Davita Grosse Pointe Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 15195 Based on observation, interview, and record review, the facility failed to take measures to prevent healthcare associated infections for the entire 83 in-center patient census and all 13 patients at Skilled Nursing Facility “A”, resulting in the risk for transmission of infectious agents among patients who receive dialysis treatments from the provider. Findings include: See specific tags: V-111 Failed to maintain a sanitary environment V-113 Failed to perform hand hygiene V-115 Failed to use personal protective equipment correctly V-122 Failed to completely disinfect the dialysis station V-147 Failed to disinfect central venous catheters during dressing change, initiation and discontinuation of treatment”

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 22960 Based on interview and record review, the facility failed to develop arrangements with other facilities to receive patients in the event of an emergency, potentially affecting all patients receiving hemodialysis treatment at Skilled Nursing Facility (SNF) “A”, resulting in an increased potential for harm. Findings include: On 10/24/24 at 10:00 AM, the Emergency Plan for SNF “A” was reviewed with Facility Administrator (FA) “J”. When queried about a transfer agreement or contract with other facilities to receive patients if the facility was unable to perform hemodialysis treatments, FA “J” stated that it was the responsibility of the nursing home to arrange those services. FA “J” confirmed that there was no transfer agreement located in their Emergency Plan binder. On 10/24/24 at 10:15 AM, Nursing Home Administrator “V” was queried about a transfer agreement if the residents in the nursing home were unable to receive hemodialysis in the dialysis den of the facility. Nursing Home Administrator “V” stated there was no written policy, but if they were unable to perform dialysis in the facility, they would just send the resident to the hospital.”

“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: 38269 Based on observation and interview, the facility failed to monitor and maintain a sanitary environment to minimize the transmission of infectious agents at both the dialysis facility and at Skilled Nursing Facility (SNF) “A”, resulting in an increased risk of infection to all 24 patients receiving dialysis treatment at time of observation. Findings include: On 10/22/2024, an observational tour was conducted between the hours of 1030 and 1200. While touring, the treatment room floor was observed to have discarded plastic supply wrappers, dialysis fluid and tubing caps, paper clips, and accumulated dust and debris scattered in and around patient treatment stations. Three of four observed trash cans were observed to be overflowing with trash. Discarded paper hand towels were observed on the floor around two of three designated clean hand washing sinks. On 10/23/2024, between 0935 and 1145, 12 of 24 (stations #1, 4, 5, 9, 11, 12, 13, 14, 17, 22, 23, 24) patient stations were observed to have patient belongings setting on the treatment floor next to the dialysis delivery machines within the treatment station. Findings were reviewed with and acknowledged by the Facility Administrator (Staff A) at the time of observations and again during an interview conducted on 10/24/2024 at 1100. 22960 On 10/24/24 at 9:30 AM, the “clean” sink located in the treatment area of Skilled Nursing Facility (SNF) “A” was observed. The sink countertop surface was warped and rough, with missing laminate. The surface of the countertop was no longer smooth and easily cleanable. In addition, the stainless steel sink basin was rusted. On 10/24/24 at 10:30 AM, Maintenance Supervisor “U” confirmed that the sink and countertop needed to be replaced for proper sanitization.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 38269 Based on observation, interview, and record review, one (Staff H) staff members failed to perform hand hygiene during 6 of 6 opportunities for hand hygiene following removal of gloves, resulting in the potential for transmission of infectious agents to the 18 patients receiving treatment at the time of observation. Findings include: On 10/23/2024, Patient Care Technician Staff H, was observed performing patient care between 1111 and 1126 at station #15. Staff H failed to perform hand hygiene in between glove exchanges in 6 of 6 opportunities observed within the timeframe noted above. At 1130, Staff H was informed of the above observations and queried what the policy was regarding hand hygiene after glove removal. Staff H was able to verbalize that hand hygiene was required after removal of gloves and acknowledged their deficient practice. On 10/23/2024 at 1135, the above finding was reviewed and acknowledged by the Regional Operations Director (Staff A), as well as the Facility Administrator (Staff B). Both agreed that Staff H failed to follow the facility policy. Review of Facility Policy: 1-05-01 Infection Control for Dialysis Facilities (revised April 2023) stated, HAND HYGEINE 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact, e. after interacting with wall boxes (i.e., plugging/unplugging acid/bicarb lines form dialysis machine, changing acid types, when exchanging a dialysis machine) f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 27408 Based on observation, interview and record review, the facility failed to ensure that all staff wear personal protective equipment (PPE) properly in the treatment area, resulting in the potential to spread infectious agents among the 22 patients receiving dialysis treatment at the time of observation. Findings include: On 10/23/24 at 1115, Staff K was observed at station #14 taking a patient off dialysis with the PPE sleeves pushed up and arms exposed. On 10/23/24 at 1117, an interview with Staff K revealed that she was not aware that she needed to pull the arms of the PPE gown down for protection. On 10/23/24 at 1130, Staff L was observed at station #24 putting a patient on dialysis, with the PPE sleeves pushed up and arms exposed. On 10/23/24 at 1132, an interview with Staff L, revealed that she had “always done this” and “no one has ever said anything to me”. On 10/23/24 at 1445, review of policy “Infection Control for Dialysis Facilities”, policy: 1-05-01 dated/revised 4/2023 on page 2 stated under “PPE (i.e. gown, gloves, eye protection, face shield), 5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas”.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 15195 Based on observation, interview, and record review, the facility staff failed to disinfect the entire dialysis station following dialysis treatments for 1 (station #13) of 2 dialysis stations observed, resulting in the potential for transmission of infectious pathogens to all 22 patients receiving treatment at the time of observation. Findings include: On 10/22/24 at approximately 1015, observation of Tech H disinfecting station #13 revealed that he did not disinfect the interior of the prime container (intravenous fluid waste bucket on the dialysis machine) or disinfect the back shelf of the station. Interview with Tech H, on 10/22/24 at approximately 1020 revealed that he had completed disinfecting the station and he stated that he forgot to disinfect those areas. Review of the facility policy titled “Infection Control for Dialysis Facilities, #1-05-01, revised 4/2023” documented, “At the end of each treatment, the dialysis station will be cleaned and disinfected... Priming containers are to be emptied prior to disinfection.””

