Usrc Old Alexandria Dialysis

“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: 47759 Based on observations, a staff interview, and record review, the facility’s governing body failed to ensure that staff members maintained a clean and sanitary environment in patient care and medication preparation areas. This failure placed the patients and the staff at potential risk of exposure to infectious diseases through cross contamination. Findings Included: Review of the facility’s policies and procedures titled “Infection Control and Precautions for All Patients (POLICY # C-IC-0010) page 1 number 3 stated, “Clean areas will be clearly designated and separated from contaminated areas and unused supplies and equipment.” In addition, according to the Centers for Disease Control and Prevention (CDC), pathogens or microorganisms capable of causing disease can survive on surfaces for days or even weeks. To mitigate the risk of patient exposure to infectious diseases through cross-contamination, the CDC emphasizes the importance of thorough disinfection of equipment and environmental surfaces. On 09/15/2025 between 09:40 a.m. -12:00 p.m., during observations of the treatment floor, the surveyor observed the following: 1. Wet surfaces with white and brown stains surrounding both dirty sinks located on either side of the treatment floor. 2. Several tourniquettes placed on top of a Purell hand sanitizer dispenser located at one of the nursing stations. 3. Multiple tape residues and adhesive marks covering the surface of one of the nursing station areas. 4. Multiple tape residues and adhesive marks present on the facility ipad. 5. Pink and brown residue on the interior part of the facility’s Medication refrigerator located in the Medication Room. 6. Medication cups adjacent to the sink located in the Medication Room. According to the Clinical Specialist, the positioning of the medication cups near the sink poses a risk for cross contamination At 12:00 p.m., the Clinical Specialist stated that the treatment floor will need to be decluttered.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 47759 Based on observations, a staff interview, and record review, the facility’s governing body failed to ensure that potentially infectious wastes were transported in a manner that promotes safe handling and proper disposal practices. This failure placed the staff and patients at potential risk of exposure to blood-borne pathogens and infectious diseases. Findings Included: Review of the facility’s policy titled “Guidelines for the Handling and Disposal of Infectious Medical Waste” (POLICY # C-IC-0100) page 1 number 3 under policy, it stated, “Biohazard container will be brought to the point of use (e.g. near chairside) to dispose of biohazard waste.” In addition, according to the Centers for Disease Control and Prevention (CDC) guidelines, facilities must ensure that sharps containers are removed prior to reaching the recommended fill line or more than ¾ full of the container. Exceeding these recommendations can increase the risk of a needlestick injury and a bloodborne pathogen exposure. 1. On 09/15/2025 between 09:40 a.m. -12:00 p.m., during observations of the treatment floor, the surveyor observed: a. Staff #1 carry an AVF/AVG needle from Station #7 to a needle bucket located across from Station #3. b. Staff #2 carry a used bloodline from Station #14 to a hazardous waste container near Station #12. 2. On 09/17/2025 at 12:30 p.m., the surveyor observed a sharps container located at Training Room #2 filled beyond 3/4ths of its capacity. Similarly, upon observation of the treatment floor, the surveyor observed a sharps container, located near Station #15 that was nearly full. a. The Clinical Specialist also observed these findings and confirmed that staff are expected to empty sharps containers before the container gets nearly full.”

“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 a staff interview and record reviews, the facility’s governing body failed to ensure Hepatitis B routine testing was completed for all new and existing patients. This failure placed patients and staff at risk of contracting infectious diseases. Findings Included: Review of the facility’s policy titled “Patient Hepatitis B Testing/ Vaccination/Seroconversion” (POLICY # C-IC-0110) page 2 number 1 stated “HBV serological status (e.g., HBsAg, total anti-HBc and anti-HBs) of all patients should be known prior to admission to facility.” Page 2 under Schedule for Routine Testing for Hepatitis B (HBV) Infection stated that susceptible patients with X<10 Hepatitis B Antibody (HBsAb) must have Hepatitis B Antigen (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. 1. On 09/16/2025 from 07:00 a.m. -10:30 a.m. during medical record review of selected patients, the surveyor observed the following: a. Patient A, a susceptible patient with a HBsAB <10 as of May 2025 did not have HBsAg done for the months of July, August, and September. b. Patient E, admitted on 06/08/2024 did not have an antibody test result until 06/26/2024, 18 days after the admission date. 2. Interviews with the Clinical Specialist agreed with the surveyor’s finding that Patient A and Patient E should have had Antigen and Antibody testing based on the facility policy.”

