Dci - Kings Mountain

“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: 35306 Based on observation, patient and staff interview, and procedures, dialysis registered nurse job description, Pest Control Service Agreement, pest control reports, and email correspondence review, the facility staff failed to maintain a sanitary environment. Findings included: Observation on 09/10/2024 from 1030 -1230 in the patient treatment area revealed a heavy layer of dust build up on the counters behind HDM, window seals, and wall boxes and a heavy layer of crystalized buildup inside the wall box on the HD connection sites at Station #12 and Station #1. Observation revealed multiple loose test strips plastic lids, and other debris scattered on the floor inside the wall boxes throughout the treatment area. Tears in dialysis chairs were observed at Station #12: an approximate 2.5-inch tear in the seat, with multiple cracks stemming from the tear; Station #7: an approximate 1-inch tear in the right outside corner of the footrest; Station #4: an approximate 1-inch tears in left outside corner of the arm rest and right corner of the footrest; Station #3: an approximate 1.5-inch tear in the seat; Station #1: an approximate 2-inch tear in the seat, two approximate 1.5-inch tears in the left arm rest, and two approximate 1-inch tears in the right corner of the footrest; Station #16: an approximate 1.5-inch tear in the leg rest; and Station #13: an approximate1.5-inch tear in the seat. Observation revealed bright red splatter droplets along the wall behind the HD station and on top of the sharps container beside the dialysis chair and a reddish-brown smear on the bottom receptacle of the duplex (double) receptacle behind the HD station at Station #12; on the wall plate around the dialysate distribution box at Station #14; in the sink located in Laboratory #1; a bright red droplet, smeared along the base of the HDM and a red smear along the outside edge of the dialysis chair table at Station #13. Reddish-brown splatter was observed on the back wall behind the dialysis chair at Station #1, on the inside of dialysis chair frame near the footrest at Station #4, and on the receptacle located on the wall behind the HDM at Station #8. Observation of the dialysate drain beneath the wall box at Station #9 revealed a thick buildup of black sludge around the drain and a thick build-up of black sludge around the opening of each drain hole in the cover for the floor drain in the patient bathroom on the treatment floor. Observation of the “Clean” sink across from the patient bathroom, labeled, “South Side Sink” revealed a two-door cabinet under the sink with a thick buildup of rust on all four hinges, preventing the left-sided door from closing. Noted in the bottom of the cabinet beneath the sink was thick layers of rust powder from the hinges in the front two corners of the cabinet and a large hole around the plumbing with a large area of a white crystalized substance and black mold build-up and debris accumulation on the floor beneath the sink. The wood framing under the sink was rotted with black mold noted where the wood was pulled away from the cabinet. Observation of the countertop beside the “Clean” sink revealed a counter-top mounted, stainless steel paper towel dispenser with a thick layer of rust noted around the parameters of the metal plate. Below the countertop, in the cabinet beneath the paper towel dispenser, blood clamps that had fallen through the empty opening of the paper towel dispenser were observed in the paper towel housing. Observation beneath the “Dirty” sink across from Station #14 revealed a heavy layer of rust build-up on the cabinet hinges, a brown substance smeared throughout the bottom of the cabinet, a build-up of debris (plastic tubing end covers, heplock caps) and heavy layer of dust accumulation around the double foot floor pedals. Observation of the “Clean” sink across from the Isolation room, Station #1, revealed the water faucet and emergency eyewash outlet head were loose, a thick buildup of rust on all four hinges of the cabinet doors under the sink and a thick accumulation of dirt and debris in the bottom of the cabinet. Interview on 09/10/2024 at 1000 with the SW revealed there had been “spotting’s of roaches [in the treatment area and employee break room]. One was killed on the treatment room floor the other day, maybe last Friday [09/06/2024]. I don’t think our current vendor is doing what they should to effectively manage our needs. I know that Corporate is in the process of reviewing the contract.” Interview on 09/10/2024 at 1043 with Patient #1 dialyzing at Station #14 revealed he had been a patient at the facility since February 2018 (6.5 years). Patient #1 stated, “I have no problems with staff or the care here. But they’ve had an issue with roaches since the beginning of Summer. I came in one morning, and roaches were coming out of the ticket dispenser at the scale. I heard somebody scream and they said they were crawling everywhere. I told [NM] about it. I felt like they’ve probably been spraying because I haven’t seen any lately. My [family member] called up here, concerned because I had marks on my arm that we thought came from bed bugs. They were tearing my arms up. I went by the doctor’s office and they told me it was