322505 Las Cruces Dialysis (Fmc)

“EP Program Patient Population CFR(s): §403.748(a)(3), §416.54(a)(3), §418.113(a)(3), §441.184(a)(3), §460.84(a)(3), §482.15(a)(3), §483.73(a)(3), §483.475(a)(3), §484.102(a)(3), §485.68(a)(3), §485.542(a)(3), §485.625(a)(3), §485.727(a)(3), §485.920(a)(3), §491.12(a)(3), §494.62(a)(3). [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (3) Address [patient/client] population, including, but not limited to, persons at-risk; the type of services the [facility] has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans.** *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do all of the following: (3) Address resident population, including, but not limited to, persons at-risk; the type of services the LTC facility has the ability to provide in an emergency; and continuity of operations, including delegations of authority and succession plans. *NOTE: [“Persons at risk” does not apply to: ASC, hospice, PACE, HHA, CORF, CMCH, RHC/FQHC, or ESRD facilities.] This Standard is not met as evidenced by: 51995 Based on record review and interviews, the facility failed to develop an Emergency Preparedness Plan (EPP) that addresses the needs of their patients during an emergency and any continuity of operations, including delegations of authority and succession plans (a plan describing who will be in charge during an emergency event if current leadership is unavailable). This deficient practice has the potential to affect all patients who receive services at the facility if an emergency were to occur due to the facility not clearly identifying and communicating about at-risk patients and not having clear alternative leadership set up prior to an emergency. The findings are: A. Record review of the facility’s Emergency Preparedness Plan (EPP), undated, revealed the plan did not contain any written procedure in place regarding how the facility plans to attend to patients during an emergency and succession plans. B. During an interview with S (staff) 1, clinical, on 01/23/2025 at 3:25 PM, S1 confirmed that there is a verbal understanding with facility staff that individual patient’s mobility will impact evacuation for patients. S1 confirmed that there is no written policy regarding succession plans in current EPP.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to develop an Emergency Preparedness Plan (EPP) with an evacuation location and a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. This deficient practice has the potential to affect all patients who receive services at the facility due to not having a system in place to track patients and staff if an emergency event were to occur. The findings are: A. Record review of the facility’s EPP, undated, revealed the plan did not contain any written policy or procedure to track patients and staff who evacuate or is a shelter in place during an emergency. B. During an interview with S (Staff)1, clinical, on 01/23/2025 at 3:25 PM, S1 confirmed the EPP did not have a written procedure in place for tracking patients and staff who evacuate or is a shelter in place during an emergency.”

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 51995 Based on record review and observation, the facility failed to develop a policy in their Emergency Preparedness Plan (EPP) to address guidelines for sheltering-in-place during an emergency. In emergency cases where staff and patients cannot safely leave the facility, it is important to have a pre-established meeting place to shelter in place. This deficient practice has the potential to affect all patients who receive services at the facility if a shelter-in-place emergency were to occur at this facility. The findings are: A. Record review of the facility’s policy titled “[Name of Company Clinical Services Policy and Procedure Updates” dated 02/14/2018 under “Guidelines for shelter-in-place during emergencies policy” stated “Shelter in place location must be identified on all posted facility evacuation maps.” B. During an observation of the evacuation map on 1/22/2025 at 2:12 PM, in the main patient treatment area, revealed the posted map did not clearly show where to shelter in place.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to develop an Emergency Preparedness Plan (EPP) that addresses a system of medical documentation that preserves patient information, protects confidentiality and secures and maintains availability of records. This deficient practice has the potential to affect all patients who receive services at the facility by not having a system in place to protect sensitive health information if an emergency were to occur. The findings are: A. Record review of the facility’s EPP, undated, revealed, the plan did not have a written policy and procedure in place regarding a system for medical documentation in case of an emergency. B. During an interview with S (Staff)1, clinical, on 01/23/2025 at 3:25 PM, S1 confirmed that the facility did not have a procedure in place for medical documentation in case of emergencies.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to ensure policies and procedures were developed for managing surge staffing (a plan to rapidly increase staff availability in case of an emergency). Failure to develop strategies to maintain adequate staffing levels could lead to negative patient outcomes for all patients receiving care at this facility in an emergency due to the facility being unable to meet unexpectedly increased patient volume or demand. The findings are: A. Record review of the facility’s Emergency Preparedness Plan (EPP), undated, revealed the plan did not have a written procedure in place regarding surge staffing. B. During an interview with S (Staff)1, clinical, on 01/23/2025 at 3:25 PM, S1 confirmed that there is a verbal understanding amongst facility staff of what to do to maintain adequate staffing in an emergency. S1 confirmed the facility did not have a written policy and procedure in place regarding surge staffing.”

