Bma - Fort Washington

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 47759 Based on a staff interview and review of the facility’s policies and procedures, the facility’s governing body failed to reassess the facility and community based all-hazards risk assessment. This failure placed the patients and staff at potential risk of harm in case of an emergency. Findings Included: On 11/14/2024 from 01:00 p.m.-01:30 p.m, review of the facility’s policy titled “Guidelines for Emergency Preparedness” (Reference Number: 25907) page 2 stated “The Interdisciplinary Team led by the DO (Director of Operations) will annually complete the Hazard Vulnerability Assessment (HVA) spreadsheet identifying hazardous events that may affect clinical operations ....Consider: geographic location and types of natural emergencies common to the area ...” On 11/13/2024 from 11:00 a.m.-11:30 a.m., record review of the facility’s Emergency Preparedness/Emergency Management Plan binder revealed that the last documented facility and community based all-hazards risk assessment was completed in 2020. Interviews with Staff #11 revealed that all hazards risk assessment per policy should be completed annually.”

“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: 47759 Based on observations and a staff interview, the facility’s governing body failed to provide a clean area for medication preparation. This failure increased the risk of cross contamination and placed patients at potential risk for exposures to infectious diseases. Findings Included: Clean supplies should not be near areas of splashing water (e.g., within 3 feet of a sink). According to the American Society for HealthCare Engineering (ASHE) in partnership with the Centers for Disease Control and Prevention, “Best practices related to the design of hand hygiene facilities include: Ensure adequate space between areas used for medical preparation, and use splash guards where appropriate.” On 11/12/2024 from 09:30 a.m. -10:40 a.m., during observations of the treatment floor, the surveyor observed that the medication preparation area was set up adjacent to the clean sink which the surveyor observed Staff #1 washing his/her hands. According to Staff #12, Staff #1 should not have used the clean sink located in that area.”

“IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT CFR(s): 494.30(a)(1)(i) Routine Testing for Hepatitis B The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit. Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results. This Standard is not met as evidenced by: 47759 Based on staff interview and record review, the facility’s governing body failed to ensure Hepatitis B routine testing was completed for all patients. This failure placed patients and staff at risk of contracting infectious diseases. Findings Included: On 11/14/2024 from 01:00 p.m.-01:30 p.m, review of the facility’s policy titled “Patient Hepatitis B Testing Requirements” (Reference Number: 47694) page 4, “Hepatitis B laboratory testing is required for all patients based upon immunity status. Susceptible patients with <10 HBsAb must have HBsAg testing done monthly.” According to the Centers for Disease Control and Prevention (CDC), although the incidence of Hepatitis B virus (HBV) infection is low among chronic hemodialysis patients, preventing transmission depends on timely detection of patients converting from HBsAg negative to HBsAg positive and rapid implementation of isolation procedures before cross-contamination can occur. On 11/12/2024 from 12:30 a.m. -01:00 p.m. , during record review of the facility’s Hepatitis B Audit Report, the surveyor observed the following: 1. Patient C, a susceptible patient with a HBsAB <10 did not have HBsAg results for the month of 10/2024 2. Patient J, a susceptible patient with a HBsAB <10 did not have HBsAg results for the month of 10/2024 3. Patient K, a susceptible patient with a HBsAB <10 did not have HBsAg results for the month of 10/2024 4. Patient L, a susceptible patient with a HBsAB <10 did not have HBsAg results for the month of 10/2024 At 01:00 p.m., interviews with Staff #11 stated that the staff members did not follow policy and immediately asked the provider to put orders in to check the patients’ hepatitis B antigen status.”