bed bugs. I hear staff talking about turning the lights on when they open in the morning and the roaches go flying, especially in the breakroom.” Interview on 09/10/2024 at 1205 with Patient #2 dialyzing at Station #16 revealed he had been a patient at the facility since November 2019 (4 years). “We see them [roaches] everywhere, in the bathroom and in here [treatment area]. It’s been a while since I’ve seen a live one [roach]. The drain in the bathroom has an odor to it, especially when it rains, like sewage. We need some new chairs. Half of them don’t lock and almost every one of them have tears.” Interview on 09/10/2024 at 1256 with PCT #1 revealed, “I’ve observed more than one [bed bug] during hook up [referencing Patient #3]. When he pulled his stuff out [blanket] and put it on, I saw a bed bug on the blanket. I was hooking him up and saw 4 [bed bugs] crawling on his blanket. I put the blanket in a garbage bag and put it in the heater to kill the bugs. I left it [patient blanket] in [the heater] until he left and put it in a bag. Interview revealed the facility did not have plastic containers with lids or disposable blankets. “We had a hand-held steamer but I haven’t seen it in well over a year. We also haven’t been using alcohol [to clean the chair], just bleach water used for wipe-down. [Pest Control contracted vendor] did come in and sprayed for bugs with a routine treatment. He [vendor] said he did not have the chemical to treat bed bugs.” PCT #1 stated that when she opens in the morning, “roaches scattered in the treatment area” when she turned the lights on. “It’s gotten worse since Spring. I continue to see them at opening. Last week, between Stations #2 and #3, there were about 11 [roaches] on the floor when I was about to move the patient. I’ve seen them in the employee breakroom as well.” Interview revealed blood splatter or spills are cleaned with a “dry white cloth, because wet ones smear it [blood] and then we clean it with a cloth soaked in the bleach concentrate [1:100] we mix every day for normal disinfection. We clean spills or splatters immediately, as soon as possible. If I notice it and I did it, I clean it up. But if it is unnoticed, I don’t. We should clean the wall boxes but I’m guilty of not doing that. We are not required to wipe down the counter [behind the HDM] or wall box housing. I don’t think they [contracted Housekeeping service] do a good job. When we have a heavy rain, it smells like sewage in the treatment area.” Interview on 09/10/2024 at 1448 with PCT #2 revealed, “I’ve never been told that I am responsible for dusting any part of the treatment area and have never done that. I thought that was housekeeping’s responsibility.” PCT #2 stated that she had heard rumors of bed bugs but had never seen one. Interview revealed, “I have seen roaches since I’ve been here but I don’t see as much as everyone else because I don’t open. I’ve heard that when they turn the lights on in the morning, they scatter everywhere. I’ve seen a few in the breakroom about three months ago but don’t see them as often now. [Contracted pest control vendor] just came and sprayed a couple weeks ago and I have seen dead [roach] carcasses.” Interview revealed, “I try to wipe down the wall boxes but some of them are corroded and hard to clean because it’s been there a while and I spray the wall boxes down with bleach water. If I get blood on there [wall], yes, I wipe that but as a routine, I don’t wipe that [wall behind the HDM and station] routinely. I could be more responsible for cleaning blood. I think it gets forgotten because the station [Station #12] is not an assigned station. It [treatment area] does need a good cleaning.” Interview on 09/10/2024 at 1517 with PCT #3 revealed the facility did not have any patients that were currently being “treated” for bed bugs. “Interventions for [Patient #3] are ongoing, because he still has them. We periodically pick one off of him.” PCT #3 stated the last time a bed bug was observed by staff on Patient #3 was “maybe a month ago.” Interview revealed the facility staff were not using disposable chair covers during HD treatments for Patient #3, “No, we are not using putting a cover over the chair currently.” Interview revealed PCT #3 had observed roaches “crawling out around the [HD] machines and from the drain boxes behind the machines” and that the NM was aware of the ongoing issue. “When [PCT #1] comes in to open in the morning, she said they’re [roaches] scattering everywhere, especially the breakroom.” Interview on 09/11/2024 at 1120 with the ATM revealed, “The previous AOD managed contracted services prior to changes with the organizational structure. Going forward, the ATM will provide oversight and management [of services]. I got a quote from [Vendor #2] on 08/29/2024 for Pest Control Services. I was gone to an annual meeting last week and signed it [quote] upon return. I didn’t know about the bed bugs until you [surveyor] came in [09/10/2024] and called them [Pest Control Vendor #2] yesterday. They added it [treatment for bed bugs] to the quote and it was signed on 09/10/2024. Within the past two weeks, we’ve [new AOD and ATM] been discussing me taking control of contracts. Now that we have a new AOD, things are getting so much better. We are in the process of getting new contracts