Davita Mississippi Gateway Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility 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. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 22676 Based on observation, staff interview, and policy review, the facility failed to ensure expired medication was removed from the emergency cart as to not be available for use. Two of four syringes of Epinephrine Injection in the emergency cart expired. Failure to remove expired medication from the cart can lead to expired medications being given to all 29 patients in case of an emergency. Findings include: During review of the emergency equipment cart and contents of the emergency cart on 01/28/25 at 9:15 AM two of four syringes of Epinephrine Injection (used to treat severe allergic reactions) Lot # 2FM567, was observed to have expired in August 2024. Interview with the facility Administrator on 01/28/25 at 9:15 AM, confirmed the syringes of Epinephrine were found expired in the cart used for emergency patient conditions. Review of facility’s policy titled “Emergency Equipment Checks” revised April 2022, indicated, “...3. The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional. . .Weekly...Emergency cart (crash cart) is clean, operational and supplies/medications have not expired.” Review of the form titled “Weekly emergency medication checklist” revealed the cart was last checked on 01/27/25, the date was not initialed to determine who checked the emergency crash cart. Review of facility’s policy titled, “Medication Policy,” revised November 2023, indicated, “...13. Do not use any medication that has been stored improperly or has expired...31. Medications are ordered and replaced prior to expiration.””

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 26190 Based on record review, interview and policy review, the facility failed to document completion of emergency preparedness (EP) training for one of three facility staff’s (Registered Nurse [RN]) personnel records that were in the reviewed sample and failed to hold quarterly fire drill exercises. Findings include: Review of RN’s (hired by the facility on 12/11/18) personnel file indicated no documentation of EP training during 2024. Review of the facility’s form titled, “Facility Emergency Preparedness Training Form” revised 03/01/23 indicated, on 03/26/24 the Facility Administrator completed training on Emergency Preparedness for eight staff members. The eight staff members listed did not include RN. Review of the facility’s form titled, “Fire Safety Drill” undated indicated, on 05/31/24 was the only fire drill held in 2024. During an interview on 01/29/25 at 9:00 AM with the Manager Clinical Services (MCS), he/she confirmed that RN was not included in the EP training that was held on 03/26/24 and he/she was not aware of any additional EP training that was provided to RN. The MCS also confirmed the facility completed one fire drill (05/31/24) during 2024 instead of the four required as stated in their policy. The MCS did not know why the fire drills were not completed. Review of the facility’s policy, “Facility Emergency Management Plan,” revised 10/24 stated, “ ...Training and Education Emergency Management Plan ...1. The FA (Facility Administrator), or designee, is responsible to provide training of EMP (Emergency Management Plan). A. Teammates: 1. Annually 1. Policy Facility Emergency Management Plan 2. Appropriate hazard policies, per HVA 3. Clinical emergency policies 4. Facility specific emergency response procedures ...ii. Quarterly 1. Fire Safety Preparedness ...v. Document training in teammate file. 1. Training/In-service Documentation Form ...””

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 26190 Based on record review, interview and policy review the facility failed to document in the patient’s medical record the completion of emergency preparedness (EP) training for five of five sampled in-center patients (Patient (P) 1, P2, P3, P4, P5). Findings include: 1. Review of P1’s face sheet that was provided by facility staff revealed P1 was admitted to the facility on 11/08/24 with one of his/her diagnosis being End Stage Renal Disease (ESRD). Review of P1’s electronic medical record (EMR) indicated no documentation of EP training being provided to P1. 2. Review of P2’s face sheet that was provided by facility staff revealed P2 was admitted to the facility on 10/17/22 with one of his/her diagnoses being ESRD. Review of P2’s EMR indicated no documentation of EP training being provided to P2. 3. Review of P3’s face sheet that was provided by facility staff revealed P3 was admitted to the facility on 08/09/23 with one of his/her diagnoses being ESRD. Review of P3’s EMR indicated no documentation of EP training being provided to P3. 4. Review of P4’s face sheet that was provided by the facility staff revealed P4 was admitted to the facility on 09/25/24 with one of his/her diagnoses being ESRD. Review of P4’s EMR indicated no documentation of EP training being provided to P4. 5. Review of P5’s face sheet that was provided by facility staff revealed P5 was admitted to the facility on 10/17/22 with one of his/her diagnoses being ESRD. Review of P5’s EMR indicated no documentation of EP training being provided to P5. During an interview on 01/28/25 at 10:30 AM with the Manager Clinical Services (MCS), he/she explained the staff member in charge of completing the EP education with patients was no longer employed at the facility. The MCS said the facility reviewed EP with all patients when they were admitted to the facility and once a year (usually in April) thereafter. The MCS confirmed there was no documentation in the patients’ EMR regarding them receiving EP education. The MCS provided a copy of the EP information that should be provided to patients titled, “Emergency Preparedness Plan”. Review of the facility’s policy, “Facility Emergency Management Plan” revised 10/24 stated, “ ...Training and Education Emergency Management Plan ...b. Patients i. Annually ...2. Personal/family/pet preparedness, to include but not limited to: a. What to do if an emergency occurs away from the facility i. Provide local emergency and hazard preparedness information ii. Additional fuel for vehicle iii. Additional cash on hand iv. Copies of: 1. Dialysis treatment records 2. Medication list 3. Medical records 4. Immunizations v. Prepare to care for self: At least 72 hours ...vi. Facility dietician will provide patients with a three day emergency diet to follow at home ...””

