Southeast Michigan Kidney Center

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 38040 Based on record review and interview, the facility failed to ensure the fire alarm system was tested and maintained in accordance with an approved program complying with NFPA 70 and NFPA 72, and records are readily available as required by 19.6.1.3, 9.6.1.5, NFPA 70 and NFPA 72. This deficient practice could affect all of the occupants in the event of a fire emergency. Findings Include: A) On November 20, 2023 at 10:45 AM. record review reveled the facility failed to provide documentation on the annual inspection, testing and maintenance on the facility’s automatic fire alarm system. No annual inspection documents were available at the time of survey. B) On November 20, 2023 at 10:45 AM. record review reveled the facility failed to provide documentation on the required quarterly dialer tests. No dialer tests were available at the time of survey. The Facility Administrator confirmed these findings during interview at the time of Record Review.”

“Fire Alarm System - Out of Service CFR(s): NFPA 101 Fire Alarm - Out of Service Where required fire alarm system is out of services for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.6 This Standard is not met as evidenced by: 38040 Based on record review and interview, the facility failed to ensure when a required fire alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction (AHJ) has been notified, and all unprotected areas of the building have been evacuated or an approved Fire Watch is provided until the system is restored as required by 9.6.1.6. This deficient practice could affect all of the occupants in the event of a fire emergency. Findings Include: On November 20, 2023 at approximately 10:00 AM. record review revealed the facility failed to provide a fire watch policy in the event of a fire alarm system impairment to include the correct phone number to contact the state when a fire watch is required. The Facility Administrator confirmed these findings during interview at the time of record review.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 38040 Based on record review and interview, the facility failed to ensure the automatic sprinkler and standpipe systems are inspected, tested and maintained in accordance with NFPA 25, and records are readily available as required by 9.7.5, 9.7.7, 9.7.8 and NFPA 25. This deficient practice could affect all of the occupants in the event of a fire emergency. Findings Include: A) On November 20, 2023 at approximately 10:00 AM. record review revealed the facility failed provide documentation on the required 5 year internal pipe inspection on the automatic sprinkler system. No record of a internal pipe inspection was available at the time of survey. B) On November 20, 2023 at approximately 10:00 AM. observation revealed the facility failed to provide a sprinkler head wrench readily available and stored in the spare sprinkler head cabinet. C) On November 20, 2023 at approximately 10:00 AM. record review revealed the facility failed provide documentation of the automatic sprinkler systems required Annual and quarterly maintenance water flow tests. D) On November 20, 2023 at approximately 10:00 AM. observation revealed the facility failed to replace or re-calibrate the automatic sprinkler systems’ pressure gauge every five years. A date of 2016 was observed on the pressure gauge face. The Facility Administrator confirmed these findings during interview at the time of record review.”

