Davita Atlantic County at Home

“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: 51227 Based on two of three observations, staff interview, and review of facility documents, it was determined that the facility failed to ensure that hand hygiene is performed during the initiation of hemodialysis through a Central Venous Catheter (CVC, a type of access used for hemodialysis) and during the initiation of hemodialysis through an arteriovenous fistula (AVF, a type of vascular access used for hemodialysis) to prevent cross contamination in accordance with facility policy. Finding include: On 3/25/25 at 10:45 AM in Station 11, Staff (S) 6, a Registered Nurse (RN) initiated hemodialysis through a CVC. After cleaning the exit site, S6 removed his/her gloves and donned (put on) a new pair of gloves. S6 did not perform hand hygiene before donning new gloves. S6 then applied a new dressing onto the exit site before he/she removed his/her gloves. Without the benefit of performing hand hygiene first, S6 donned a new pair of gloves and scrubbed the caps. S6 connected a pre-filled saline syringe and injected the fluid into each CVC line. S6 then removed his/her gloves and without the benefit of performing hand hygiene first, donned a new pair of gloves before he/she connected the patient to the hemodialysis machine. During an interview at 11:00 AM, S6 stated, “I realized that there was no hand sanitizer at the Station for me to perform hand hygiene after taking off my gloves.” On 3/25/25 at 10:35 AM in Station 10, S5, a Patient Care Technician (PCT), was observed initiating hemodialysis through an AVF. S5 checked the site for a bruit (using a stethoscope to listen for a whooshing or swishing sound, indicating blood flow through the access) and thrill (feeling for a vibration by touching). S5 then removed his/her gloves, went to the nurse’s station and grabbed supplies. Without the benefit of performing hand hygiene first, S5 donned a new pair of gloves to clean the access site. After cleaning the site with iodine, S5 removed his/her gloves. Without the benefit of performing hand hygiene first, S5 donned a new pair of gloves and proceeded to insert the needles. During an interview at 11:05 AM, S5 stated, “I should have performed hand hygiene after I removed my gloves each time.” Facility policy titled, “INFECTION CONTROL FOR DIALYSIS FACILITIES,” revised April 2023, stated, ...” HAND HYGIENE: 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, ...” N.J.A.C. 8:43A-24.8(b)”

“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: 39223 Based on one of two observations for the cleaning and disinfection of the hemodialysis station, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that the hemodialysis machine prime bucket, television and arm, blue supply bag, and chase wall (a wall built to enclose and conceal pipes, ducts, or other utilities) are cleaned and disinfected after patient use. Findings include: On 3/25/25 at 9:35 AM, after the patient left, Staff (S) 6, a Registered Nurse, used bleach-soaked cloths to clean and disinfect Station 11. S6 wiped the outer surfaces of the hemodialysis machine. S6 did not empty liquid remaining in the prime bucket and wipe the bucket with bleach-soaked cloths. S6 then proceeded to open the sides of the patient recliner chair and wiped the outside, top, and inside surfaces of the arms of the chair before immediately closing the arms. S6 did not allow the arms of the chair to dry in an open position before closing. Next, S6 wiped the headrest, back support, and seat of the patient recliner chair. S6 then wiped the leg support of the chair while it remained in a closed position. S6 performed hand hygiene and changed his/her gloves before setting up the hemodialysis machine with new tubing. During an interview at 9:54 AM, S6 stated that the arms of the recliner chair should be left open to dry after wiping with bleach-soaked cloths. S6 also stated that he/she did not clean the prime bucket before setting the station up for the next patient and confirmed that some clear liquid from the previous patient treatment remained in the prime bucket. S6 confirmed that he/she did not wipe the television and arm, blue supply bag, and chase wall with a bleach-soaked cloth. After interview, S6 proceeded to reclean and then set the patient station up a second time for a new patient. Facility policy titled, “Infection Control for Dialysis Facilities,” revised October 2022, stated, “... DIALYSIS STATION MANAGEMENT ... 66. Teammates will thoroughly wipe down all non-disposable items and equipment such as the blood pressure cuff, the inside and outside of the prime container, and the dialysis delivery systems, with an appropriate disinfectant after every treatment ...” N.J.A.C. 8:43A-24.4(b)”

