Miller Street Dialysis Center

“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: 27438 Based on policy review, observations, and staff interviews, the facility staff failed to ensure emergency supplies were ready for immediate use for 2 of 3 survey days for 2 of 2 observations. Findings included: Review on August 26, 2024 revealed the facility was unable to provide a policy related to the Emergency Code Cart and expired supply removal. Review of the facility’s policy, “Expiration Date Policy,” revised August 23, 2023, indicated, “The following medical supplies should be discarded after the appointed expiration date ...ExSept Plus.” 1. Observation on January 24, 2024 at 1:30PM of the Emergency Code Cart for in-center patients revealed four vials of Atropine 0.4 milligram/milliliter (mg/ml) measurement of concentration) had an expiration date of November 20, 2023. Interview on January 24, 2024 at 1:35 PM with the Charge Nurse revealed, the expiration date of the four Atropine 0.4 mg/ml vials as November 20, 2023, verified he/she was responsible to check the Emergency Code Cart, and it was the facility’s expectation that soon to expire items in the Emergency Code Cart are replaced prior to expiration to ensure supplies are always available and ready for use. 2. Observation on January 26, 2024 at 11:40 AM of the Emergency Evacuation Kit for Home Programs revealed, one bottle of ExSept Plus (antimicrobial exit site skin and wound cleaner) had an expiration date of December 3, 2022. Interview on January 26, 2024 at 11:45 AM with the Charge Nurse revealed, the expiration date of the ExSept Plus had an expiration date of December 3, 2022, he/she was responsible to check the Emergency Evacuation Kit, and it was the facility’s expectation that soon to expire items in the Emergency Evacuation Kit are replaced prior to expiration to ensure supplies are always available and ready for use.”

“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: 27438 Based on policy review, observation, and staff interviews, the facility staff failed to ensure a PCT performed hand hygiene after removing gloves, after touching patient care equipment, and before contact with the patient for 1 of 3 survey days and for 1 of 1 observation. Findings included: Review of the facility’s policy, “Infection Control Practices for Hemodialysis,” revised May 2023 revealed, “Infection Control Practices ... Gloves are to be removed and hands washed between each patient and/or machine contact ...Gloves are to be removed before obtaining supplies from any clean area (supply cart, med cart ...).” Observation on January 25, 2024 at 9:25 AM of the hemodialysis treatment area revealed, PCT- 3 was observed disconnecting at Station C-24. PCT-3 removed his/her gloves however, failed to use hand sanitizer to perform hand hygiene prior to donning clean gloves. PCT-3 failed to remove dirty gloves prior to obtaining a clean glove from glove box for Patient #9 to wear while holding his/her needle site. Observation revealed PCT-3 failed to perform hand hygiene during patient care activities. Interview on January 25, 2024 at 9:40 AM, PCT3 revealed PCT-3 failed to perform hand hygiene during patient care activities. Interview on January 25, 2024 at 1:30 PM, the Nurse Administrator revealed that after removing gloves and donning new gloves, hand hygiene should be performed. Clinic Manager 2 revealed that staff are not to move from one station to the clean cart without removing gloves and using hand sanitizer or washing hands.”