and resigning them.” The ATM stated that the facility administrative staff were unable to locate a written contract agreement for EVS. “I’ve spoken with cleaning companies everywhere to review services and frequency [of services provided]. I’ve requested [current EVS vendor] send a schedule with the frequency of services outlined. We are going to tweak those [to meet the needs of the facility] and review the services annually. I want to set a good schedule and give them [EVS vendor] an opportunity to meet our expectations. If expectations are not met, we will go with someone else. Facilities should do it annually [review contracted services agreements] and clinical staff should inspect the facility weekly.” Interview revealed the two sinks on each end of the treatment area (sink #1 across from Station #12 and sink #2 across from the Isolation room), “Will be replaced.” Interview on 09/11/2024 at 1319 with the new AOD [DOH: 08/05/2024] revealed, “Annual review and renewal [of contracted services] should occur. Going forward, the new [Pest Control] contract has already started [Vendor #2]. I want all clinics to have the same contracts. We currently don’t have anything in writing [for EVS] but need a contract, something in writing.” Interview revealed the ATM had been in telephone contact with the owner of the current EVS vendor who stated that they would bring the original contract, “late this afternoon or in the morning. We are also going to follow up with the appropriate disciplines for all repairs and services.” Interview revealed ongoing evaluation and repairs would “remain on the QAPI agenda until resolved. “The first thing I said we need to do is to get quotes for new chairs. We are going to replace chairs, counter tops, sinks, cabinets. Things have not been maintained or repaired to save money but Corporate is very supportive in assuring that facilities have what is needed to ensure a safe, clean, and sanitary environment.” Interview revealed the facility had started working on contracted services and facility repairs the week of 08/26/2024 and that administrative staff had attended an annual convention “last week” but had planned to resume improvement initiatives prior to the State Agency’s arrival. “If companies are not working out, we will go with another one and address in GB. Going forward, the culture has to change. People [staff] cannot be afraid to speak up and we need to work on that. None of this [findings] is acceptable. Our patients deserve better.” Interview on 09/11/2024 at 1352 with the NM revealed concerns with EVS had been shared with the previous AOD, “many times.” The NM stated, the facility needed “chairs and a complete overhaul in the treatment area [cabinets, sinks, countertops, etc.].” Interview revealed, “I feel comfortable sharing concerns with the new AOD and we are on our way to a Just Culture. We have never reviewed contracted services. I plan to re-Inservice staff on the expectations for blood spills, splatters, and job expectations related to Infection Control practices. None of this [survey findings] is acceptable.” Interview on 09/11/2024 at 1420 with the ATM regarding follow up on the request for the EVS contract agreement revealed after telephone consultation with the current EVS vendor, the service agreement originated “25 years ago and there is no written contract with them that anyone can find. I’m going to write up a whole new contract.” Telephone interview on 09/11/2024 at 1430 with the interim MD revealed, “I will go over the expectations with the new MD and get an update on what improvements were done.” Interview revealed observational findings during the survey (blood splatter, blood droplets, torn chairs, damaged cabinets and sinks, presence of roaches and gnats in the clinic, failure to follow established policies and procedures regarding bed bugs and Infection Control practices) was “Absolutely, not acceptable. No, not at all. Contracts will be reviewed and evaluated as required.” Review on 09/11/2024 of the North Carolina General Statues 130A-235 under “Rules Governing the Sanitation of ...and other Institutions” revealed, “... 15A NCAC 18A .1317 VERMIN CONTROL ... (a) Effective measures shall be taken to keep flies, rodents, cockroaches, and other vermin out of the establishment and to prevent their breeding or presence on the premises ... (c) the premises under control of the management shall be kept neat, clean, and free of litter ... (d) Cleaning shall minimize accumulation of feces and other allergens generated by insects and other vermin ... 15A NCAC 18A .1319 FURNISHINGS AND PATIENT CONTACT ITEMS ... (a) All furniture ... venetian blinds, or other furnishings .... shall be kept clean and in good repair ... (c) Patient contact items shall be kept clean and in good repair.” Review on 09/11/2024 of the policy, “Routine Disinfection of the Hemodialysis Unit” updated 02/24/2024 revealed, “ ... Proper cleaning and disinfection of environmental surfaces (including patient chairs .... dialysis equipment services, adjacent tables and work surfaces) must be performed between patient uses to prevent transmission of dangerous pathogens ... For visible blood, the intermediate-level disinfection protocol must be followed, which requires the area be immediately cleaned with a cloth soaked with tuberculocidal disinfectant or 1:100 dilution of bleach ... After cleaning up all visible blood, a disinfectant must be applied a second time using a new cloth or towel ...13. Chase/water boxes will be cleaned at a scheduled interval per facility protocol. All connectors will be kept clean free of acid and bicarbonate buildup ...” Review on 09/11/2024 of the policy, “Surface Disinfection-Dilution of 1:100 Bleach Solutions” effective 01/16/2019 revealed, “ ... 