“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: 22676 Based on observation, staff interview, and policy review, the facility failed to ensure the policies for infection control were followed by all staff in the facility two of six computer carts were pushed back between hemodialysis machines in a blood splash/splatter area. In addition, one of two bottles of Chlorine Peroxide strips was not dated when they opened it. There was also one bottle of heparin observed to be opened but not dated. In addition, there were 26 out of 26 syringes with clear liquid on a desk in the treatment area left unattended. Failure of staff to follow these infection control guidelines, date medications and supplies when open and securing filled syringes put all 29 patients at risk for increased infections and complications from tampered with syringes. Findings include: During a tour of the treatment area on 01/27/25 at 9:15 AM it was observed that the computer cart with the monitor and keyboard was pushed back in between the dialysis machines in an area where blood and infectious matter could contaminate the cart and contents of the cart. The computer cart was shared between two stations of six computer carts being used during patient treatments were pushed back into the splash/spatter zone of the patient station. A bottle of Water Check Chlorine Peroxide test strips was opened and not dated to indicate the date it was opened. The manufactures instruction on the side of the bottle states “strips expire 3 months from opening”. A bottle of Heparin 30,000 units (a blood thinning agent) was observed on the desk in the treatment. It was opened but not dated as when it was opened. Review of the manufactures instruction for Heparin reveal it expires “28 days from opening.” There were 26 syringes with clear liquid observed on a desk in the treatment area unattended which could lead to tampering. In an interview with Patient Care Technician (PCT)2 on 01/24/25 at 9:15 AM he/she stated that the computer cart is on wheels and that staff push it back between the patient hemodialysis machines. He/she further stated the computer, and cart is considered clean and acknowledged the cart is in an area of potential blood contamination when pushed back between the dialysis machines. He/she acknowledged the bottle of Water Check Chlorine Peroxide test strips was opened and ¾ full, and the bottle was not dated when opened. He/she also acknowledged the Heparin was not dated when it was opened. Review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, indicated, “. . .8. Supplies will be stored in a manner that maintains their integrity. Expiration date and package integrity will be verified prior to use....12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e., used or brought to the station) ...15. The chair-side cart, terminals mounted on the counter, monitor and keyboard are considered clean areas.” Review of the facility’s policy titled, “Medication Policy,” dated October 2023, states “ ... medications with preservatives are dated and initialed once opened.””

“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: 22676 Based on observation, interview, and policy review, the facility failed to restrict access to the water purification system to only authorized users on one of three survey days. Failure to restrict access to the water treatment area had the potential to negatively impact the safety and well-being of all 29 in-center dialysis patients receiving treatments at this facility. Findings include: During the flash tour observation on 01/27/25 at 9:10 AM, it was revealed the door designated as the entrance to both the water purification system and storage system was secured by a keyless entry lock. Upon entering the water treatment area, the door was found standing open and there were no staff in the water room. During an interview on 01/27/25 at 9:10 AM the facility Administrator confirmed the door was left standing open and that no staff were in the water room. Review of facility’s policy titled, “Water Treatment System Minimum Component Requirement” dated October 2021. States “Access to the water treatment system should be restricted to those personnel/trained teammates responsible for monitoring, maintenance of the system and supply ordering ...””