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 15195 Based on observation, interview, and record review, the facility failed to ensure staff took measures to reduce the risk for central venous catheter (CVC) bloodstream infections for patients observed with CVC’s in 2 (station #2, #11) of 5 observations, resulting in the increased risk for bloodstream infections for the 22 patients with a CVC being served by this facility. Findings include: On 10/23/24 at 1006, Tech R was observed at station #2 discontinuing a CVC without wiping exterior of the connection before disconnecting the blood lines or prior to connecting the syringes and administrating normal saline. Interview with Tech R, on 10/23/24 at approximately 1015 revealed that she had done ten (10) other disconnections while in training without wiping or disinfecting the exterior of the blood lines prior to connecting and administering normal saline. On 10/23/24 at approximately 1030, interview with the Nurse Facility Administrator B, revealed that she needed to check the policy to see what was required. On 10/23/24 at approximately 1430, interview with the Clinical Coordinator N revealed that he thought staff should disinfect the exterior line connection prior to connecting syringes. The next day on 10/24/24 at approximately 1000, Tech S was observed at station #11 discontinuing a CVC without wiping exterior of the connection before disconnecting the blood lines, or prior to connecting syringes and administering normal saline. On 10/24/24 at 1300, interview with the Medical Director revealed that staff should disinfect the CVC blood lines prior to disconnection, and/or just prior to syringe connection and administration of normal saline. He stated that the language was not clear in the policy and procedure. Review of the facility policy and procedure titled “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure, #1-04-02B, revised 10/2024” documented, “Upon Completion of Dialysis... Clamp venous catheter limb and blood line. Aseptically disconnect venous blood line and connect 10 ml syringe with normal saline to the venous catheter hub...” There was no mention of wiping or disinfecting prior to connecting the normal saline syringe. On 10/24/24 at approximately 1300, review of quality outcome measures in the Quarterly and Annual Dialysis Facility Report (DFR) with the Medical Director, revealed that the facility had higher than average CVC rate and a higher hospitalizations with septicemia (blood infection) rate when comparing rates with the state, network, and U.S. The Medical Director stated he hadn’t seen the recent DFR reports and stated that the facility was working on those outcome measures. Review of “ESRD Core Survey Observations of Hemodialysis Care and Infection Control Practices, Centers for Medicare & Medicaid Services ESRD Core Survey Version 1.6” documented, “Discontinuation of Dialysis with Central Venous Catheter, ...Close CVC clamps; Disinfect CVC connections with appropriate antiseptic. May perform one or both: External disinfection wiping exterior of connections before disconnecting blood lines; or Open hub disinfection wiping threads and top of open CVC hubs, removing any residue/blood after disconnecting blood lines; Closed connector devices: wiping exterior of connections before disconnecting blood lines (V147), (then) Disconnect blood lines aseptically...” This had not been done.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 15195 Based on interview and record review, the facility failed to implement a plan of care for 1 (#2) of 1 new patients admitted, resulting in the potential for un-recognized and un-met patient needs. Findings include: Record review on 10/24/24 revealed that patient #2 was newly admitted to the facility on 9/5/24 as an end stage renal disease patient. He had been dialyzing at the facility over 30 days and for more than thirteen treatments. He did not have an interdisciplinary team plan of care (IDT-POC) documented. Interview with Facility Administrator B, on 10/23/24 at approximately 1600, revealed that she would have to check with the Social Worker, the team member who coordinated the IDT-POC. On 10/24/24 at approximately 1100, interview with Social Worker P revealed that the team had started their assessments but had not met to do the IDT-POC. A review of the facility policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care, #1-14-01, revised 10/2024” documented, “A comprehensive assessment will be conducted on all new patients within 30 calendar days (or within 13 treatments) for new patients...””

