Northside Dialysis Center

“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: 32003 Based on policy review, observations, personnel worksheet review, infection control audit reviews, and staff interview, the facility staff failed to promote barrier precautions by failing to ensure in-center staff members wore side shields with personal eyeglasses for 3 of 3 observations. Findings included: Review on June 28, 2024 of the facility’s policy, “Infection Control Practices for Hemodialysis” revised May 2023 revealed, “Purpose: ...Policy: ...Points of Emphasis [space] 1. ...8. Face protection that covers the eyes, nose, and mouth is to be worn at all time there is a high risk of exposure to blood/body fluids/chemicals. ...” 1. Observation on June 25, 2024 from 2:30 PM to 3:00 PM (30-minutes) revealed, PCT #4 was 1 of 2 staff members that provided care to seven patients in Bay B. Observation revealed, the technician failed to wear side shields with personal eyeglasses while performing patient care. Review on June 28, 2024 of the personnel worksheet revealed, ten PCTs were employed at the in-center facility and the infection control training dates were not listed for all ten PCTs. Review on June 28, 2024 of infection control audits revealed from January 2024 through June 2024 (six months), the facility staff performed infection control audits and no concerns were identified with PPE. Interview on June 25, 2024 at 3:00 PM with the Charge Nurse revealed, PCT #4 should have side protectors on while performing patient care. Interview on June 28, 2024 at 2:52 PM with the Clinical Nurse Administrator revealed, infection control practices were last discussed on June 21, 2024 in the “Lean Huddle”. Interview failed to reveal which staff members participated in the huddle. 2. Observation on June 25, 2024 from 2:30 PM to 3:00 PM (30-minutes) revealed, CCHT #8 was 1 of 2 staff members that provided care to seven patients in Bay B. Observation revealed, the technician failed to wear side shields with personal eyeglasses while performing patient care. Review on June 28, 2024 of the personnel worksheet revealed, eight CCHTs were employed at the in-center facility and infection control training dates were only listed for 5 of 8 CCHTs - no date was listed for CCHT #8. Review on June 28, 2024 of infection control audits revealed from January 2024 through June 2024 (six months), the facility staff performed infection control audits and no concerns were identified with PPE. Interview on June 25, 2024 at 3:00 PM with the Charge Nurse revealed, CCHT #8 should have side protectors on while performing patient care. Interview on June 28, 2024 at 2:52 PM with the Clinical Nurse Administrator revealed, infection control practices were last discussed on June 21, 2024 in the “Lean Huddle”. Interview failed to reveal which staff members participated in the huddle. 3. Observation on June 26, 2024 from 9:30 AM to 10:15 AM (45-minutes) revealed, CCHT #2 was 1 of 4 staff members that provided care to nine patients in Bay B. Observation revealed, the technician failed to wear side shields with personal eyeglasses while performing patient care. Review on June 28, 2024 of the personnel worksheet revealed, eight CCHTs were employed at the in-center facility and infection control training dates were only listed for 5 of 8 CCHTs - no date was listed for CCHT #2. Review on June 28, 2024 of infection control audits revealed from January 2024 through June 2024 (six months), the facility staff performed infection control audits and no concerns were identified with PPE. Interview on June 25, 2024 at 3:00 PM with the Charge Nurse revealed, CCHT #8 should have side protectors on while performing patient care Interview on June 28, 2024 at 2:52 PM with the Clinical Nurse Administrator revealed, infection control practices were last discussed on June 21, 2024 in the “Lean Huddle”. Interview failed to reveal which staff members participated in the huddle.”