“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: 47759 Based on record review and a staff interview, the facility’s governing body failed to ensure that facility staff members received education and training on infection control practices for hemodialysis units annually. This failure placed patients, visitors, and staff at potential risk for exposure to blood borne pathogens and infectious diseases. Findings include: According to the Occupational Safety and Health Administration (OSHA), dialysis staff must receive bloodborne pathogen training annually with personnel records reflecting staff having received appropriate infection control training. Furthermore, the Centers for Disease Control and Prevention (CDC) also states that they recommend infection control training initially on employment and annually. On 11/13/2024 from 11:00 a.m. -11:30 a.m.., during review of the facility’s personnel file, the surveyor observed that 3 out of the 23 (13%) staff members had outdated infection control training. 1. Staff #4’s documented training was 12/8/2022 2. Staff #5’s documented training was 06/05/2020 According to the Area Team Lead, retraining will be provided to the staff members immediately.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 47759 Based on observations and record review, the facility’s governing body failed to ensure that every patient’s vascular access was visible during hemodialysis treatment. This failure placed the patients at potential risk of harm and possible death. Findings included: According to an article titled “Venous Needle Dislodgement and Access-Bloodline Separation” page 349 stated, “Failure to visualize the patient access and bloodlines has been identified as a cause of patient harm in multiple publications. Inadequate patient observation by staff has been noted as a risk factor by multiple authors (Axley et al., 2012; Lee et al., 2016; The Truax Group, 2019; Van Waeleghem et al., 2008).” On 11/12/2024 from 09:41 -09:50 a.m., during observations on the treatment floor, the surveyor observed that Patient H and Patient I’s access sites were covered with a blanket and were not easily visible. During record reviews, the surveyor did not observe a note/comment by Staff #1 and Staff #2 educating the patients of the importance of having a patient’s vascular access site visible at all times.”

“PR-INFORMED OF OWN MEDICAL STATUS CFR(s): 494.70(a)(10) The patient has the right to- (10) Be informed by the physician, nurse practitioner, clinical nurse specialist, or physician’s assistant treating the patient for ESRD of his or her own medical status as documented in the patient’s medical record, unless the medical record contains a documented contraindication; This Standard is not met as evidenced by: 47759 Based on record review and a staff interview, the facility’s governing body failed to ensure that all of the facility’s patients had completed Medical Orders for Life-Sustaining Treatment Form (MOLST) on their patient records. This failure denied the patients their rights to formulate treatment decisions that served their end of life needs. Findings Included: The Code of Maryland Regulations (COMAR) at 10.01.21.04B states the following: “Beginning July 1, 2013, the following health care facilities are required to accept, update if appropriate, and complete the MOLST form for each patient during the admission process in accordance with the form’s instructions: ... (4) A kidney dialysis center.” Additionally, COMAR 10.01.21.04E requires: When initially completing a MOLST form or updating an existing MOLST form, a health care facility shall: (1) Offer the patient or authorized decision maker the opportunity to participate in completing or updating the MOLST form, and on request of the patient, offer any physician [or], nurse practitioner, or physician assistant selected by the patient the opportunity to participate in updating or completing the MOLST form; (2) Note in the medical record when a patient or an authorized decision maker declines to participate in completing or updating the MOLST form, indicating the date and time of discussion, with whom the form was discussed, and a summary of the discussion; [and] (3) Inform the competent patient or authorized decision maker that the MOLST form will become part of the medical record and can be accessed through the procedures used to access a medical record. On 11/13/2024, from 09:30 a.m. -11:00 a.m., during record review of the sampled patient’s medical records, the surveyor observed that Patients C, D and G had incomplete MOLST forms with no notes found in the medical record indicating that the patient declined to participate in completing the form. Interviews with Staff #11 revealed that the MOLST forms should have been completed during admission.”