“Sprinkler System - Out of Service CFR(s): NFPA 101 Sprinkler System - Out of Service Where the sprinkler system is impaired, the extent and duration of the impairment has been determined, areas or buildings involved are inspected and risks are determined, recommendations are submitted to management or designated representative, and the fire department and other authorities having jurisdiction have been notified. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the building or portion of the building affected are evacuated or an approved fire watch is provided until the sprinkler system has been returned to service. 18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) This Standard is not met as evidenced by: 38040 Based on record review and interview, the facility failed to ensure when the sprinkler system is out of service for more than 10 hours in a 24-hour period, the affected areas are evacuated or an approved Fire Watch is provided until the sprinkler system is returned to service as required by 19.3.5.1 and 9.7.5 of the LSC and 15.5.2 of NFPA 25. This deficient practice could affect all of the occupants in the event of a fire emergency. Findings Include: On November 20, 2023 at approximately 10:00 AM. record review revealed the facility failed to provide a fire watch policy in the event of a automatic fire sprinkler system impairment to include the correct phone number to contact the state when a fire watch is required. The Facility Administrator confirmed these findings during interview at the time of record review.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 38040 Based on record review and interview, the facility failed to inspect and test annually in accordance with NFPA 101, 19.7.6, 8.3.3.1 and NFPA 80, Standard for Fire Doors and Other Opening Protectives 5.2, 5.2.3. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. This deficient practice could affect all of the occupants in the event of a fire emergency. Findings Include: On November 20, 2023, at approximately 9:30 AM. record review revealed the facility failed to provide documentation for the annual inspection, testing, and maintenance on the building’s fire door assemblies in compliance with NFPA 80, 2010 edition. No door inspection records for the stairwell doors were available at the time of survey. The Facility Administrator confirmed these findings during interview at the time of record review.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 38040 Based on observation and interview, the facility failed to ensure portable space heating devices shall be prohibited in all health care occupancies. Unless used in non-sleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit as required by 18.7.8, 19.7.8. This deficient practice could affect all of the occupants in the event of a fire emergency. Findings Include: On November 20, 2023 at approximately 9:45 AM. observation revealed a portable space heater plugged into a multi-plug device at the Nursing Station. No policy for the safe and correct use of the heater was available at the time of survey. The Facility Administrator confirmed these findings during interview at the time of observation.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 38269 Based on observation, interview, and record review, the facility failed to meet the requirements for participation in Medicare/Medicaid at 42 CFR 494.60(d), Life Safety from Fire and the applicable provisions of the 2012 Edition of the National Fire Protection Agency (NFPA) 101, Life Safety Code and the 2012 Edition of NFPA 99, Health Care Facilities Code. Findings include: See specific K tags dated 11/20/2023 K-0345 K-0346 K-0353 K-0354 K-0761 K-0781”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 15195 Based on record review and interview, the facility failed to ensure home patient’s treatment sheets were reviewed at least every two months for 5 (#1, #2, #3, #4, #5) of 5 home patients reviewed, resulting in the potential failure to determine if the patient was following their dialysis prescription and/or resulting in less than optimal outcomes. Findings include: On 11/20/23 at approximately 1100, review of patient #1’s medical record revealed no treatment sheets in the record. Patient #1 was admitted on 9/12/23 and her last monthly clinic visit was 11/15/23. On 11/20/23 at approximately 1115, interview with Home Nurse Coordinator A revealed that the patient had forgotten to bring in her treatment sheets. Nurse A stated that both she and Nurse G remind patients to bring this information in every visit. On 11/20/23 at 1130, review of patient #2’s medical record revealed electronic computer print out treatment sheets dated for the months of 2021 and initialed and reviewed by Nurse A on 9/20/21. Interview with Nurse A on 11/20/23 at approximately 1145 revealed that there had been an issue with the patient bringing the computer cartridge in and/or with printing out the treatment sheets. Treatment sheets for the present year were requested but not provided. On 11/20/23 at 1200, review of patient #3’s medical record revealed manual treatment sheets dated for July 2023 and reviewed by Nurse G on 8/11/23. Interview with Nurse A, on 11/20/23 at approximately 1215, revealed that the patient’s last monthly clinic visit was on 11/10/23, but the patient did not bring in treatment sheets. Treatment sheets had not been reviewed in over three months. On 11/20/23 at 1400, review of patient #4’s medical record revealed electronic computer print out treatment sheets dated for the months of 2021 and initialed and reviewed by Nurse A on 7/15/21. Again, interview with Nurse A on 11/20/23 at approximately 1415 revealed that there had been an issue with the patient bringing the computer cartridge in and/or with printing out the treatment sheets. Treatment sheets for the present year were requested but not provided. On 11/20/23 at 1500, review of patient #5’s medical record revealed electronic computer printout treatment sheets dated for the months of 2022 and initialed and reviewed by Nurse A on 7/19/22. The next batch of treatment sheets were for March 2023 and review by Nurse A on 4/18/23 (nine months later). The subsequent batch of treatment sheets for June 2023 were reviewed and dated by Nurse A on 7/21/23 (three months later). The most recent review of treatment sheets for September and October 2023 was reviewed three months after the last review on 10/20/23 by Nurse A. On 11/20/23 at approximately 1530, interview with Nurse A verified that she was aware that patients should bring in treatment sheets at least every two months. Also, she stated that with the computer cartridge issue, she should have had the patients do a back-up manual treatment sheets or get the computer issue fixed. She also stated that the computer issue had been going on for a while. Review of the facility policy titled “Home Dialysis Training Program, dated/revised 11/2020” documented, Proper completion of patient monitoring logs and return of completed logs to the dialysis clinic at least every two months for nursing review. Electronic logs may be used if available.” This had not been done.”