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 27408 Based on record review and interview, the facility failed to implement the plan of care within 15 days of the interdisciplinary assessment for 2 (#12 and #13) of seven patients records reviewed, resulting in the potential for unrecognized and unmet patient needs. Findings include: On 10/25/24 at 1030, during record review for P-12, it was revealed the initial interdisciplinary plan of care was dated 01/17/24. Staff J signed that the nursing portion was completed on 02/17/24, 30 days after the meeting. Staff J confirmed these findings. On 10/25/24 at 1045, during record review for P-13, it was revealed the initial interdisciplinary plan of care was dated 08/03/24. Staff J signed that the nursing portion was completed on 08/26/24, 23 days after the meeting. Staff J confirmed these findings. On 10/25/24 at 1230, review of the policy titled, “Comprehensive Interdisciplinary Assessment/Plan of Care (CIPA/POC),” policy 12-16-01, revision date of 04/2024. According to the policy, “5. Frequency of CIPA/POC completion, e., The POC (plan of care) following will be implemented with 15 days in the response to completion of any re-assessment...”

“H-RECORDKEEPING SYSTEM CFR(s): 494.100(c)(2) (2) The dialysis facility must maintain a recordkeeping system that ensures continuity of care and patient privacy. This includes items and services furnished by durable medical equipment (DME) suppliers referred to in §414.330(a)(2) of this chapter. This Standard is not met as evidenced by: 27408 Based on record review and interview, the facility failed to keep records of items furnished by the durable medical equipment (DME) supplier for all 18 of 18 home patients, which could result in the potential for unidentified lack of supplies needed for continuity of care for all home peritoneal dialysis (PD) patients. Findings include: On 10/24/24 at 1000, during review of medical records for all 15 patients who perform home peritoneal dialysis, it was noted that the records lacked documentation of supplies furnished by the DME supplier. On 10/24/24 at 1015, Staff D was queried about the records of supplies ordered by the patient. She replied, “I can look at them online”. Staff D was queried as to if she maintained a log, or other such record of supplies ordered from the DME supplier for the 15 patients. Staff D replied, “No, I didn’t know. I do look at them yearly, but I didn’t know I had to save them.” Staff I was also present and stated that they would “start monitoring the patients orders”.”

“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: 15195 Based on observation, interview, and record review, the Medical Director failed to ensure staff gave intravenous Venofer (iron) medications correctly for 1 (station #17) of 2 medication observations, resulting in the potential for unsatisfactory outcomes for any patient receiving intravenous Venofer. Findings include: On 10/22/24 at 1025, Registered Nurse Staff Q was observed giving intravenous Venofer 50 milligrams (mg) within fifteen seconds. On 10/22/24 at approximately 1050, Staff Q was queried about Venofer administration and she was not aware of the drug manufacture’s direction for administration or the facility policy and procedure. Interview with Clinical Coordinator Staff N, on 10/23/24 at approximately 1430, revealed that he usually gives Venofer 100 mg over 2 to 5 minutes. Review of the facility policy and procedure titled “Preparation and Administration of Parenteral Medications (Non-ESA, Non-Parsabiv), # 1-06-01A, revised 4/2024” documented, “Inject medication over the time specified in the package insert. For example, per package insert, Iron Sucrose (Venofer) is administered undiluted by slow intravenous push (IVP) at a rate of 100 mg over 2 to 5 minutes.” Interview with the Medical Director, on 10/24/24 at 1300, revealed that he expected staff to follow the facility policies and procedures.”