Dci Blackfeet

“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: 44769 Based on interview and record review, the facility failed to conduct an Emergency Plan exercise on an annual basis. This deficiency affects all staff and patients receiving services at the facility. Findings include: A review of the facility’s EP records indicate staff responded to emergency events on 8/28/24 and 10/19/24. The most recent emergency preparedness exercise prior to those was on 2/25/22. During an interview on 11/5/25 at 2:06 p.m., staff member C stated there was no documentation for EP exercises for 2023.”

“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: 46400 Based on observation and record review, facility staff failed to follow infection control guidelines regarding glove use for 2 (#s 6 & 8) of 12 patients sampled. Findings include: 1. During an observation on 11/5/24 at 11:55 a.m., staff member G was initiating dialysis for patient #8. Staff member G removed her gloves and proceeded to touch the patient’s machine typing in pretreatment information, increasing the pump speed, and securing the patient’s blood lines (extracorporeal system). Review of the facility policy, Standard Precautions, dated July 2014, showed: “... 3. Gloves a. Required whenever caring for a patient b. Required when touching patient’s medical equipment and/or handling blood or body fluid specimen containers, extracorporeal system ...” 2. During an observation on 11/6/24 at 11:50 a.m., staff member J was initiating dialysis for patient #6. Staff member J arranged the patient’s clothing and blanket, picked up a paper from the floor, and then placed a clean field under patient 6’s catheter without changing gloves or hand sanitizing when moving from the dirty to clean task. Staff member J also grabbed supplies from the clean supply area with her dirty gloves on. Review of the facility policy, Standard Precautions, dated July 2014, showed: “... 3. Gloves ...d. will be removed after contact with a patient and/or the surrounding environment (including equipment) ... e. will be changed whenever moving from one patient or machine to another or a dirty site to clean site of the same patient ...””

“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: 46400 Based on observation and record review, facility staff failed to follow PPE guidelines regarding face shield use during the termination of dialysis for 1 (#6) of 12 patients sampled. Findings include: During an observation on 11/4/24 at 3:30 p.m., staff member F was discontinuing dialysis for patient #6. Staff member F was not wearing a face shield while disconnecting blood lines and flushing the patient’s catheter. Review of the facility policy, Standard Precautions, dated July 2014, showed: “ ... Standard precautions will be utilized in this facility by all employees where there is a risk of exposure to blood and body fluids ... Facial coverings required in procedures for which there is chance of splattering, splashing of blood or other body fluids ...””

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 46400 Based on observation and record review, facility staff failed to ensure items brought to the patient station were disinfected or thrown away (single use) for 1 (#6) of 12 patients sampled. Findings include: During an observation on 11/6/24 at 11:50 a.m., staff member J brought over a roll of tape to patient #6’s station. Staff member J placed the roll of tape on the chair table next to the dirty syringes used for flushing the patient’s catheter. Patient #6 picked up the tape and was “playing” with it, unrolling large pieces and sticking them to things before the tape was taken away and placed on the nearby nurses’ desk. A second staff member picked up the roll of tape and asked staff member J if it was still good. She replied yes and the second staff member folded the corner in and placed the tape with the clean supplies. Review of the facility policy, Standard Precautions, dated July 2014, showed: “ ... Standard precautions will be utilized in this facility by all employees where there is a risk of exposure to blood and body fluids ... 11. Equipment and supplies (if not single patient use) will be properly disinfected ...””

“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: 46400 Based on observation and record review, the facility did not remove expired supplies for testing blood leaks in dialysate. This deficient practice had the potential to impact all patients being dialyzed in the facility. Findings include: During an observation on 11/5/24 at 12:34 p.m., three tubes of strips used for detecting blood leaks in dialysate were observed sitting on the shelf in the spare machine/equipment room off the patient care floor. Two of the bottles had expiration dates of March 2023. Review of the facility policy, Dialyzer Blood Leak, dated January 2016, showed: “Purpose: to provide guidelines in the management of a dialyzer blood leak. Definition: a tear in the dialyzer membrane which allows blood to escape into the dialysate compartment. Supplies: Stericheck Blood Leak Reagent Strips (check expiration date) Procedure Steps ... 7. DO NOT RETURN BLOOD if positive Blood Leak Test Strip result obtained. A blood leak poses the risk of nonsterile dialysate crossing into the blood compartment ...””