“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 an interview and record reviews, the facility’s governing body failed to ensure that staff consistently followed prescribed dialysis treatment parameters and accurately documented any deviations. This failure placed patients at potential risk of harm by preventing timely identification of treatment issues and delaying appropriate interventions to improve care. Findings included: According to the facility’s policy titled “Intradialytic Monitoring of Patient” (POLICY # C-ID-0010) page 1 number 3 stated, “Blood flow rate: any variance from prescribed order requires documentation of reason.” Number 4 stated, “Dialysate flow rate: any variance from prescribed order requires documentation of reason.” Number 8 stated, “Delivery of dialysis prescription: review prescribed treatment orders against actual machine settings.” On 09/17/2025, the Clinical Specialist confirmed during interviews that the facility applies a standard maximum Ultrafiltration Rate (UFR) of 13 mL/kg/hr for all patients. The Clinical Specialist further stated that when staff members cannot meet prescribed treatment parameters, they must notify the nurse and document the reason in the patient ’ s medical record. Between 11:00 a.m. and 12:00 p.m. on 09/17/2025, the surveyor reviewed 21 patient treatment flowsheets and identified multiple discrepancies where staff members failed to follow prescribed orders or provide supporting documentation. See the following: 1. Blood Flow Rate (BFR): Staff members failed to follow the prescribed Blood Flow Rate (BFR) in 3 out of 21 treatment flowsheets. a. For example: Review of Patient F’s treatment flowsheet on treatment date 09/12/2025, revealed that Patient F had a BFR order of 400 millileter(mL)/minute(min). Documentation revealed that from 01:05 p.m. -03:34 p.m., BFR was set at 300mL/min. with no supporting documentation found why the prescribed BFR was not followed. 2. Dialysate Flow Rate (DFR): Staff members failed to follow the prescribed Dialysis Flow Rate (DFR) in 5 out of 21 treatment flowsheets. a. For example: Review of Patient D’s treatment flowsheet on treatment date 09/11/2025, revealed that Patient E had a DFR order of 600 mL/min. Documentation revealed that from 10:54 a.m. -02:21 a.m., DFR was set at 500mL/min. with no supporting documentation found why the prescribed DFR was not followed. 3. Ultrafiltration Rate (UFR): Staff members failed to follow the standardized maximum ultrafiltration rate (UFR) in 4 out of 21 treatment flowsheets. a. For example: Review of patient F’s treatment flowsheet on treatment date 09/15/2025, revealed that Patient F had a maximum UFR of 970 mL/hr based on the 13mL/kg/hr standard. Documentation revealed that from 12:16 p.m. -2:38 p.m. UFR was set at 970 mL/hr with no supporting documentation found why the standard maximum UFR per hour was not followed. 4. Target weight (TW): Staff members failed to adhere to the prescribed patient target weight in 10 out 21 treatment flowsheets. a. For example: Review of patient A’s treatment flowsheet on treatment date 09/10/2025 revealed that Patient A was ordered a dry weight also known as the Target Weight of 62 kg. Documentation revealed that the post dialysis weight was 66.8 and according to the nurse, “Patient post-weight is +/- 1kg of their ordered dry weight.” This documentation does not align with the prescribed target weight/dry weight.”