“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: 51227 Based on one of one observation of initiation of hemodialysis using a central venous catheter (CVC, a type of access used for hemodialysis), staff interview, and review of facility policy, it was determined that the facility failed to implement infection control practices for cleaning the CVC access site and limbs prior to initiating hemodialysis. Findings include: On 3/25/25 at 10:45 AM, in Station 11, Staff (S) 6, a Registered Nurse (RN), initiated hemodialysis through a CVC. S6 cleaned the CVC exit site using a 2% Chlorhexidine Gluconate prepackaged swab for seven seconds, this was 22 seconds less than required by facility policy. S6 then used one alcohol preparation (prep) pad each to clean both the red cap and the blue cap. S6 did not clean the limbs of the CVC. S6 did not clean the CVC exit site for 30 seconds and did not cleanse the limbs of the CVC as required by facility policy. During an interview on 3/25/25 at 11:00 AM, S6 stated, “the site should be cleansed for 30 seconds with the chlorhexidine swap and then clean the caps with an alcohol prep pad for 15 seconds.” When questioned if he/she should clean the limbs of the CVC, S6 stated, “the limbs of the CVC don’t need to be cleaned.” Facility policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure,” revised October 2024, stated, “... Procedure: ... 8. Holding catheter with non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70 % Isopropyl Alcohol swap for a minimum of 30 seconds ... 9. Clean each CVC limb/cap with a new LARGE alcohol prep pad, starting close to the exit site and finishing with the cap ...” N.J.A.C. 8:43A-24.8(b)”

“BACT CONTROL-DISINFECT 1X/MO/DWELL CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: disinfect monthly/disinfection dwell Routine low-level disinfection of the pipes should be performed to control bacterial contamination of the distribution system. The frequency of disinfection will vary with the design of the system and the extent to which biofilm has already formed in existing systems, but disinfection must be performed at least monthly. A mechanism should be incorporated in the distribution system to ensure that disinfectant does not drain from pipes during the disinfection period. This Standard is not met as evidenced by: 39223 Based on review of facility documents and staff interview, it was determined that the facility failed to maintain a record that confirms successful completion of chemical disinfection of the Reverse Osmosis (RO) machine and testing for residual disinfectant after chemical disinfection for three of 26 weeks reviewed. Findings include: A review of the ‘CWP Daily Water Logs’ for September 2024 through February 2025, revealed that the space on the logs for “Check for Chemical Consumption ... YES (Y) OR NO (N) ...” was left blank on 11/29/24, 12/27/24, and 1/31/25. Additionally, a review of the ‘CWP Daily Water Logs’ also revealed that the space on the logs for “Chemical Disinfection Initiated ... Time of Day ...” was left blank on 12/26/24. During an interview on 3/26/25 at 11:50 AM, Staff (S) 3, the Biomedical Technician, confirmed that the CWP Daily Water Logs were incomplete as stated above. S3 stated that he/she completed a chemical disinfection of the Reverse Osmosis machine on 12/26/24, but forgot to document it on the log. Facility policy titled, “Water Treatment System Disinfection,” revised October 2021, stated, “... 10. Some hot water-disinfected direct feed systems utilize chemicals for the RO and hot water for the distribution system: The RO is disinfected at least weekly using peracetic acid (PAA) solution. The distribution system is disinfected at least weekly. ... 15. Facility teammates are to perform independent residual chemical testing prior to the beginning of the daily activities on the first treatment day following a water treatment system or membrane chemical disinfection at ALL locations listed below where applicable. ...” N.J.A.C. 8:43A-24.10(a)(8)”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 51227 Based on one of two observations of the initiation of hemodialysis through an arteriovenous fistula (AVF, a type of vascular access used for hemodialysis), staff interview, and a review of facility documents, it was determined that the facility failed to ensure that staff perform skin disinfection of the access site prior to initiating the dialysis treatment in accordance with facility policy. Findings include: On 3/25/25 at 10:35 AM, Staff (S) 5, a Patient Care Technician (PCT), entered Station 10 to initiate hemodialysis through an AVF. S5 cleansed the first site of the AVF with povidone iodine preparation (prep) pad in a circular motion for six seconds. This was 24 seconds less than required per facility policy. S5 proceeded to clean the second site with povidone iodine for seven seconds, this was 23 seconds less than required per facility policy. During an interview at 11:05 AM, S5 was asked about the procedure on performing skin disinfection of the site for an AVF. S5 stated, “You clean the site with iodine for 60 seconds.” When asked if he/she cleansed the site for 60 seconds, S5 stated, “I don’t know.” Facility policy titled, “AV Fistula or Graft Cannulation With Nipro Or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised October 2022, stated, “Skin Antiseptic ... Povidone Iodine ... Effective Contact Time ... 30 seconds ... Procedure: ... 