“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: 27438 Based on policy review, observations, and staff interviews, the facility staff failed to ensure the pHoenix Meters (used to verify the conductivity) were cleaned appropriately after use for 2 of 3 survey days for 3 of 3 observations. Findings included: Review of the facility’s policy, “Infection Control Practices for Hemodialysis” revised May 2023 revealed, “Cleaning and Disinfection Practices...pHoenix meters etc. taken to the patient’s station must be disinfected with a 2:100 bleach solution or according to manufacturer’s instructions prior to being returned to a common clean area or used on another patient.” 1. Observation on January 24, 2024 at 11:20 AM, at Station 5 revealed, PCT-8 failed to disinfect the pHoenix meter after use. Interview on January 25, 2024 at 1:30 PM, PCT-2 revealed, he/she failed to disinfect the pHoenix meter prior to returning the meter to a designated clean area. PCT2 stated the facility policy was to disinfect the meter after each use. Interview on January 25, 2024 at 2:15 PM, the Nurse Administrator confirmed the facility policy for disinfection of the pHoenix meters. 2. Observation on January 25, 2024 at 10:00 AM, at Station 25 revealed, PCT-2 failed to disinfect the pHoenix meter after use. Interview on January 25, 2024 at 1:30 PM, PCT 2 revealed, he/she failed to disinfect the pHoenix meter prior to returning the meter to a designated clean area. PCT2 stated the facility policy was to disinfect the meter after each use. Interview on January 25, 2024 at 2:15 PM, the Nurse Administrator confirmed the facility policy for disinfection of the pHoenix meters. 3. Observation on January 25, 2024 at 10:50 AM, at Station 22 revealed, PCT-2 failed to disinfect the pHoenix meter after use. Interview on January 25, 2024 at 1:30 PM, PCT 2 revealed, he/she failed to disinfect the pHoenix meter prior to returning the meter to a designated clean area. PCT2 stated the facility policy was to disinfect the meter after each use. Interview on January 25, 2024 at 2:15 PM, the Nurse Administrator confirmed the facility policy for disinfection of the pHoenix meters.”

“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: 27438 Based on policy review, observation, and staff interview, the facility staff failed to follow the medication labeling policy for 1 of 1 observation of the medication prep room. Findings included: Review of the facility’s policy, “Infection Control Practices for Hemodialysis,” revised May 2023 revealed, “Medication Practices ...All multi-dose vials must be dated with the date and time of entry. All multi-dose vials must be discarded 28 days after the date of initial entry or if sterility is compromised.” Observation on January 24, 2024 at 1:45 PM of the facility’s medication preparation room revealed, the following open injectable medications without the date and time: one multi use vial of Zemplar (injectable vitamin used to treat and prevent overactive parathyroid glands) 2 milliliter (ml)measurement of volume) vial, without date and time the vial was opened, one vial of Epogen (injectable medication used to treat anemia) 20,000 units (amount of medication)/ml vial without date and time the vial was opened by staff. Interview on January 24, 2024 at 10:50 PM, the Charge Nurse revealed, the nursing staff using medications in the medication room are required to date and initial all multi dose medications when opened.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 27438 Based on policy review, observation, and staff interview, the facility staff failed to ensure all patients used personal protective masks correctly during CVC access care for 1 of 2 observations. Findings included: Review of the facility’s policy, “Initiating, Monitoring, and Discontinuing Hemodialysis Treatments Utilizing a Central Venous Catheter (CVC) with TEGO (company name for catheter end caps) caps in place,” revision date 9/2023, indicated, “Initiating Treatment: Wash hands and don a clean pair of gloves and face mask. Place face mask on the patient.” Observation on January 24, 2024 at 10:20 AM of the hemodialysis treatment area revealed, PCT-8 initiated CVC access treatment for Patient #1 at Station #5. PCT-8 failed to ensure the patient wore a mask appropriately, so it covered his/her nose during treatment initiation, when the CVC lines are open and exposed to potential contamination. Interview on January 24, 2024 at 10:30 AM, with PCT-8 revealed, Patient #1 mask was below his/her nose during CVC treatment initiation. PCT 8 confirmed he/she was aware of the facility policy that requires staff to ensure patients wear masks appropriately during CVC treatment discontinuation.”