“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: 47759 Based on record review, observations and staff interviews, the facility’s governing body failed to ensure that the dialysis treatment provided to patients was in accordance with the written prescription. This failure placed the affected patients at potential risk of harm and denied patients their rights to a minimum standard of medical care. Findings Included: On 11/14/2024 from 01:00 p.m.-01:30 p.m, review of the facility’s policy titled “Patient Assessment and Monitoring” (reference number 45284) page 6 number 3 stated, “check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered.” Page 7 number 1 stated “Obtain the patient ’ s post weight. Ensure the post weight is consistent with the goal set of the machine.” On 11/13/2024 at 12:00 p.m.-01:00 p.m., during review of Patient C and F’s treatment flowsheet, the surveyor observed the following: 1. On treatment date 11/08/2024, patient F was prescribed a blood flow rate (BFR) of 450 milliliters per min (mL/min). From 09:06 a.m. -11:20 a.m., the documented BFR was 350 mL/min. No notes were found explaining why the prescribed orders were not followed. 2. On treatment date 11/08/2024, patient C was prescribed a BFR of 350 mL/min. From 05:00 p.m. -07:40 p.m., the documented BFR was 450 mL/min. No notes were found explaining why the prescribed orders were not followed. 3. On treatment date 11/11/2024, patient C was prescribed a dialysate flow rate (DFR) of 500 mL/min. From 02:15 p.m. - 05:18 p.m., the documented DFR was 800 mL/min. No notes were found explaining why the prescribed orders were not followed. 4. On treatment date 11/05/2024, patient A had an estimated dry weight of 70 kg. Patient A ’ s documented post weight was 71.5 kg. No notes were found explaining why the prescribed orders were not followed. On 11/13/2024 at 01:00 p.m., interviews with Staff #11 stated that the staff members did not follow policy.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 47759 Based on a staff interview and record reviews, the facility’s governing body failed to demonstrate that all patients had accurate and up to date allergy information. This failure placed the patient in potential risk and denied their rights a minimum standard of medical care. Findings Included: According to an article titled “Appropriate Assessment of Patient Medication Allergies,” allergy reporting can help decrease incidence of adverse drug reaction and ultimately improve overall patient care. (Sastic C.,2014). On 11/13/2024 from 09:30 a.m. -11:00 a.m., during medical chart review, the surveyor observed the following: 1. Review of Patient F’s hard copy chart revealed no known allergy. However, upon review of Patient F’s electronic chart, the surveyor observed that the patient has an allergy to ciprofloxacin. 2. Review of Patient G’s hard copy chart did not reveal an allergy sticker. According to Staff #11, Patient F’s allergy status is unknown.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 47759 Based on record reviews and a staff interview, the facility’s governing body failed to ensure that an initial comprehensive assessment has been conducted on all new patients within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first outpatient dialysis session. This failure placed the affected patients at potential risk of harm and denied patients right to a minimum standard of care. Findings Included: On 11/14/2024 from 01:00 p.m.-01:30 p.m, review of the facility’s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” (Reference Number: 45283) page 2 stated “An initial comprehensive interdisciplinary assessment (CIA) and plan of care (POC) must be conducted on all patients new to dialysis within the later of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. On 11/13/2024 from 09:30 a.m -11:00 a.m., upon request of Plan of Care documents for the selected patients, the facility’s representative, Staff #11, could not present the 30 day plan of care for Patient C and G. Interviews with Staff #11 stated that the facility staff members did not follow policy, the CIA and the POC should have been completed within 30 days.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 47759 Based on record review and observation, the facility’s governing body failed to ensure that the clinical staff members complied with the facility’s access assessment and cannulation protocol. This failure placed patients at potential risk for infection. Findings Included: On 11/14/2024 from 01:00 p.m.-01:30 p.m, review of the facility’s policy titled “Access Assessment and Cannulation “ (Reference Number: 45178) page 4 step 1 stated “Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulating.” On 11/13/2024 at 11:47 a.m., during observation of the treatment floor, the surveyor observed the following: 1. At 11:47 a.m., during access assessment and cannulation of Patient M, the surveyor observed that Staff #10 disinfected Patient M’s access for 10 seconds total and cannulated. 2. At 11:51 a.m., during access assessment and cannulation of Patient N, the surveyor observed that Staff #7 disinfected Patient N’s access for 6 seconds total and cannulated”