11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. (For contact and dry time refer to table above) ...” N.J.A.C. 8:43A-24.8(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: 49828 Based on five of the six monthly physician notes reviewed for Patient (P) 7, staff interviews, and review of facilty documents, it was determined that the facility failed to ensure that monthly notes are completed by the physician for five of the six months reviewed while under the care of Staff (S) 17, the Medical Director. Findings include: A review of P7’s medical record lacked documented evidence of a physician’s monthly progress note for September, October, November, and December of 2024, and January 2025. On 3/26/25 at 9:50 AM, upon request for the missing physician monthly progress notes listed above, S1, the Clinical Coordinator, provided physician monthly progress notes for September, October, November, and December 2024. Review of the provided documents revealed that all the provided physician progress notes contained the following statement, “Disclaimer: This note was created on 3/26/25. The documented visit occurred [9/30/24, 10/21/24, 11/25/24, and 12/17/24]. Please note that more recent lab data may have become available after the date of the visit and may have been displayed on the patient chair and included in this note.” S1 stated that the notes for 9/24, 10/24, 11/24, and 12/24 were created on the day of survey as indicated by the disclaimer. S1 stated that there was no documented evidence of a physician monthly progress note for January 2025. During an interview on 3/27/25 at 12:05 PM, S17, the Medical Director, stated that he/she is the physician for P7 and was made aware after surveyors had requested the monthly physician notes for P7 that “some notes were delinquent.” S17 stated that the system generates his/her patients to chart on. P7 was missing from the list and therefore he/she did not document until being made aware the notes were missing yesterday (3/26/25). S17 further stated that while there were no documented monthly progress notes, he/she had done monthly in-person rounds on P7 until the patient was transferred to Long-Term Care (LTC). Facilty policy titled, “Progress Note Policy,” Revised October 2024, stated, “... Policy: ... 5. All progress notes are to be dated and signed at the time they are written or entered electronically ... 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)”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 48966 Based on two of two peritoneal dialysis (PD) medical records reviewed (Patient (P) 7, and P8), staff interviews, and review of facility documents, it was determined that the facility failed to ensure that each home PD patient’s treatment records are completed to include pre- (before) weight and pre-blood pressures. Findings include: A review of P7’s medical record revealed the following: The “CCPD [Continuous Cycling Peritoneal Dialysis] Treatment” orders from 3/5/25 and 3/24/25 were reviewed and stated, “... Frequency, One time a day ...” Ten of 21 treatments reviewed lacked documented evidence of a pre-treatment blood pressure on: 3/7/25, 3/8/25, 3/9/25, 3/14/25, 3/15/25, 3/17/25, 3/19/25, 3/22/25, 3/24/25, and 3/25/25. The “Pre-Sys [systolic]/Dia [Diastolic]” blood pressures were documented as “Skipped” or left blank. During an interview on 3/27/25 at 10:30 AM, Staff (S) 9, the Home PD Registered Nurse (RN), stated that he/she did not catch that on the above dates. The vital signs, inclusive of a blood pressure, for P7 were not documented by the Long-Term Care (LTC) facility staff. On 3/26/25, a review of P8’s medical record revealed the following: The “Homechoice Claria Prescribed Versus Actual Report,” an electronically transmitted treatment report from the PD Cycler (a machine used to perform PD treatments), from 2/17/25 to 3/25/25, indicated there were 30 PD treatments that lacked documentation of the patient’s pre-treatment weight and pre-treatment blood pressure. A review of the “Comprehensive Assessment Report,” dated 11/22/25, did not contain documentation by a RN that P8 was educated or re-educated on how to record pre-weight and pre-treatment blood pressures on the patient’s electronic flowsheets. A review of the “Patient Plan of Care,” dated 11/25/25, stated, “... Pre-Treatment Blood Pressure, No Data Available ... Blood Pressure Screening, Is blood pressure elevated per the Daily Home Treatment Records and clinic visits during the last 30 days? Yes ...” During an interview on 3/26/25 at 1:32 PM, S15, a RN, stated that P8 consistently failed to document blood pressures (BP) in the electronic record. S15 explained that when P8 is asked to record the BP on a paper PD flowsheet, P8 refuses. S15 also stated the electronic PD record is reviewed daily and P8 receives constant education on the importance of documenting BPs. During an interview on 3/27/27 at 9:48 AM, S9, a RN, stated P8 is not compliant with their requests to document his/her BPs on the electronic record or on the manual paper flowsheets. P8 has even received education by the Home Program Manager, but still fails to document his/her BP. S9 showed a “Care Activity” from 9/17/24 regarding education on how to document vital signs. S9 stated each time the staff educates P8 on documenting vital signs a note needs to be entered into the electronic medical record. Facility policy tilted, “Daily Home Treatment Record (Flowsheet),” revision date October 2024, stated, “... Definitions: ... 