“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: 27438 Based on policy review, observation, and staff interview, the staff facility failed to remove expired supplies from the facility’s inventory for 1 of 1 observation of the laboratory room Findings included: Review of the facility’s policy, “Expiration Date Policy,” revised August 23, 2023 revealed, “Medical supplies should be discarded after the appointed expiration date.” Observation on January 24, 2024 at 2:00 PM of the laboratory room revealed the following expired supplies; four Ketostix Reagent Test Strips (used to test urine) with an expiration date of 07/31/21 printed on the container, and five unopened boxes and one opened box of HemoCue Hb 261 microcuvettes (used in testing blood glucose) with an expiration date of 04/30/22 printed on the containers. Interview on January 24, 2024 at 2:20 PM, the Nurse Manager revealed, the expired supplies in the laboratory room would be removed and disposed of when expired.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 27438 Based on policy review, observation, and staff interviews, the facility staff failed to ensure patient’s hemodialysis access site was uncovered and visible for 1 of 3 days of the survey days. Findings included: Review of the facility’s policy, “Initiating, Monitoring, and Discontinuing Hemodialysis Treatments Utilizing a Central Venous Catheter with TEGO caps in Place,” revision date 9/2023, indicated, “Monitoring During Treatment: The patient’s access must be visible throughout the treatment. Patients may not cover the CVC with a blanket, etc. as it prevents the staff from verifying issues such as catheter dislodgement, line separation, etc...” Observations on January 24, 2024 between 10:00 AM and 11:00 AM (60-minutes) revealed, Patient #1 was at Station #5 and his/her CVC) chest access site covered by clothing. Interview on January 24, 2024 at 11:00 AM with PCT-8 revealed Patient #1 access should always be uncovered for safety purposes. Interview on January 24, 2024 at 12:20 PM with the Nurse Manager revealed staff are to ensure patient access was to be visible during treatment.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 32003 Based on policy review, observations, QAPI meeting minutes review, and staff interviews, the facility staff failed to have an effective quality assurance program by not ensuring improvements made to the water treatment system was documented in monthly QAPI meeting. Findings included: Review on January 26, 2024 of the facility’s policy, “Quality Assessment Performance Improvement” revised May 19, 2023 revealed, “QAPI Purpose Statement....Guiding Principles...Quality Assessment Performance Improvement Progress...The following areas will be addressed (includes but is not limited to) [space] 1. ...20. Water Quality and Water Systems Safety... .” 1. Observation on January 24, 2024 at 2:15 PM in the water treatment room revealed, the water treatment system had two carbon tanks. The amount of carbon in each tank was documented as 13. Observation revealed the EBCT was not documented for each carbon tank. Review on January 24, 2024 revealed the EBCT resulted as 10 for August 2, 2023 and for October 17, 2023. On January 16, 2024, the EBCT result was 9.74. Review revealed 1 of 3 EBCT quarterly results was less than 10. Interview on January 24, 2024 at about 2:15 PM with the Assistant Regional Biomedical Technician revealed within the last six months, the biomed staff started checking EBCT on a quarterly basis. The last EBCT was last checked on January 16, 2024 and resulted as 9.74. During the interview, the technician recalculated the EBCT, and the result was 9.50. Interview revealed the result should not be rounded up to 10. The EBCT should be 10 or greater. Interview revealed because the recent EBCT was less than 10, the plan was to add more carbon to each carbon tank and to make adjustments with Booster pump A.. 2. Observation on January 25, 2024 at 8:50 AM revealed the amount of carbon in each tank was 15 and the total EBCT still was not documented on the carbon tanks. Interview on January 25, 2024 at 8:50 AM with the Assistant Regional Biomedical Technician revealed the facility had problems in April 2023, wherein, one of the carbon tanks piston went bad and at that time, the amount of carbon in each tank was increased to 14. As of January 24, 2024, the amount of carbon in each tank was increased from 14 to 15 and the booster pump was decreased. Interview revealed changes were made to the water treatment system and the EBCT calculated as 10.94. 3. Observation on January 26, 2024 at 8:30 AM revealed the EBCT was documented as 10.94 on the label for each carbon tank. Review on January 26, 2024 of the QAPI meeting minutes failed to revealed there was no documentation that spoke to the improvements made to the water treatment system beginning in Apil 2023. Interview on January 26, 2024 at about 12:30 PM with visiting the Clinical Nurse Administrator revealed there was no documentation in QAPI that spoke to the improvements made to the water treatment system beginning in April 2023.”