Usrc Ellisville 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: 17026 Based on record review and staff interview, the facility staff failed to conduct a full scale or table top emergency preparedness exercise. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 43. Findings included: 1. Review of the facility’s emergency preparedness documentation showed it did not contain information that showed staff conducted a full scale or table top emergency preparedness exercise. 2. During an interview on 11/13/24 at 1:07 PM, the clinical specialist said she could not find documentation that showed staff completed a full scale or table top emergency preparedness exercise.”

“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: 17026 Based on observations and staff interview, the facility staff failed to wear gloves when they adjusted the dialysis machines during three (station # 2, # 5, and # 17) observations and failed to not potentially cross contaminate the base of the dialysis machine during one (station # 17) observation. This had the potential to effect all patients on dialysis and cause an increase in cross contamination. The facility census was 43. Findings included: 1. Observation on 11/12/24 at 1:48 PM showed Certified Clinical Hemodialysis Technician (CCHT) ( E) adjusted the dialysis machine at station # 17 without gloves on her hands. 2. Observation on 11/12/24 at 2:17 PM showed staff (H) rested her foot on the base of the dialysis machine at station # 17 and potentially contaminated the dialysis machine with floor contaminants. 3. Observation on 11/12/24 at 3:34 PM showed CCHT (E) adjusted the dialysis machine at station # 5 without gloves on her hands. 4. Observation on 11/12/24 at 3:51 PM showed CCHT (C) adjusted the dialysis machine at station # 2 without gloves on her hands. 5. During an interview on 11/13/24 at 1:07 PM the clinical specialist said staff should wear gloves when they adjust the dialysis machines and staff should not rest their foot on the base of the dialysis machine.”

“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: 17026 Based on observations and staff interview, the facility staff failed to fully disinfect the dialysis station by not disinfecting the chase wall (wall that houses the water distribution system) behind the station during three (station # 2, # 3, and # 11) station disinfection observations. This had the potential to effect all patients on dialysis and cause an increase in cross contamination. The facility census was 43. Findings included: 1. Observation on 11/12/24 at 12:56 PM showed Certified Clinical Hemodialysis Technician (CCHT) (B) disinfected station # 2 but did not disinfect the chase wall behind the station. 2. Observation on 11/12/24 at 2:20 PM showed CCHT (E) disinfected station # 11 but did not disinfect the chase wall behind the station. 3. Observation on 11/12/24 at 2:23 PM showed CCHT (B) disinfected station # 3 but did not disinfect the chase wall behind the station. 4. During an interview on 11/13/24 at 1:07 PM, the clinical specialist said staff should disinfect the entire station including the chase wall behind the station during station disinfection.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to provide the Hepatitis (inflammation of the liver) B vaccine to three (Patient # 8, # 31, and #32) patients that requested it and failed to obtain consent or vaccine declination from five (Patient # 11 # 13, # 18, # 20, and # 23) patients out of five clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 43. Findings included: 1. Review of the facility’s Hepatitis B summary report showed Patients’ # 18, # 31, and # 32 requested the Hepatitis B vaccine but had not received it from staff. Further review of the facility’s Hepatitis B summary report showed staff did not obtain consent or vaccine declination from Patients’ # 11 # 13, # 18, # 20, or # 23. 2. During an interview on 11/12/24 at 8:40 AM, the clinical specialist said staff were behind on some of the Hepatitis B vaccines for some patients and staff need to ensure they obtain consent or vaccine declination from all patients.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 17026 Based on observations and staff interview, the facility staff failed to ensure six vials of medication were not expired. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 43. Findings included: 1. Observation on 11/12/24 at 11:21 AM of the medication area showed six vials of Cefepime (antibiotic medication) that expired 7/31/24. 2. During an interview on 11/13/24 at 1:07 PM, the clinical specialist said staff need to ensure the medications were not expired.”

“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: 17026 Based on observations and staff interview, the facility staff failed to ensure a sanitary and clean water room, failed to conduct the monthly fire extinguisher checks for four out of four facility fire extinguishers, and failed to maintain a clean laboratory refrigerator. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 43. Findings included: 1. Observation of the water room on 11/12/24 at 11:12 AM showed an approximately three feet by two feet area of brown rust on the floor below the reverse osmosis machine. Further observation showed an approximately one foot diameter floor drain in the corner of the water room with brown, black, and yellow discoloration around the edges. Observation also showed spills and stains on the top and sides of the acid mixer. 2. Observation on 11/12/24 at 11:01 AM of the fire extinguisher near the facility conference room showed staff completed the most recent monthly check on 8/12/24. Further observation of the other three fire extinguishers in the facility showed staff completed the most recent monthly check on 8/12/24. 3. Observation on 11/12/24 at 11:15 AM showed the facility laboratory refrigerator had yellow and brown spills on the inside at the bottom of the refrigerator. 4. During an interview on 11/12/24 at 1:07 PM, the clinical specialist said staff need to ensure they conduct the monthly fire extinguisher checks, maintain a clean water room, and maintain a clean laboratory refrigerator.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to complete an initial care plan within 30 days for two (Patient # 18 and # 36) patients out of five clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 43. Findings included: 1. Review of the clinical record for Patient # 18 showed the patient started on dialysis treatment on 9/12/24 but staff did not complete the initial care plan for the patient. 2. Review of the clinical record for Patient # 36 showed the patient started on dialysis treatment on 10/22/24 but staff did not complete the initial care plan for the patient. 3. During an interview on 11/13/24 at 9:44 AM, the clinical specialist said staff started both of the initial care plans but had not completed the care plans yet.”

“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: 17026 Based on record review and staff interview, the facility staff failed to conduct the initial nursing assessment within one hour of a patient starting on dialysis treatment for two (Patient # 18 and # 41) patients out of five clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 43. Findings included: 1. Review of the treatment flow sheet dated 11/5/24 for Patient # 41 showed staff started the patient on dialysis treatment at 9:53 AM but did not conduct the pre nursing assessment until 12:16 PM. 2. Review of the treatment flow sheet dated 11/7/24 for Patient # 41 showed staff started the patient on dialysis treatment at 10:02 AM but did not conduct the pre nursing assessment until 1:51 PM. 3. Review of the treatment flow sheet dated 11/2/24 for Patient # 18 showed staff started the patient on dialysis treatment at 9:00 AM but did not conduct the pre nursing assessment until 10:49 AM. 4. Review of the treatment flow sheet dated 10/31/24 for Patient # 18 showed staff started the patient on dialysis treatment at 9:08 AM but did not conduct the pre nursing assessment until 11:30 AM. 5. During an interview on 11/13/24 at 1:07 PM, the clinical specialist said staff should conduct the pre nursing assessment within one hour of a patient starting on dialysis treatment.”