in a clean plastic sample cup. * Remove one test strip from its foil package and swish it in the sample for the amount of time indicated according to the temperature ranges. * Move the strip back and forth at a constant gentle rate of approximately two, 1-2 inch wide strokes, per second. * Remove the strip and shake once, briskly, to remove excess water. * Wait 20 seconds for the test strip color to develop. While waiting, fold the white plastic handle of the test strip under the reagent area aperture so that it provides a consistent viewing background. * After the 20 second wait period, immediately compare the strip color to the color chart to determine the Total Chlorine level in the sample. During an observation on 3/12/24 at 8:55 A.M., the surveyor observed CCHT #1 obtain a fresh 100 ml sample of water in a clean plastic sample cup. She moved a test strip back and forth in the sample for an acceptable amount of time, removed the excess water, and immediately compared the strip color to the color chart without waiting 20 seconds for the test to develop. During an interview on 3/12/24 at 9:0 A.M., CCHT #1 and the Technical Manager said that she should have waited 20 seconds before comparing the test results to the color chart.”

“MIXING SYSTEMS-PERM RECORD/VERIF TEST CFR(s): 494.40(a) 5.4.4.1 Mixing systems: perm record/verification testing In addition to container labeling, there should be permanent records of batches produced. These records should include the concentrate formula produced, the volume of the batch, the lot numbers of powdered concentrate packages, the manufacturer of the powdered concentrate, the date and time of mixing, any test results, the person performing the mixing, the person verifying mixing and test results, and the expiration date (if applicable). 6.4.1 Mixing systems Acid and bicarbonate concentrates may be tested by using conductivity or by using a hydrometer. Concentrates should not be used or transferred to holding tanks or distribution systems until all tests are completed. The test results and verification that they meet all applicable criteria should be recorded and signed by the individuals performing the tests. This Standard is not met as evidenced by: 37349 Based on record review, interview and policy review, the facility failed to ensure that acid concentrate batches mixed and transferred were verified to ensure the concentrate was properly proportioned, and transferred to the appropriate storage tank. Findings include: Review of the facility policy titled, Acid Concentrate Mixing, Transferring, and Rinsing of the Fresenius Dissolution Unit (Granuflo) Mixer, dated 3/18/16, included the following: *Purpose: Ensure the dry powder acid concentrate is correctly mixed into solution at the proper proportioning ratio and formulation(s). *General: If acid concentrate is pumped into a bulk storage tank at the dialysis facility, the user is responsible for maintaining the concentrate in its original state and to ensure that the correct formula is used according to the patient’s prescription. Acid concentrate prepared at the dialysis facility from powder and water is also the responsibility of the user. *Policy: The following documentation requirements for mixing acid concentrate will be recorded on the Acid Concentrate Batch Mix and Transfer Log as the steps are completed: - Time and date concentrate is mixed - Preparation steps (Pre Rinse and Filter Change) - Total batch size of concentrate mixed - Expiration date(s) of each different Lot Number - Concentrate formula produced (Catalog # and Calcium and Potassium) - Specified (sic) Gravity reading from a hydrometer - The initials of the person(s) mixing the concentrate - Transfer verification of mixed concentrate to appropriate storage tank *Procedure: Document the Tank Identification information on the Acid Concentrate Batch Mix and Transfer Log with the initial of both the responsible technician and verifying person. During the tour of the water room on 3/14/24 at 8:40 A.M., the surveyor observed a mixing machine and 2 acid storage tanks. One acid storage tank was labeled as containing 2 K (potassium) and 2.5 Ca (Calcium), and the other acid storage tank was labeled as containing 3 K 2.5 Ca. Review of the Granuflo Batch Production Records indicated that acid had been mixed 5 times between 2/13/24 to 3/14/24, 3 K had been mixed once and 2 K had been mixed 4 times. The records indicated the specific gravity of the acid was obtained by the person mixing the solution, but failed to include the results were verified. The log also failed to include acid transfer verification including both the responsible technician and verifying person. During an interview on 3/14/24 at 8:45 A.M., the Technical Manager said that technical staff is responsible for mixing acid concentrates and transferring the solutions to the storage tanks. He said they do not have a second staff person verify the mixing and transfer of the acid.”