“PR-PRIVACY & CONFIDENTIALITY-RECORDS CFR(s): 494.70(a)(4) The patient has the right to- (4) Privacy and confidentiality in personal medical records; This Standard is not met as evidenced by: 44769 Based on observation and record review, the facility failed to conceal personal medical information from the line of sight of patients and visitors of the facility. This deficient practice affected all of the patients utilizing the facility for dialysis treatment. Findings include: During an observation on 11/5/24 at 11:06 a.m., a list of the facility’s patients was observed, posted on the wall at the end of the hall entering the treatment area. The list contained each patient’s identification number, date of birth, and primary nephrologist. During an observation on 11/5/24 at 11:09 a.m., patient #9 was observed walking within sight of the list while proceeding to the facility’s exit. A review of a facility policy, titled, “General Introduction and Definitions HIPAA Policies and Procedures,” with an issue date of 4/14/16, showed: “PURPOSE: Provide an introduction to HIPAA concepts and definitions. Also, to establish a uniform point of reference for the language used relating to protected health information under the HIPAA regulations. ... HIPAA is the first set of comprehensive federal laws and regulations designed to protect patient privacy and security in their protected health information ... Protected Health Information: Protected Health Information means any information, whether oral or recorded, in any form or medium: ... (2) that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual.””

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 46400 Based on observation, interview, and record review, the facility failed to ensure a patient was dialyzing on the correct prescription for 1 (#7) of 12 sampled patients. Findings include: During an observation on 11/5/24 at 1:40 p.m., patient #7 was running her treatment on a 2K 2.5ca acid with a DFR of 600. Review of patient #7’s dialysis prescription showed she was supposed to be on a 3K 2.5ca acid with a DFR of 800. During an interview on 11/5/24 at 1:45 p.m., staff member F stated patient #7 had the wrong acid jug and replaced it with the correct one.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 46400 Based on interview and record review, the facility failed to ensure patients received evaluation of their nutritional status by a dietician for 2 (#s 4 & 6) of 12 sampled residents. This deficient practice had the potential to affect all patients receiving care in the facility. Findings include: During an interview on 11/5/24 at 11:08 a.m. staff members B & C stated the facility had not had a dietician since January 2023. A dietician had been hired with a start date of December 2024. All patient nutrition labs and concerns were being handled by nursing staff or the medical director. 1. Review of resident #6’s Nutritional Assessment, dated 5/25/24, showed, “This assessment was not electronically completed for the following reason: position is open and not staffed.” Review of resident #6’s medical record showed she was admitted 3/2022. Resident #6 should have been receiving annual assessments from a qualified dietitian. 2. Review of resident #4’s Nutritional Assessment, dated 4/12/24, showed, “This assessment was not electronically completed for the following reason: position is open and not staffed.” Review of resident #4’s medical record showed he was admitted on 1/2024. He should have received an initial and three-month comprehensive assessment with evaluation of nutritional status by a qualified dietitian. Review of resident #4’s most recent nutrition labs showed: - 10/21/24 Albumin low 3.3; goal of greater than or equal to 3.9 - 10/21/24 Potassium high 6.5; goal of 3.8 to 5.5 - 10/21/24 Phosphorus high 8.2; goal of 2.5 to 5.5 - 10/21/24 Calcium low 8.1; goal of 8.4 to 10.2 During an interview on 11/6/24 at 9:12 a.m., staff member K stated patient #4 was chronically missing dialysis or shortening his treatments. Staff member K stated there was and continued to be education offered regarding his poor lab values and lifestyle changes required. Staff member K stated he made any necessary bone and mineral medication adjustments in the absence of a dietician.”