Davita Wall Township Home Training

“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: 39228 Based on one of one observation in the Peritoneal Dialysis (PD) Training Room and review of facility policy, it was determined that the facility failed to ensure that hand hygiene is performed to prevent potential cross contamination. Findings include: On 6/6/24, during an observation of Patient (P)9’s PD training, in Room 6, the following was revealed: At 11:10 AM, Staff (S)6, Registered Nurse, set up clean supplies on a tabletop designated as a clean area. At 11:17 AM, S6 exited the room and then at 11:18 AM, re-entered the room with a bag of dialysate solution, did not perform hand hygiene and then opened the bag of dialysate solution and placed it onto the clean table. S6, then touched a bottle of Alcavis disinfectant solution that was also located on the table and then performed hand hygiene. Review of facility policy titled, “Infection Control For Dialysis Facilities,” revision date: April 2023, stated, “... Hand hygiene 1. All teammates, ... will perform hand hygiene a. upon entering the patient treatment/training area, ... g. before touching clean areas such as supplies ...” N.J.A.C. 8:43A-24.8(b)”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 48966 Based on one of three observations of Home Training Rooms, staff interviews, and review of facility policy, it was determined that the facility failed to ensure that clean supplies are separated from contaminated areas in order to avoid possible cross contamination. Findings include: During a tour of the Home Training Rooms on 6/6/24 starting at 10:15 AM, the following was observed: In Training Room 3 at 10:31 AM, a labeled rectangular bleach container with one blue clamp submerged in the clear liquid was located on the dirty sink countertop. Next to the bleach container was a stethoscope. In front of the bleach container was a small blood tube rack with two blood filled purple top lab tubes and one blood filled yellow top lab tube. Next to the lab tubes was a blue disposable pad that had two red ultra clamps and one blue clamp on it. During an interview on 6/6/24 at 10:34 AM, Staff (S)5, a Registered Nurse, stated that the three clamps on the blue disposable pad were cleaned and drying. During an interview on 6/6/24 at 10:36 AM, S6, a Registered Nurse stated that he/she made the bleach this morning and was unsure if the blue clamp submerged in the bleach was present when he/she prepared it. S6 stated the blood tubes were from a peritoneal patient from yesterday. S6 stated the three clamps on the blue disposable pad were clean and should not be in the dirty sink area. S6 stated that the three clean clamps should be drying in the clean area. A review of the facility policy titled, “Infection Control For Dialysis Facilities,” revised in April 2023, stated, ... “Facility Hygiene 16. Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled ...” N.J.A.C 8:43A-24.8(b)”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 39228 Based on one of one observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure the chlorine and chloramine test strips available for use are not expired. The chlorine and chloramine test strips are utilized to indicate low levels of total chlorine in feed water used to prepare dialysis. Findings include: On 6/6/24 at 10:25 AM, a tour of Training Room 4, a Home Hemodialysis (HHD) Training Room, was conducted. The E-Z Chek Sensitive Total Chlorine & Chloramine test strips available for use in the room had a manufacturer’s expiration date of 5/31/24. At 10:30 AM, an interview was conducted with Staff (S)5, a Registered Nurse, who explained that the test strips are used after a new batch of dialysate is made to test for total chlorine/chloramines in water leaving the PureFlow machine. S5 also stated that facility staff is responsible to check for the expiration date prior to use. S5 stated that Training Room 4 was last used on 6/3/24 and that the patient that occupied the room had initiated training in Training Room 1, but was transferred to Training Room 4 to complete the training. S5 explained that unexpired test strips from Training Room 1 were used to test for total chlorine in Training Room 4. S5 explained that a plastic bin that contained supplies for the patient from Training Room 1, which included unexpired test strips, was brought into Training Room 4, and that those test strips were utilized to test for total chlorine in Training Room 4. At 1:00 PM, an interview was conducted with S2, Manager of Clinical Services, who provided the patient schedule for HHD training. Upon review of the schedule with S2, it was determined that no other HHD patients received training in Training Room 4 from 5/31/24 to the date of discovery of the expired testing strips on 6/6/24. Review of the manufacturer’s instructions for use for the E-Z Chek Sensitive Total Chlorine & Chloramines Test Strips, stated, “... Test Procedure ... 1. Verify the test strips have not expired ...” N.J.A.C. 8:43A-24.10(a)(3)”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 37656 Based on two of seven medical record reviews (Medical Records (MR) 1 and 2), staff interview, and a review of facility policy, it was determined that the facility failed to ensure that all Plans of Care are signed by the interdisciplinary team (IDT) members, including the patient or the patient’s designee. Findings include: A review of MR 1 and MR 2 revealed the following: A review of the initial Plan of Care meeting for Patient (P)1 held on 4/12/24, indicated it was signed by the Registered Nurse (RN), Registered Dietitian (RD), Social Worker (SW), and P1. The initial Plan of Care was not signed by the physician. Upon interview on 6/6/24 at 3:00 PM, Staff (S)3, Social Worker, stated that it was faxed to the physician to be signed but it was not returned. S3 stated that they have 30 days to sign it. A review of P2’s medical record indicated that his/her status was designated as unstable in March due to re-hospitalizations. An unstable Plan of Care meeting was held on 3/25/24. The plan of care was not signed by the physician. A review of P2’s stable Plan of Care dated, 4/25/24 was not signed by the physician and the designated caregiver. During an interview at on 6/7/24 at 11:30 AM, S3 stated that due to P2’s condition, his/her spouse, who was P2’s caregiver, was not able to attend. S3 stated that the physician attended remotely and he/she faxed the plan of care to the physician to be signed but the signed form was not returned. A review of the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised July 2023, stated, “...14. The patient’s plan of care will be completed by facility’s interdisciplinary team, including the patient or personal representative and be signed by team members including the patient or patient’s personal representative. ...” N.J.A.C 8:43A-24.13(b)”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 48966 Based on one of two medical record reviews, staff interview, and review of facility documents, it was determined that the facility failed to ensure monthly notes are completed by the physician. Findings include: On 6/7/24, a review of the medical record of Patient (P)6 lacked documented evidence of a physician’s monthly progress note for February, March, April, and May 2024. P6 was determined to be unstable in February 2024. The above was reviewed with Staff (S)1, the Facility Administrator, at 11:20 AM. S1 confirmed that no physician notes were found for the above mentioned months for P6. S1 explained this physician has his/her patients go to his/her office for monthly visits, but no documentation was evident in the medical record for the above mentioned months. A review of the facility policy and procedure titled, “Progress Note Policy,” revised in October 2023, stated, “... Physician: The attending Nephrologist is required to record progress notes at least monthly and for any clinical event, which must be recorded in a timeframe that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times ...” N.J.A.C. 8:43A-24.13(d)”