“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: 32003 Based on policy review, observations, personnel worksheet review, and staff interview, the facility staff failed to promote standards of practice for infection control by failing to ensure a station chair was properly disinfected between patient use for 1 of 2 observations. Findings included: Review on June 28, 2024 of the facility’s policy, “Infection Control Practices for Hemodialysis” revised May 2023 revealed, “Purpose: ...Policy: ...Points of Emphasis [space] 1. ...Infection Control Practices ...Patient Practice ...Medication Practices ...Supply Practices ...Cleaning and Disinfection Practices [space] ...The dialysis station ...must be disinfected with a 2:100 bleach solution between each patient. ...” Observation on June 26, 2024 at 10:11 AM revealed CCHT #2 cleaned and disinfected dialysis station #28 but failed to open and disinfect the insides of the station chair. Review on June 28, 2024 of the infection control log revealed from January 2024 through June 2024 (six months), the facility staff performed infection control audits and no concerns were identified with cleaning and disinfection of the dialysis station. Review on June 28, 2024 of the personnel worksheet revealed, eight CCHTs were employed at the in-center facility and infection control training dates were only listed for 5 of 8 CCHTs - no date was listed for CCHT #2. Interview on June 28, 2024 at 11:40 AM with the Clinical Nurse Administrator revealed, infection control practices were last discussed on June 21, 2024 in the “Lean Huddle”. Interview failed to reveal which staff members participated in the huddle.”

“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: 32003 Based on policy review, observations, and staff interview, the facility staff failed to promote medication safety by failing to ensure a multi-dose vial was dated and timed upon initial entry for 1 of 2 in-center medication storage area observations. Findings included: Review on July 28, 2024 of the facility’s policy, “Infection Control Practices for Hemodialysis” revised May 2023 revealed, “Purpose: ...Policy: ...Points of Emphasis [space] 1. ...Infection Control Practices ...Patient Practice ...Medication Practices ...1. ...2. All multi-dose vials must be dated with the date and time of initial entry. ...” Observation on July 28, 2024 12:00 noon time revealed 1 of 3 Lidocaine multi-dose vials was open without the date and time of initial entry. Interview on July 28, 2024 at 12:00 noon time with the Charge Nurse revealed, the Lidocaine multi-dose vial should have been dated and timed upon initial entry.”

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 32003 Based on policy review, medical record reviews, and staff interview, the facility staff failed to ensure a CIPA and plan of care meeting invite was provided to 5 of 5 in-center patients (Patients #3, #11, #18, #23, and #24) and for 2 of 2 home therapy patients (Patients #21 and #22). Findings included: Review on June 28, 2024 of the facility’s policy “Comprehensive Interdisciplinary Patient Assessment (CIPA) and Plan of Care” revised July 2023 revealed no documentation that patients should receive a CIPA and plan of care meeting invite. 1. Open medical record review on June 28, 2024 revealed Patient #3 was admitted to the in-center facility, wherein the most recent CIPA and plan of care meeting was held on January 11, 2024, but there was no documentation that the patient received an invite to the meeting. Interview on June 28, 2024 at 11:40 AM with the Clinical Nurse Administrator revealed, the CIPA and plan of care meeting invite was all verbal, wherein all in-center patients were asked if they would like for the meeting to be held in private or at the chairside and the policy did not outline that patients should receive an invite to the meeting. 2. Open medical record review on June 28, 2024 revealed Patient #11 was admitted to the in-center facility, wherein the most recent CIPA and plan of care meeting was held May 29, 2024, but there was no documentation that the patient received an invite to the meeting. Interview on June 28, 2024 at 11:40 AM with the Clinical Nurse Administrator revealed, the CIPA and plan of care meeting invite was all verbal, wherein all in-center patients were asked if they would like for the meeting to be held in private or at the chairside and the policy did not outline that patients should receive an invite to the meeting. 3. Open medical record review on June 28, 2024 revealed Patient #18 was admitted to the in-center facility, wherein the most recent CIPA and plan of care meeting was held March 13, 2024, but there was no documentation that the patient received an invite to the meeting. Interview on June 28, 2024 at 11:40 AM with the Clinical Nurse Administrator revealed, the CIPA and plan of care meeting invite was all verbal, wherein all in-center patients were asked if they would like for the meeting to be held in private or at the chairside and the policy did not outline that patients should receive an invite to the meeting. 4. Open medical record review on June 28, 2024 revealed Patient #21 was admitted to the home therapy program, wherein the most recent CIPA and plan of care meeting was held April 19, 2024, but there was no documentation that the patient received an invite to the meeting. Interview on June 28, 2024 at 11:40 AM with the Home Therapy Nurse Manager revealed, Patient #21 received an invite the day of the CIPA and plan of care meeting. 5. Open medical record review on June 28, 2024 revealed Patient #22 was admitted to the home therapy program, wherein the most recent CIPA and plan of care meeting was held June 7, 2024, but there was no documentation that the patient received an invite to the meeting. Interview on June 28, 2024 at 11:40 AM with the Home Therapy Nurse Manager revealed, Patient #22 received an invite the day of the CIPA and plan of care meeting. 6. Open medical record review on June 28, 2024 revealed Patient #23 was admitted to the in-center facility, wherein the most recent CIPA and plan of care meeting was held April 9, 2024, but there was no documentation that the patient received an invite to the meeting. Interview on June 28, 2024 at 11:40 AM with the Clinical Nurse Administrator revealed, the CIPA and plan of care meeting invite was all verbal, wherein all in-center patients were asked if they would like for the meeting to be held in private or at the chairside and the policy did not outline that patients should receive an invite to the meeting. 7. Open medical record review on June 28, 2024 revealed Patient #24 was admitted to the in-center facility, wherein the most recent CIPA and plan of care meeting was held June 21, 2024, but there was no documentation that the patient received an invite to the meeting. Interview on June 28, 2024 at 11:40 AM with the Clinical Nurse Administrator revealed, the CIPA and plan of care meeting invitation was all verbal, wherein all in-center patients were asked if they would like for the meeting to be held in private or at the chairside and the policy did not outline that patients should receive an invitation to the meeting.”