“PA-MSW-PSYCHOSOCIAL NEEDS CFR(s): 494.80(a)(7) The patient’s comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker. This Standard is not met as evidenced by: 44223 Based on record review, interview, and policy review, the facility failed to ensure that an annual evaluation of psychosocial needs by a Social Worker (SW) was completed for 1 of 10 applicable patients (#4), out of a total sample of 13 patients. Findings Include: Review of the facility policy titled, Care Plans, dated 9/15/23, indicated the following, but is not limited to: Purpose: To provide guidance on the care pan process per the Centers for Medicare and Medicaid Services (CMS) conditions for coverage. Policy: *The interdisciplinary team must develop a plan of care that integrates all disciplines. Each plan of care must show evidence of participation/contribution from all of the professional members of the IDT (interdisciplinary team). *All disciplines will complete an assessment before the care plan meeting. This may be done using individual assessments for each discipline as long as they are brought together, discussed, shared, and used to develop a comprehensive assessment of the patient’s needs for the care plan. Assessments can be paper or electronic. These assessments will be discussed by the interdisciplinary team and problems identified for the care plan. *All assessments and a new plan of care must be completed with 90 days of completion of the initial care plan. *All assessments and care plan will be completed annually thereafter unless state regulations require more completion. For Patient #4, the facility failed to ensure an annual psychosocial assessment was completed by a SW. Patient #4 was admitted to the facility in April 2019 with a diagnosis of End Stage Renal Disease (ESRD), requiring dialysis. Review of the medical record indicated that the annual Comprehensive Interdisciplinary Assessment (CIA) was completed in July 2023. Review of the Psychosocial Assessment form for the annual assessment, dated 6/30/23, was blank with an electronic note that indicated the assessment was not completed because the position was open and not staffed. During an interview on 3/13/24 at 11:00 A.M., the Area Operations Director said the psychosocial assessment was documented as justified because they had no SW. He said the assessment was scheduled to be completed this month, 6 months after the original due date. During an interview on 3/13/24 at 3:30 P.M., the SW said that she is not assigned to care for that person so she would not have completed that assessment. She said she believed the assessment was scheduled to be completed this month.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 37349 Based on observation, policy review, and interview, 1 of 2 facility staff (Certified Clinical Hemodialysis Technician [CCHT] #2) failed to assess an arteriovenous fistula (AVF) prior to cannulation for 1 of 2 patients (#12) with fistulas/grafts observed, out of a total sample of 13 patients. Findings include: Review of the facility policy titled, Cannulation of Established Arteriovenous Fistula (AVF) with Safety Needles, dated 9/15/23, included the following: *Perform assessment of the AVF: Look at the AVF. Inspect for any abnormal findings. Listen to the access with a stethoscope along the entire length of the access, including the anastomosis. Feel with a gloved hand for the presence of a thrill, and the depth, shape and temperature of the access. Palpate the entire length of the access, as well as above and below the access. During an observation on 3/12/24 at 10:25 A.M., the surveyor observed CCHT #2 initiate treatment for Patient #12 via an AVF. Without listening to, or feeling the access, she used an alcohol wipe to disinfect and cannulated first the lower access site and then the upper access site. During an interview on 3/12/24 at 10:40 A.M., CCHT #2 said she could feel the access pulsating through the alcohol swab she was disinfecting with, so she didn’t think she needed to feel or listen to the access before cannulating.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 10249 Based on record review, interview, and policy review, the facility failed to ensure the care plan was signed by the patient or the patient’s designee, or if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided, to ensure the patient had involvement with his/her plan of care for 2 of 10 applicable patients (#8, #9), from a total sample of 13 patients. Findings include: Review of the facility policy entitled, Home Program Care Plans, date issued 2/17/2017, indicated the following: *The patient must be invited to participate and attend the care plan meeting. If patient refuses, it should be documented and the plan of care thoroughly reviewed with the patient, and their wishes considered and implemented when possible. If the patient refused to sign the plan of care, the refusal should be documented. 1. For Patient #8, the facility failed to ensure the patient’s involvement in his/her plan of care occurred by signing the plan of care or if the patient chose not to sign, and document as to why. Patient #8 was admitted to the facility in April 2019 with a diagnosis of End Stage Renal Disease (ESRD), requiring hemodialysis. Patient #8 was receiving peritoneal dialysis treatments at home. Review of the clinical record indicated the annual assessment and care plan were developed on 8/3/23, and the care plan meeting was held on 8/11/23. Review of the IDT signature section of the care plan included the electronic signatures of the nurse and dietitian, dated 8/11/23, the social worker, dated 8/14/23, and the physician dated 9/8/23. Patient #8’s signature was not on the document, nor was there any documented reason why Patient #8 did not provide a signature. During an interview on 3/13/24 at 10:30 A.M., The Home Program Manager said they did a telehealth meeting with the patient, but should have reviewed the care plan with the patient the next time he/she was at the clinic, and then have him/she sign the care plan. 2. For Patient #9, the facility failed to ensure the patient’s involvement in his/her plan of care occurred by signing the plan of care or if the patient chose not to sign, and document as to why. Patient #9 was admitted to the facility in September 2019 with a diagnosis of ESRD, requiring hemodialysis. Patient #9 was receiving peritoneal dialysis treatments at home. Review of the clinical record indicated the annual assessment and care plan were developed on 11/3/23, and the care plan meeting was held on 11/20/23. Review of the IDT signature section of the care plan included the electronic signatures of the physician, nurse, and dietitian, dated 11/20/23, and the social worker dated 11/21/23. The care plan signature page reflected that the patient did not attend. Patient #8’s signature was not on the document, nor was there any documented reason why Patient #8 did not provide a signature. During an interview on 3/13/24 at 1:30 P.M., the Home Program Manager said we should have identified why the patient declined to attend, and the next time he/she arrived at the clinic, review the care plan and have the patient sign.”

“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: 10249 Based on review of facility policies and interviews, the Medical Director failed to ensure that facility policies were provided to the long term care facility related to home dialysis treatment for 1 of 1 applicable patient (Patient #9), receiving care at a long term care facility, from a total sample of 13 patients. Findings include: Review of the Long Term Care Facility-Home Dialysis Services Memorandum of Understanding between the Dialysis clinic and the long term care facility dated 12/31/19 indicated the following: * Responsibilities of DCI: provide information, protocols and procedures for delivery of residents’ dialysis treatment. * Responsibility of LTCF (long term care facility): implement and adhere to DCI information, protocols and procedures for delivery of residents’ dialysis treatment. Patient #9 was admitted to the dialysis center in 9/2019 with a diagnosis of End Stage Renal Disease (ESRD), requiring dialysis. Patient #9 was admitted to the long term care facility in 3/2024 after hospitalization, requiring peritoneal dialysis at the facility. During an onsite visit to the long term care facility on 3/14/24, the Director of Nursing was interviewed at 9:35 A.M., and said that she does not have any policies and procedures from the dialysis center that addresses the care of the patient who requires Peritoneal Dialysis (PD). During an interview on 3/14/24 at 11:30 A.M., the Home Program Manager said they did not provide the long term care facility with policies and procedures to assist in caring for the PD patient who was currently receiving care at the long term care facility. She did say they provided staff with education and handouts that do review some of the topics mentions, but not policies.”