12. Blood spills will be cleaned up immediately with 1:10 bleach solution. After all visible blood has been removed with a careful mechanical cleaning; a new disposable washcloth with fresh 1:100 bleach solution (saturated and wrung out) will be used to disinfect the surface ...” Review on 09/11/2024 of the “[Facility Name] Dialysis Registered Nurse” job description revealed, “ ... After dialysis, performs or assures that a machine is disinfected internally, according to the facility protocol; disinfects the outside of the machine, chair, and counter behind the machine ... Maintains a clean and orderly work environment. Knows and implement safe and effective infection control procedures in accordance with facility policies and procedures ... adheres to OSHA (Occupational Safety and Health Administration) requirements for job safety and prevention of bloodborne pathogens ...” Review on 09/11/2024 of the Pest Control Service agreement with Vendor #1 revealed the agreement was dated “11/13/2017”, with an expiration date of “04/13/2017” (4 months). Review of the termination agreement revealed, “This agreement may be cancelled by either party at any time by giving 30 days written notice to that affect. After the above agreement period ends the agreement will continue on a month-to-month basis until termination is given in writing by either party.” Review of “PESTS” to be treated outlined in the contract agreement revealed roaches and bed bugs were included on the list. Review on 09/11/2024 of the “Completed Appointment History by Customer” summary from Vendor #1 revealed monthly pest control services were provided by the contracted pest control vendor from 10/12/2020-08/23/2024 with a “Reservice” noted 08/30/2024. Review on 09/11/2024 of the contracted pest control “Billing Statement” for 2024 from Vendor #1 revealed the facility was treated with the following insecticides: “Fendona CS” (used to kill bed bugs and cockroaches) 01/26/2024 and 04/19/2024; “Suspend Polyzone (used to kill cockroaches) 02/22/2024; Suspend Polyzone and Doxem Precise (Dry Flowable Cockroach Bait: used to kill cockroaches) 03/11/2024; “Lambdastar CS” (used to kill bed bugs and cockroaches) and Doxem Precise 05/24/2024 and 06/28/2024; “Lambdastar CS and Tekko” (inhibits re-infestation by cockroaches for up to 6 months for up to seven months) 07/26/2024 and 08/23/2024; and “Alpine WSG” (used to kill bed bugs and cockroaches) on 08/30/2024. Review on 09/11/2024 of the new “Pest Management Service Agreement,” dated 09/10/2024, with Vendor #2 revealed an expiration date of 08/19/2024 (11 months). Review of pests treated listed in the contract agreement revealed roaches was listed; however bed bugs were not included. Review of the termination agreement revealed, “[Vendor #2] will inspect and treat the premises at least monthly to control the above named pests. This agreement covers only the pests specified above Should the customer request service for a pest other than the pests listed above (a pest requiring additional treatment) there will be a reasonable additional charge.” Review on 09/11/2024 of the “Pest Management Service Agreement,” dated 09/10/2024, with Vendor #2 revealed a “ONE-TIME SERVICE AGREEMENT” stating, “[Vendor #2] agrees to provide pest control service by application of proper control measures for the following pests: Treat treatment floor and lobby for bed bugs.” Review on 10/04/2024 of updated information from the AOD via email at 1217 revealed, “The below is the things already in place ...We are still using the chair covers for the chairs at [Facility name] until we get the new chairs that are ordered. Please see the above attached contracts for Cleaning and Pest Control [included in above findings]. We had already decided prior to your coming on 9/10/24 we had to utilize a different vendor for the “Roach situation” as it was not being resolved ...we now have [Vendor #2] and there have been no more roaches reported or seen. The cleaning crew as stated above has a new contract which gives schedules for all the cleaning that is requires on a daily, weekly, monthly basis...this was not the previous case before it was listed “As needed”. [NM] has a staff meeting with her staff to go over the findings of the survey in more detail even though there was a run down after you left on 9/10/2024 to just make plans for the next day of how we needed chair covers for all the chairs etc., and the bleach 1:10 needing to be made on a daily basis to clean up any blood spills immediately. The cleaning crew was called and they came in and did cleaning the same night, mopping the floors, dusting...The foul smell that was mentioned when it rains is no longer the case for the drains were cleaned and there is no mention of smell even during the hurricane rains. There will be ongoing routine cleaning of the drains as well.””