“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: 22676 Based on review of glucometer logs, interview, review of glucometer policy, and manufacturer’s instructions, the facility failed to ensure the glucometer was in the correct control range and follow manufacturer’s instructions for one of one glucometer used in the facility. This deficient practice had the potential to provide incorrect blood glucose results and could result in inaccurate glucose level results for all 29 patients receiving care at the facility. Findings included: Review of electronic “Blood Glucose Logs” for the treatment unit, from 01/02/25 through 01/24/25 revealed the following: Review of the meter for the treatment unit labeled “facility 00204” for January revealed: On 01/08/25, the recorded acceptable low control range was 90-120, the recorded low control was 126. On 01/10/25, the recorded acceptable low control range was 90-120, and the recorded low control was 168. The acceptable high control was 284-384 and the control results was recorded as “HI”. On 01/24/25, the acceptable control was 93-125, the recorded control was documented as being 134. During an interview on 01/27/25 at 1:15 PM, the Facility Administrator confirmed the findings and agreed the staff did not repeat the low-level and high-level control as required by the manufacturer’s instruction. Review of the facility’s policy titled, “Blood Glucose Monitoring Device,” dated 12/19, revealed, under “Quality Control (QC)” section revealed, “QC procedures are performed according to manufactures instruction ...” Review of the “Embrace Pro” blood glucose monitoring system manufactures instruction revision, date 09/2020, revealed, “ ...p. eleven, if the “test fall outside the range printed on the test strip vial, repeat the test ...””

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 26190 Based on record review, interview, and policy review, the facility failed to follow the patient’s plan of care by addressing the care provided by the interdisciplinary team and monitoring the patient’s medical status throughout the dialysis treatment for four of five sampled in-center patients (P1, P3, P4 and P5). Failure to follow the plan of care had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the all 29 patients receiving in-center dialysis treatments at this facility. Findings include: 1. Review of P1’s electronic medical record (EMR) revealed P1’s pre-treatment nursing assessment was not completed within an one hour time period of beginning of their dialysis treatment. Review of one of six “Post Treatment” flowsheets from 01/13/25 through 01/24/25, in the EMR indicated the following: On 01/17/25, there was a dialysis treatment start time of 12:12 PM with a pre-treatment nursing assessment time of 1:46 PM, a time period of one hour and 34 minutes between the treatment start and the nursing assessment. There was no documented rationale for the delayed nursing assessment. 2. Review of P3’s EMR revealed P3’s pre-treatment nursing assessment was not completed within an one hour time period of beginning their dialysis treatment. Review of one of six “Post Treatment” flowsheets from 01/13/25 through 01/24/25, in the EMR indicated the following: On 01/13/25, there was a dialysis treatment start time of 11:20 AM with a pre-treatment nursing assessment time of 1:51 PM, a time period of two hours and 31 minutes between the treatment start and the nursing assessment. There was no documented rationale for the delayed nursing assessment. 3. Review of P4’s EMR revealed P4’s pre-treatment nursing assessment was not completed within an one hour time period of beginning their dialysis treatment. Review of one of five “Post Treatment” flowsheets from 01/13/25 through 01/22/25, in the EMR indicated the following: On 01/13/25, there was a dialysis treatment start time of 11:30 AM with a pre-treatment nursing assessment time of 1:45 PM, a time period of two hours and 15 minutes between the treatment start and the nursing assessment. There was no documented rationale for the delayed nursing assessment. 4. Review of P5’s EMR revealed P5’s pre-treatment nursing assessment was not completed within an one hour time period of beginning their dialysis treatment. Review of one of six “Post Treatment” flowsheets from 12/04/24 through 01/10/25, in the EMR indicated the following: On 12/04/24, there was a dialysis treatment start time of 10:39 AM with a pre-treatment nursing assessment time of 12:12 PM, a time period of one hour and 33 minutes between the treatment start and the nursing assessment. There was no documented rationale for the delayed nursing assessment. During an interview on 01/29/25 at 10:49 AM, the Manager Clinical Services (MCS) confirmed there were instances where the pre-treatment nursing assessment was not completed within the one hour timeframe from dialysis treatment start. The MCS did not know why this was occurring. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and nursing assessment,” revised 04/24 revealed, “ ...Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment ...Intradialytic Data Collection/Assessment ...8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one hour of dialysis treatment initiation ...””