7. Daily Home Treatment Record (flowsheet)- record submitted by the patient or care partner of applicable treatment data including, but not limited to, date, vital signs ... This collection and submission of data can be completed by paper submission as well as various electronic channels, including but not limited to connected cycler data ... Policy: 1. Each peritoneal dialysis patient has agreed and been trained to complete documentation of each treatment on the Daily Home Treatment Record, also referred to as a flowsheet ...” N.J.A.C. 8.43A-13.1(a) 49828”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 39223 Based on observation, medical record review, staff interview, and review of facility documents, it was determined that the Medical Director failed to ensure that: 1) the Patient Care Technician (PCT) did not administer medications for one of two medication administrations observed, and; 2) the facility policy for patients ending treatment early is followed for three of the seven hemodialysis treatments reviewed for Patient (P) 7. Findings include: 1. During a tour of the hemodialysis treatment room on 3/25/25 at 10:22 AM, Staff (S) 5, a PCT entered Station 13 and checked the patient’s blood pressure. S5 then informed S6, a Registered Nurse (RN), that the patient’s systolic blood pressure was 94. S5 then proceeded to obtain the patient’s home prescription bottle of Midodrine 5 milligram (mg) (medication used to treat low blood pressure) from the patient’s personal bag. S5 removed one pill from the bottle and placed it into the patient’s mouth. During an interview at 10:25 AM, S5 stated that he/she was a PCT and should not administer medications. S5 stated that if the RN tells him/her that it is ok to give the home medication, and the patient requires assistance to get the medication out, then he/she is allowed to assist the patient. S5 explained that he/she can open the medication bottle and hand the medication to the patient, if the patient asks for help. During an interview on 3/26/25 at 1:54 PM, S1, the Clinical Coordinator, stated that the PCT should ask the RN if it is ok for the patient to take his/her home medication. S1 also explained that the PCT would not be able to check the patient’s medication orders to see if the Midodrine was a current order. Facility policy titled, “Medication Policy,” revised October 2023, stated, “... NOTES: ... The scope of practice and other statutes, rules and regulations that impact the practice of the RN, LPN/LVN [licensed practical nurse/licensed vocational nurse], and PCT may vary among states. ... 10. Prior to administration of medication verify physician or NPP order. Check for patient allergies when receiving or entering a medication order and prior to administering any medication. ...” N.J.A.C. 8:43A-24.6(f)(4)(iv) 49828 2. A review of P7’s medical record revealed the following: The “Backup Hemodialysis Treatment” orders stated, “... Frequency/TX [treatment]time Three times a week, (210 min[minutes]) ...” On 2/6/25, the “Treatment Details Report” indicated that P7’s initiation of hemodialysis began at 2:30 PM, and that treatment was terminated at 4:39 PM, 1 hour and 21 minutes earlier than the prescribed treatment time. The “Close Treatment Reason” section revealed, “Patient Transportation (arrived late, transportation issue, other medical appt.[appointment]).” The medical record lacked documented evidence that P7’s nephrologist was notified of the shortened treatment as required by facility policy. On 2/8/25, the “Treatment Details Report” indicated that P7’s initiation of hemodialysis began at 2:27 PM, and that treatment was terminated at 5:11 PM, 46 minutes earlier than the prescribed treatment time. The “Close Treatment Reason” section revealed, “Patient Choice [AMA (against medical advice), feels unwell/cramping, patient behavioral issue].” The medical record lacked documented evidence that P7’s nephrologist was notified of the shortened treatment as required by facility policy. On 2/18/25, the “Treatment Details Report” indicated that P7’s initiation of hemodialysis began at 2:22 PM, and that treatment was terminated at 5:01 PM, 51 minutes earlier than the prescribed treatment time. The “Close Treatment Reason” section revealed, “Patient Transportation (arrived late, transportation issue, other medical appt.).” The medical record lacked documented evidence that P7’s nephrologist was notified of the shortened treatment per facility policy. During at interview on 3/26/25 at 9:50 AM, S1, the Clinical Coordinator, confirmed the above findings that on 2/6/25, 2/8/25, and 2/18/25, there was no documented evidence that P7’s nephrologist was notified that P7’s hemodialysis treatment was shortened. S1 stated that whenever treatment is shortened more than 30 minutes early, the patient’s nephrologist should be notified per facility policy. Facility policy and procedure titled, “Prescribed Treatment Time Not Met,” Revised April 2024, stated, “... Policy: ... B. Prescribed Treatment Time Not Met 1. If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patients attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs. ...” N.J.A.C. 8:43A-24.4(a)”