“GOV-ELECTRONIC DATA SUBMISSION REQUIRED CFR(s): 494.180(h) (8) Effective February 1, 2009, the dialysis facility must furnish data and information to CMS and at intervals as specified by the Secretary. This information is used in a national ESRD information system and in compilations relevant to program administration, including claims processing and reimbursement, quality improvement, and performance assessment. The data and information must- (1) Be submitted at the intervals specified by the Secretary; (2) Be submitted electronically in the format specified by the Secretary; (3) Include, but not be limited to- (i) Cost reports; (ii) ESRD administrative forms; (iii) Patient survival information; and (iv) Existing ESRD clinical performance measures, and any future clinical performance standards developed in accordance with a voluntary consensus standards process identified by the Secretary. This Standard is not met as evidenced by: 32003 Based on 2728-instructions review, new patient listing review, medical record review, email reviews, and staff interview, the facility staff failed to ensure a 2728 was not created for 1 of 1 randomly selected patients listed as AKI. (Patient #20). Findings included: Review on June 28, 2024 of the “2728 Form Instructions” updated February 26, 2024 revealed, “The 2728 Form ...is required to add a patient to the ESRD registry ...2728 Facts ...Due for all ESRD patients (not AKI patients). ...” Review on June 25, 2024 of the listing for new patients revealed, Patient #20 was admitted to the in-center facility on May 6, 2024 and was listed as an AKI patient. Open medical record review on June 28, 2024 revealed, Patient #20 had a 2728 that had been numerically coded as AKI and signed by Nephrologist #24. Laboratory tests were billed as ESRD from May 6, 2024 through June 12, 2024 and from June 13, 2024 through June 19, 2024, laboratory tests were billed as AKI. Review revealed the patient was classified as ESRD and AKI. Review on June 28, 2024 of emails revealed on June 12, 2024, communication occurred between the nurses and a floating administrative assistant regarding whether the patient was ESRD or AKI. Review revealed Nephrologist #24 was not included in the email communication. Interview on June 28, 2024 at 11:40 AM with the Clinical Nurse Administrator revealed, a floating administrative assistant sent out an email to change the patient from ESRD to AKI without notifying Nephrologist #24. NC00202632 NC00206769 NC00216276”