“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 a staff interview, observations and record review, the facility’s governing body failed to ensure that the clinical staff practiced the correct infection control protocol for accessing vascular access sites. This failure placed the safety and wellbeing of the patients at potential risk of harm in maintaining their vascular access. Findings Included: Review of the facility’s policy titled “Assessment and Cannulation for AV Fistula/Graft and Patient Self Cannulation” (POLICY # C-TI-0030)”, page 2 number 3 stated, using an alcohol prep pad, “Utilize a rubbing motion for at least 30 seconds. “ Page 2 number 4 stated, “do not repalpate vessel” On 09/15/2025 and 09/16/2025, during clinical observations of the treatment floor, the surveyor observed the following: 1. On 09/15/2025 at 10:46 a.m., Staff #2 disinfected the access site of the [patient sitting in Station #13 Machine #13] for a total of 7 seconds, applied a tourniquette and then cannulated. 2. On 09/16/2025 at 11:10 a.m., Staff #3 disinfected the access site of the [patient sitting in Station #14 Machine #15] for a total of 8 seconds, auscultated the access and then cannulated. 3. On 09/16/2025 at 11:51 a.m., Staff #4 disinfected the access site of the [patient sitting in Station #9 Machine #9] for 6 seconds on one side and 4 seconds on the other, then cannulated. 4. On 09/16/2025 at 12:08 p.m., Staff #3 disinfected the access site of the [patient sitting in Station #6 Machine #7] for 5 seconds on each side, auscultated, disinfected again for 1 second, and then cannulated. Interviews with the Clinical Specialist confirmed that the identified finding with AVF/AVG access care have been a recurring concern within the facility and indicated that the facility plans to take steps to resolve the problem.”

“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: 47759 Based on a staff interview and record reviews, the facility’s governing body failed to ensure that documentations were maintained in a manner that is accurate, legible, and clear. This failure placed patients at potential risk of harm by failing to utilize the data gathered to effectively identify trends and implement timely interventions to improve quality of care. Findings Included: Review of the facility’s policy titled “Medical Records” (POLICY #C-AD-0440) page 6 number 10 stated ‘Errors made in the paper medical record will be crossed out with a single line through the entry and followed with the initials of the person making the correction and the date. Erasures and/or “white out” are not permitted in the patient’s medical record. All entries will be made in black ink for photocopy quality.’ On 09/17/2025 at 10:00 a.m., interviews with the Clinical Specialist and the Facility Manager confirmed that the staffing schedule, with copies provided to the surveyor is the documentation used by the facility to conduct Staff Scheduling audits. Between 10:00 a.m. -11:00 a.m. on the same day, during reviews of the facility’s Staffing Schedule (covering 08/24/2025-09/13/2025) the following were observed in the presence of the Clinical Specialist: 1. The staffing schedule contained white out on documentation intended for auditing purposes. a. See Staffing Schedule for 09/08/2025 as an example 2. The staffing schedule contained multiple scratch-offs and illegible or unclear entries. a. See Staffing Schedule for 09/09/2025 as an example 3. The staffing schedule included numerous handwritten notes and annotations that lacked clarity. On 09/17/2025 at 11:00 a.m., interviews with the Clinical Specialist assured the surveyor that moving forward, the facility will have an improved Staff auditing process to ensure that documentation is clear and accurate.”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 47759 Based on a staff interview and record reviews, the facility’s governing body failed to ensure an adequate number of qualified and trained staff to meet the needs of the patients. This failure placed the patients at potential risk and denied their rights to a minimum standard of medical care. Findings Included: The Code of Maryland Regulations (COMAR) 10.05.04.06C (Dialysis Monitoring for Freestanding Kidney Dialysis Centers) states:... C. Dialysis Monitoring. (1) Staffing Ratio. (a) In-Center Daytime Hemodialysis. When in-center daytime hemodialysis is performed, the monitoring individual-to-patient ratio at each center shall be: (i) A minimum of one staff member to three participants; and (ii) Sufficient to meet the needs of patients .... (c) The center shall establish provisions for back-up staff coverage during unexpected illnesses, vacations, and holidays. ... (2) Staffing Exception Reporting. (a) The center shall have a staffing exception reporting protocol in a format approved by the Department for reporting to the governing body when emergency staffing situations arise that require the charge nurse to be included in the staffing ratio. The report shall include, at a minimum:(i) The date and shift of the exception; (ii) A description of the emergency staffing situation, (iii) Actions taken in response; and (iv) Any measures taken to ensure the center’s future compliance. ... On 09/17/2025 at 9:30 a.m., during a review of the facility’s staffing schedules for the period 08/24/2025 through 09/13/2025, it was determined that the facility failed to meet the required minimum staff-to-patient ratio on 6 out of 18 audited dates, specifically: 1. 09/02/2025 2. 09/04/2025 3. 09/06/2025 4. 09/08/2025 5. 09/09/2025 6. 09/11/2025 2. On 09/17/2025, the Clinical Specialist confirmed during an interview that, per COMAR regulations, the facility is required to maintain a minimum staffing ratio of one staff member to three patients.”