“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: 47759 Based on observations and record review, the facility’s governing body failed to ensure that the interdisciplinary team (IDT) members, including the patient or the patient’s designee met as a team and signs the plan of care; or if the patient chooses not to sign the plan of care, choice be documented on the plan of care, along with the reason the signature was not provided. This failure denied the affected patients their rights to a minimum standard of medical care. Findings Included: On 11/14/2024 from 01:00 p.m.-01:30 p.m, review of the facility’s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” (Reference Number: 45283) page 7 stated, “If the patient and or designee is unable or unwilling to attend the Plan of Care meeting or if the patient attends via telehealth/virtual: The registered nurse may review the Plan of Care as developed by the IDT at the meeting with the patient and obtain the patient’s signature and any comments. If the patient is not physically present at the meeting, or is remote at the time of review, signature may be obtained at a later date.” On 11/13/2024 from 09:30 a.m. -11:00 a.m., during review of the selected patient’s medical record review, the surveyor observed that the following plan of care did not have a documented patient’s signature acknowledging that the patient agrees with the plan nor a patient signature refusing the meeting. 1. Patient B’s Plan of Care dated 11/10/2023 did not have a documented patient plan of care meeting acknowledgement or refusal 2. Patient D’s Plan of Care dated 07/23/2024 did not have a documented patient plan of care meeting acknowledgement or refusal”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 47759 Based on review of Quality Assessment and Performance Improvement (QAPI) meeting minutes and interviews with staff, the facility’s governing body failed to analyze the incorporated mortality data to identify potential problems and opportunities for improving care.This failure placed patients at potential risk of harm by failing to utilize the data gathered to identify potential problems in the facility resulting in delay in interventions aimed at improvement. Findings Included: On 11/14/2024 from 01:00 p.m.-01:30 p.m, review of the facility’s policy titled “Quality Assessment and Performance Improvement Program” (Reference Number: 25799) stated “The QAPI Committee will monitor data/information; prioritize areas for improvement; determine potential root causes; develop, implement, evaluate, and revise action plans that result in sustainable improvements in patient care. Elements to be reviewed will include: ... Patient Care Outcomes” On 11/13/2024, during review of the facility’s mortality review documentation from November 2023 through November 2024.. The surveyor observed that 13 out of 13 mortality occurrences did not have a documented “cause of death.” Interviews with the Medical Director assured the surveyor that mortality reviews are reviewed during QAPI. According to the Medical Director, moving forward, those discussions will be “documented.””

“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: 47759 Based on observations, staff interviews, and review of the facility’s policies and procedures, the medical director failed to ensure that the staff members adhered to their own policies and procedures. This failure posed a potential risk of safety to the patients, and denied patients their rights to a minimum standard of medical care Findings Included: On 11/14/2024 at 01:00 p.m., during review of the facility’s “Medical Director Compliance Guidelines” under “Specific Medical Director Responsibilities” it stated “Assuring adequate training of nurses and technicians in dialysis techniques; Assuring adequate monitoring of the patient and the dialysis process ...Assuring the development and availability of a patient care policy and procedure manual and its implementation.” Under “Quality of patient Care” it stated “The Medical Director of the facility is designated in writing to be responsible for the execution of patient care policies.” The Medical Director’s signature on the “Medical Director Compliance Guidelines” and interviews conducted on 11/14/2024 at 01:00 p.m. both confirmed awareness of the duties outlined in the agreement. 1. On 11/13/2024, review of the facility’s Emergency Preparedness/Emergency Management Plan binder revealed failure to reassess the facility and community based all hazards risk assessment on an annual basis. This finding failed to meet the facility ’ s policy titled “Guidelines for Emergency Preparedness” (Reference Number: 25907) 2. On 11/12/2024, review of patient C, J, K, and L’s Hepatitis B Audit report revealed failure to ensure Hepatitis B routine testing was completed on a timely basis. This finding failed to meet the facility ’ s policy titled “Patient Hepatitis B Testing Requirements” (Reference Number: 47694) 3. On 11/13/2024, review of patients A, C. and F’s treatment flowsheet revealed failure to ensure that the dialysis treatment provided to patients was in accordance with the written prescription.This finding failed to meet the facility ’ s policy titled “Patient Assessment and Monitoring” (Reference Number 45284) 4. On 11/13/2024, review of Patient C and G’s comprehensive assessment and plan of care revealed failure to ensure that an initial comprehensive assessment has been conducted on all new patients within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first outpatient dialysis session. .This finding failed to meet the facility ’ s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” (Reference Number: 45283) 5. On 11/13/2024, observations of Patient M and N’s access assessment and cannulation revealed failure to ensure that clinical staff members complied with the facility ’ s access assessment and cannulation protocol. This finding failed to meet the facility ’ s policy titled “Access Assessment and Cannulation “ (Reference Number: 45178) 6. On 11/13/2024, review of patient B and D’s comprehensive plan of care revealed failure to ensure that the interdisciplinary team (IDT) members, including the patient or the patient’s designee met as a team and signs the plan of care; or if the patient chooses not to sign the plan of care, choice be documented on the plan of care, along with the reason the signature was not provided. This finding failed to meet the facility ’ s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” (Reference Number: 45283) 7. On 11/13/2024, review of the facility’s mortality review revealed failure to analyze the incorporated mortality data to identify potential problems and opportunities for improving care. This finding failed to meet the facility ’ s policy titled “Quality Assessment and Performance Improvement Program” (Reference Number: 25799)”