“GOV-ADM RESP FOR FISCAL OPERATIONS CFR(s): 494.180(a)(2) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to- (2) Fiscal operations; This Standard is not met as evidenced by: 35306 Based on review of contracted services agreement, QAI documentation, and meeting minutes, the Governing Body failed to ensure a written schedule of cleaning procedures was established, reviewed, documented annually in Governing Body and implemented which sets forth the cleaning and method of decontamination considering the types of surfaces, soils, and task and procedures being performed and failed to ensure contracted service agreements were reviewed and evaluated to ensure the treatment area was conducive for dialysis treatment, and failed to ensure patients were safe from potential infectious disease within the environment. Findings included: Review on 09/11/2024 of the Pest Control Service agreement with Vendor #1 revealed the agreement was dated “11/13/2017”, with an expiration date of “04/13/2017” (4 months). Review of the termination agreement revealed, “This agreement may be cancelled by either party at any time by giving 30 days written notice to that affect. After the above agreement period ends the agreement will continue on a month-to-month basis until termination is given in writing by either party.” Review on 09/11/2024 of QAPI meeting minutes documentation failed to reveal contracted service agreements were reviewed and evaluated to ensure the contracted services met the Governing Body expectations and that services provided protected patients from potential infectious disease within the environment. Interview on 09/11/2024 at 1120 with the ATM revealed the facility administrative staff were unable to locate a written contract agreement for EVS. Interview revealed, “I’ve spoken with cleaning companies everywhere to review services and frequency [of services provided]. I’ve requested [current EVS vendor] send a schedule with the frequency of services outlined. We are going to tweak those [to meet the needs of the facility], make it perfect, and review the services annually. They said [owner of EVS company] it had been 15 or 17 years since they started cleaning the facility. I want to set a good schedule and give them [EVS vendor] an opportunity to meet our expectations. If expectations are not met, we will go with someone else. I am going to sit down with them [EVS vendor] and set expectations and the expected quality of each task. Facilities should do it annually [review contracted services agreements] and clinical staff should inspect the facility weekly.” Interview on 09/11/2024 at 1319 with the new AOD [DOH: 08/05/2024] revealed, “We currently don’t have anything in writing [for EVS] but need a contract, something in writing.” Interview revealed the ATM had been in telephone contact with the owner of the current EVS vendor who stated that they would bring the original contract, “late this afternoon or in the morning.” Interview revealed, “If companies are not working out, we will go with another one and address in GB. Going forward, the culture has to change. People [staff] cannot be afraid to speak up and we need to work on that. None of this [findings] is acceptable. Our patients deserve better.” Interview on 09/11/2024 at 1352 with the NM revealed contracted services had not been monitored, tracked, and evaluated for the effectiveness of services from a QAPI or Governing Body perspective. Interview revealed the NM was not aware of the regulatory requirements for the evaluation of contracted services. Interview on 09/11/2024 at 1420 with the ATM in follow up on the request for the EVS contract agreement revealed after telephone consultation with the current EVS vendor, the service agreement originated “25 years ago and there is no written contract with them that anyone can find. I’m going to write up a whole new contract.” Telephone interview on 09/11/2024 at 1430 with the interim MD revealed, “I will go over the expectations with the new MD and get an update on what improvements were done.” Interview revealed observational findings during the survey (blood splatter, blood droplets, torn chairs, damaged cabinets and sinks, presence of roaches and gnats in the clinic, failure to follow established policies and procedures regarding bed bugs and Infection Control practices, failure to review contracted services) was, “Absolutely, not acceptable. No, not at all. We should and will follow established policies.” Interview revealed, “Contracts will be reviewed and evaluated as required.” NC00215677”