“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 record review and staff interviews, the facility’s governing body and medical director failed to include Heating, Ventilation and Air Conditioning (HVAC) system failure on the facility’s all hazards risk assessment. This failure placed the affected patients at potential risk of heat related illnesses. Findings Included: On 08/06/2024 at 12:45 p.m., an interview with the Regional Director revealed that there was an issue with one of the three HVAC system units in the facility in 2022. On 08/06/2024 at 01:00 p.m., during record review of the facility’s “Risk Assessment Tool,” despite the knowledge of a potential HVAC issue recurrence, the surveyor observed that there were no documentation of this risk on the facility and community based all-hazards risk assessment completed in 01/15/2024. On 08/06/2024 at 12:20 p.m., interviews with the Facility Administrator corroborated that the facility was not prepared for an air conditioner malfunction and agreed that the problem could have been addressed faster if the facility was prepared.”

“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: 47759 Based on observations, interviews and record reviews, the facility’s governing body failed to ensure a comfortable temperature within the facility at all times. This failure denied the patients their right to a minimum standard of medical care and placed the affected patients at potential risk of heat related illnesses. Findings Included: On 08/06/2024 at 12:00 p.m., review of the facility’s policy titled “Facility Space/Design and Safety Requirements” page 1 stated “All facilities will have adequate ventilation and room temperature maintained between 70 degrees fahrenheit to 74 degrees fahrenheit for patient comfort.” On 07/24/2024, interviews with the complainant per the intake stated that the facility was unbearable. On 08/06/2024 at 11:20 a.m., during record review of the facility’s temperature log, the surveyor observed that temperature were out of range on the following dates: 07/22/2024 07/23/2024 07/24/2024 07/25/2024 07/26/2024 07/27/2024 07/29/2024 07/30/2024 On 08/06/2024 at 12:20 p.m., interviews with the Facility Administrator confirmed the out of range temperature readings observed on the above dates and corroborated that the facility was not prepared for an air conditioner malfunction and agreed that the problem could have been addressed faster if the facility was prepared.”

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 47759 Based on observations, record reviews and interviews, the facility’s governing body failed to ensure that all patients were treated with respect and dignity. This failure denied the patients their right to a minimum standard of medical care. Findings Included: On 08/06/2024 at 12:00 p.m., review of the facility’s policy titled “Facility Space/Design and Safety Requirements” page 1 stated “All facilities will have adequate ventilation and room temperature maintained between 70 degrees fahrenheit to 74 degrees fahrenheit for patient comfort.” On 07/24/2024, interviews with the complainant per the intake stated that the facility was unbearable. On 08/06/2024 at 11:20 a.m., review of the facility’s temperature log confirmed that the temperature was out of the facility’s policy temperature range of 70 degree fahrenheit to 74 degree fahrenheit. Restoration of the facility’s required temperature was not obtained until 7 days after the problem started and 5 days after the complainant’s call. On 08/06/2024 at 12:30 p.m., interviews with the Facility Administrator corroborated that the facility was not prepared for an air conditioner malfunction and agreed that the problem could have been addressed faster if the facility was prepared.”