Davita Greenview Dialysis

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 22960 Based on record review and interview, the facility failed to conduct exercises to test their emergency plan resulting in the potential for less than optimal outcomes for all patients in the event of an emergency. Findings include: Review of the facility’s emergency plan, revised April 2024, noted: “Emergency Drills: 1. The FA or designee, will maintain the emergency preparedness training and testing based on the facility EMP. 2. EMP training exercises: ...e. Frequency: i. The facility will conduct and/or participate in one (1) exercise to test the facility EMP at least annually, conducted opposite years (one year full-scale exercise, next year facility-based/exercise of choice: 1. Full-scale exercise that is community-based: a. Required when available b. Defined as an operation-based exercise that typically involves multiple agencies, jurisdictions, and disciplines performing functional (for example, joint field office, emergency operation centers, etc.) and integration of operational elements involved in the response to a disaster event, i.e. “boots on the ground” response activities c. Participation with any of the following i. Emergency management agency ii. Local, state, and/or federal emergency response agencies iii. Healthcare coalition. 2. Individual facility based exercise: a. Tabletop exercise that includes a group discussion led by the FA b. Scenario situation must be based on hazards relevant to facility c. Designed to challenge facility EMP ...e. Facility may choose to participate instead in a full-scale community based exercise ...f. i. Documentation is required 1. Utilize Facility Emergency Plan Activation template and document ...” On 10/30/24 at 10:30 AM, an interview with Facility Administrator “A” found they had no documentation for having performed a community based or tabletop exercise.”

“IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients. This Standard is not met as evidenced by: 29955 Based on observation and interview, the facility failed to dedicate cleaning supplies for the isolation room used for a hepatitis patient (P-6) resulting in the possibility of the spread of infectious disease to all patients receiving dialysis treatment at the facility. Findings include: On 10/29/2024 at 1140 during tour of the facility, observation occurred of the cleaning supply room. The room contained one mop and two yellow mop buckets. It was revealed the facility failed to have a dedicated mop for the isolation room used for dialysis treatment of a hepatitis B patient (P-6). On 10/29/2024 at 1150 an interview occurred with staff A, Facility Administrator. Staff A was queried about dedicated cleaning supplies for the isolation room used to treat P-6. Staff A stated, “There is a dedicated mop for the hep B room...I’m sure of it.” Staff A observed the cleaning supply room and stated, “I don’t know where the other mop is...I’m sure we had another one.” On 10/31/2024 at 0920 review of the policy titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance,” policy number 1-05-02, last revised April 2024. According to the policy, “19. Equipment and Supplies, b. ....such supplies will be labeled “isolation” and will remain in the isolation room/area or station...””

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 22960 Based on observation, interview, and record review, the facility failed to ensure the water purification system was secured resulting in the potential for unauthorized access to the water room and the potential for less than optimal outcomes for all patients receiving treatment at the time of observation. Findings include: On 10/30/24 at 9:40 AM, during an inspection of the facility with Biomed Staff “J”, the door to the water treatment room was observed to be unlocked. In addition, the keypad locks to both doors leading into the hallway which housed the unlocked water room, were observed to be non-functional. When queried at this time, Biomed Staff “J” stated that the manual lock on the water room door had been switched off, and stated that the keypad locks on the other 2 hallway doors were in need of new batteries. During an interview on 10/30/24 at 1:20 PM, Facility Manager “A” confirmed that the water room door was to remain locked at all times, and further confirmed that the other 2 keypad locks were non-functional because they needed new batteries. Review of the facility’s policy “Physical Environment” revised 4/2018 noted: “9. Systems to assure patient safety will be in place, such as a method for patients to call for help from the restrooms and exam rooms. Access to patient treatment areas, water treatment systems, supply storage and dialysis equipment is restricted to authorized personnel only. Access limitation does not preclude visitors or tours by individual(s) authorized and supervised by facility personnel.””

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 29955 Based on observation and interview, the facility failed to maintain a safe and functional environment resulting in the potential for less than optimal outcomes for all 71 patients receiving treatment at the facility. Findings include: On 10/29/2024 at 1030 during observation on the dialysis treatment floor it was observed 7 ceiling tiles were grossly stained. On 10/29/2024 at 1040 during observation on the dialysis treatment floor the drywall was noted to have gouges and nicks throughout the entire treatment floor area and missing paint. Several spackled areas were also noted and failed to have paint as a sealant allowing for moisture absorption. On 10/29/2024 at 1115 during observation on the dialysis treatment floor 6 electrical outlet covers were noted to be severely cracked and one electrical outlet cover was noted to be missing. On 10/29/2024 at 1140 during observation of the clean utility room for storage of cleaning items, a large flush hopper was observed to be dirty around the upper rim and the water was stagnant with an odor. On 10/29/2024 at 1150 an interview occurred with staff A, Facility Manager. Staff A was queried about the damaged and stained ceiling tiles, drywall gouges and nicks, exposed spackling, and the dirty hopper in the utility room. Staff A responded, “I have sent work orders and spoke to several people about things that needed to be attended to...I know my upper management has also requested assistance in repairs and replacement....As far as the hopper, I have been told that it is not an issue to have it to remain in the facility.” Staff A was then asked if the risk of water borne bacteria was ok with dialysis patients. Staff A stated, “I would think not.”. Staff A was then queried if there was a plan for repairs in the facility. Staff A stated, “Not that I have been made aware of.” On 10/29/2024 at 1400 at tour of the front waiting area was conducted. The patient bathroom in the front waiting area was observed to be filthy. The handwashing sink was pulling away from the wall. Behind the bathroom door on the interior of the patient bathroom located approximately six feet above the floor was a clump of paper products taped to the wall to keep the door hinge from hitting the wall. Stains, nicks, and gouges were noted in the walls of the patient bathroom. On 10/30/2024 at 0615 during observation a rectangular area underneath a television monitor was noted to be green. Staff E, a patient care technician, was asked why there was a green in that area. Staff E stated, “There used to be a picture there...they didn’t paint to match the wall when they removed the picture.””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 29955 Based on observation and interview, the facility failed to ensure 23 of 24 dialysis chairs were maintained and repaired resulting in the inability to clean and sanitize the chair seats and the potential for the spread of infectious agents to all 71 patients receiving dialysis treatment at the facility. Findings include: On 10/29/2024 at 1050 during observation on the dialysis treatment floor at stations 14, 15, 16, 17, and 18 the dialysis chairs without chair covers had cracks in the seat areas between 6 inches to 10 inches in length. On 10/29/2024 at 1055 an interview was conducted with staff G, registered nurse. Staff G was queried about the dialysis chairs. Staff G stated, “I feel bad for the patients because they don’t complain that often but the chairs are very uncomfortable because all the seats are broken down and the cracks in the seats keep getting bigger by the week.” On 10/29/2024 at 1540 at the end of dialysis treatment for all patients, a tour of the dialysis treatment floor dialysis chairs was conducted. Of the 24 dialysis chairs, 23 chairs had tears in the wipeable surface of the seat of the chair, exposing porus non-wipeable material. Staff A confirmed the findings at the time of observation.”