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 26190 Based on record review, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for four of five sampled in-center patients (P1, P3, P4 and P5). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for all 29 patients receiving in-center dialysis treatments at this facility. Findings include: 1. Review of P1’s electronic medical record (EMR) revealed a prescribed blood flow rate (BFR) 350 milliliters per min (ml/min). Review of one of six “Post Treatment” flowsheets from 01/13/25 through 01/24/25, in the EMR indicated the following: On 01/24/25, the BFR was documented at 200 ml/min from 1:28 PM until 3:33 PM. There was no documented rationale for the change to the prescribed BFR. 2. Review of P3’s EMR revealed a prescribed BFR 450 ml/min. Review of one of six “Post Treatment” flowsheets from 01/13/25 through 01/24/25, in the EMR indicated the following: On 01/20/25, the BFR was documented at 425 ml/min at 11:00 AM until 2:15 PM. There was no documented rationale for the change to the prescribed BFR. 3. Review of P4 ‘s EMR revealed a prescribed BFR 350 ml/min. Review of one of five “Post Treatment” flowsheets from 01/13/25 through 01/22/25, in the EMR indicated the following: On 01/20/25, the BFR was documented at 300 ml/min at 11:31 AM until 2:10 PM. There was no documented rationale for the change to the prescribed BFR. 4. Review of P5 ‘s EMR revealed a prescribed BFR 450 ml/min. Review of one of six “Post Treatment” flowsheets from 12/15/24 through 01/10/25, in the EMR indicated the following: On 12/16/24, the BFR was documented at 350 ml/min at 12:29 PM until 1:59 PM. On 01/06/25, the BFR was documented at 395 ml/min at 12:29 PM until 2:04PM. There was no documented rationale for the change to the prescribed BFR. During an interview on 01/28/25 at 3:00 PM, the Manager Clinical Services (MCS) confirmed the above findings, stating the dialysis prescription has to be followed. The MCS said if the patient cannot be run at the dialysis prescription the reason why should be documented in the patient’s medical record. During an interview on 01/29/25 at 9:10 AM with Certified Clinical Hemodialysis Technician (CCHT) 1, stated if there was a change in the BFR, the change should be discussed with the nurse and the reason for the change documented in the patient’s medical record. During an interview on 01/29/25 at 9:15 AM with Registered Nurse (RN), stated the nurse should be notified of any changes in the BFR and the reason for the change should be documented in the patient’s medical record. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and nursing assessment,” revised 04/24 revealed, “ ...Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient’s dialysis treatment, monitoring during treatment and for reviewing the patient’s response to the treatment ...Intradialytic Data Collection/Assessment ...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the license nurse informed ...””

“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: 22676 Based on observation, interview, and policy review, the facility failed to restrict access to the medical record storage system to only authorized users on one of three survey days. In addition, the facility failed to ensure white out correction tape was not used on one of two water treatment records reviewed. Failure to restrict access to the storage area medical records had the potential to negatively impact on all 29 patients receiving dialysis by failure to prevent unauthorized users from their health and personnel information. Failure to prevent use of white out corrections tape in the corrections of records has the potential to affect the release of information for all 29 patients receiving treatments at this facility. Findings. On arrival at the dialysis unit the front reception on 01/27/25 at 8:20 AM, area was found unattended with the door to the area standing open, the surveyor entered the area, and medical records could have freely been removed and reviewed. The front of the reception area was also enclosed with glass. All 29 patients’ medical records were observed to be stored in open wooden shelving without doors, with the patient’s name visible to anyone sitting in the lobby. Review of the “Water Treatment Record” on 01/27/25 at 2:30 PM, white out correction tape was observed to be used to obliterate the recording results recorded on four lines on the log. In an interview with the Administrator on 01/27/25 at 8:30 AM, confirmed the medical records were unsecured and visible from the lobby and the facility failed to ensure the records were stored according to policy. In an interview with the Administrator on 01/27/25 at 2:30 PM, confirmed white corrections tape was used to correct the waterlog entries and the staff failed to follow the facility policy. Review of the facility’s policy titled, “Administrative, Technical and Physician Safeguard for Protected Health Information,” dated June 2023, states “Medical records must be locked in a drawer or filing cabinet when not in use.” Review of the facility’s policy titled, “Medical Records Corrections,” dated October 2023 stated, “No paper medical record entry is to be erased (including the use of corrections fluid), obliterated, altered, or destroyed ...””