“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: 50585 Based on interview and record review, the facility failed to ensure staff followed policy and procedures for setting the dialysis treatment’s blood flow rate (BFR) as prescribed by the physician for 1 (P-4) of 2 patients, and failed to maintain the medication refrigerator according to policy and nationally recognized guidelines, resulting in the potential for adverse patient outcomes for P-4 and the potential for less than optimal outcomes for all patients receiving treatment at the time of refrigerator observations. Findings include: On 10/31/2024 at 1000, P-4’s treatment orders were reviewed, and the documentation revealed the following: On 10/12/2024, P-4 had a medication order for a BFR to run at 350 milliliters (mL)/minute (min) and a dialysate flow rate (DFR) to run at 600 mL/min. On 10/12/2024, P-4’s treatment documentation revealed BFRs and DFRs for the following times with corresponding comments: 1043 - BFR 200 mL/min and DFR of 600 mL/min with comments: “Treatment started without complications; Heparin infusion started; readjusting cuff” 1044 - BFR 200 mL/min and DFR 600 mL/min with comments: “cuff readjusted” 1105 - BFR 350 mL/min and DFR 600 mL/min with comments: “patient awake; alert; and stated no complaints at this time; nurse aware” 1203 - BFR 0 mL/min and DFR 600 with comments: “Patient awake; alert; and states no complaints at this time; Patient appears to be tolerating treatment well at this time” 1233 - BFR 200 mL/min and DFR 600 mL/min with comments: “Patient appears to be tolerating treatment well at this time” 1304 - BFR 200 mL/min and DFR 600 mL/min with comments: “Patient awake; alert; and states no complaints at this time” 1334 - BFR 200 mL/min and DFR 600 mL/min with comments: “Patient monitored; watching TV not complications; Patient awake; alert; and states no complaints at this time” 1404 - BFR 200 mL/min and DFR 600 mL/min with comments: “Patient monitored; watching TV no compilations” 1427 - BFR 200 mL/min and DFR 600 mL/min with comments: “Treatment ended” On 10/31/2024 at 1015, Facility Administrator Staff A was interviewed and was asked to clarify P-4’s BFR rate documentation with the BFR order for 10/12/2024. Staff A revealed that the Nurse would “take a verbal order from a doctor and document the BFR change in the comments section” for that time and date of treatment. According to the medical record, there was no documentation to run the BFR at a rate that varied from the prescriber’s order. On 10/31/2024 at 1030, Medical Director Staff L was interviewed and confirmed that they expected staff to follow policy and procedures and orders. On 10/29/2024 at 1040, during a tour of the facility’s medication preparation area, ten plastic bottles of a nutritional oral supplement beverage with each bottle containing 237 milliliters of fluid were observed inside the medication refrigerator on the top shelf next to a box of influenza vaccine syringes, 2024/2025 season. The influenza vaccine was located on the back shelf and not stored in a designated container. A box of hepatitis b vaccine vials was observed in the medication refrigerator on the third shelf (bottom shelf) next to the right wall of the refrigerator and not stored in a designated bin. On 10/30/2024 at 1400, interviewed Facility Administrator Staff B. When asked if they had a policy for storing nutritional supplements in the refrigerator, and Staff B said “no.” According to the facility’s policy” Medications Requiring Refrigeration,” dated 12/2022, the policy revealed that “Medications that require refrigeration are stored in the facility refrigerator designated for medications only” and “Per Centers for Disease Control (CDC), place vaccines in center refrigerator space, contained in original packaging, inside designated storage trays positioned 2-3 inches from refrigerator walls.” Additional review of the document “Vaccine Storage and Handling Toolkit” developed by the U.S. Centers for Disease Control and Prevention, dated March 29th, 2024, revealed “Food and beverages should never be stored in the unit with vaccines. If other biologics (medications which may include vaccines, growth factors, immune modulators, monoclonal antibodies) are stored in the unit, vaccines should be stored on the shelf above them.” Additional review of the document developed by the American Society of Health-system Pharmacists titled “Technical Assistance Bulletin on Hospital Drug Distribution and Control,” dated November 1981, the bulletin indicated “Medications stored in a refrigerator containing items other than drugs should be kept in a secured, separate compartment.” Based on observation, interview, and record review, the facility failed to maintain the medication refrigerator according to policy and nationally recognized guidelines, resulting in the potential of spreading infectious agents to the 24 patients receiving treatment at the time of observation. Findings include:”