“Arrangement with Other Facilities CFR(s): §403.748(b)(7), §418.113(b)(5), §441.184(b)(7), §460.84(b)(8), §482.15(b)(7), §483.73(b)(7), §483.475(b)(7), §485.625(b)(7), §485.920(b)(6), §494.62(b)(6). [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] *[For Hospices at §418.113(b), PRFTs at §441.184,(b) Hospitals at §482.15(b), and LTC Facilities at §483.73(b):] Policies and procedures. (7) [or (5)] The development of arrangements with other [facilities] [and] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For PACE at §460.84(b), ICF/IIDs at §483.475(b), CAHs at §486.625(b), CMHCs at §485.920(b) and ESRD Facilities at §494.62(b):] Policies and procedures. (7) [or (6), (8)] The development of arrangements with other [facilities] [or] other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. *[For RNHCIs at §403.748(b):] Policies and procedures. (7) The development of arrangements with other RNHCIs and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of non-medical services to RNHCI patients. This Standard is not met as evidenced by: 51995 Based on record review and interviews, the facility failed to ensure the emergency preparedness policies and procedure had written arrangements with other facilities and transportation services that would allow the continuity of services in the event of limitations or cessation [the facility being closed and unable to provide services]. This deficient practice has the potential to affect all patients who receive services at the facility due to not having a plan that will continue essential services if an emergency were to occur. The findings are: A. Record review of the facility’s Emergency Preparedness Plan (EPP), undated, revealed the no written agreements or recent communications with alternative, local facilities that would accept patients in an emergency. B. During an interview on 01/23/2025 at 10:52 AM, S (Staff)4, nonclinical, stated that “There is more than one [facility] in town. We would send patients there. We never signed contracts with hospitals, shelters, or transportation.” C. During an interview on 01/23/2025 at 3:25 PM, S1, clinical, confirmed that there is a verbal understanding between staff that they would send patients to local facilities for continuation of care. S1 confirmed that there are no written agreements or recent communications with alternative facilities present.”

“Dialysis Emergency Medical System Assistance CFR(s): §494.62(b)(8) 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:] (8) How emergency medical system assistance can be obtained when needed. This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to include policies and procedures for obtaining emergency medical assistance when needed in the emergency plan. Failure to arrange or communicate the facility’s capacity or need for emergency medical assistance could impact all patients receiving care at this facility and could lead to negative patient outcomes due to delays in care. The findings are: A. Record review of the facility’s Emergency Preparedness Plan (EPP), undated, revealed the plan did not have a written policy or procedure in place regarding obtaining emergency medical assistance. B. During an interview with S (Staff) 1, clinical, on 01/23/2025 at 3:25 PM, S1 confirmed that there is a verbal understanding between [name of the facility] in town. S1 confirmed that there is no written policy or procedure regarding obtaining emergency medical assistance..”

“Development of Communication Plan CFR(s): §403.748(c), §416.54(c), §418.113(c), §441.184(c), §460.84(c), §482.15(c), §483.73(c), §483.475(c), §484.102(c), §485.68(c), §485.542(c), §485.625(c), §485.727(c), §485.920(c), §486.360(c), §491.12(c), §494.62(c). (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to develop a written, comprehensive communication plan during an emergency. This deficient practice could lead to communication breakdown between emergency agencies and the facility and could impact on the health and safety of all patients who receive services at the facility if an emergency were to occur. The findings are: A. Record review of the facility’s Emergency Preparedness Plan (EPP), undated, the plan did not contain a written policy or procedure in place regarding communication planning that would comply with federal, state and local laws. B. During an interview with S (Staff)1, clinical, on 01/23/2025 at 3:25 PM, S1, clinical, stated there is an understanding that staff will need to communicate with any alternative health facilities and transport services “all necessary patient information that is readily available and should include: patient name, age, DOB, allergies, current medications, medical diagnoses, current reason for admission (if inpatient), blood type, advance directives and next of kin/emergency contacts.” S1 confirmed that there is no written communication policy and procedure at this time”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to update and maintain names and contact information of staff, providers, and other facilities that can offer dialysis care at least every two years. This deficient practice can lead to delays in care and adverse health outcomes if names and numbers are incorrect for all patients who receive services at the facility if an emergency were to occur. The findings are: A. Record review of the facility’s Emergency Preparedness Plan (EPP), undated, revealed the staff, provider, and other facilities contact number forms were not dated, and it was not noted on the last reviewed date. B. Record review of the undated directory titled “Employee Directory,” found in the EPP, staff schedules dated 01/06/2025 through 01/18/2025 did not include contact info for 7(S[staff] S6, S9, S14, S15, S16, S17, S18) listed in the staff schedule. C. During an interview on 01/23/2025 at 3:25 PM, S1, clinical, stated there was no proof that contact numbers were reviewed and updated every two years.”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to include methods of sharing patient information in their Emergency Preparedness Plan (EPP). This deficient practice could impact the health and safety of personal health information of all patients receiving care at this facility if there were an emergency. The findings are: A. Record review of the facility’s EPP, undated, revealed the plan did not contain a written policy or procedure in place regarding communication planning that would comply with federal, state and local laws. B. During an interview with S (Staff)1, clinical, on 01/23/2025 at 3:25 PM, S1 stated there is an understanding that staff will need to communicate with all emergency command centers, alternative care sites, and transportation agencies “all necessary patient information that is readily available and should include: patient name, age, DOB, allergies, current medications, medical diagnoses, current reason for admission (if inpatient), blood type, advance directives and next of kin/emergency contacts.” S1 confirmed that there is no written communication policy and procedure at this time.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to ensure emergency preparedness testing was complete. This deficient practice could result in staff not being prepared to respond to an emergency because of lack of testing, which could impact on all patients receiving care at this facility. The findings are: A. Record review of the facility’s Emergency Preparedness Plan (EPP), undated, revealed that a mock fire drill was performed for staff each shift on 12/30/2024 and 12/31/2024. The plan did not contain a debriefing or analysis of staff responses to the mock fire drill. B. During an interview on 01/23/2025 at 3:25 PM, S (Staff) 1, clinical, confirmed that they did a verbal debrief during the mock fire drill, but no recordings of debrief or analysis were recorded.”

“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: 51995 Based on record review and observations, the facility failed to ensure proper hand hygiene and glove use practices were performed by staff during dialysis treatments (a medical procedure that helps to perform the functions of a kidney when the kidney is no longer able to work properly. It removes waste, excess water and toxins from the blood that are normally filtered out by healthy kidneys. It’s often used in treating patients with chronic or acute kidney failure.) for 5 (P[patient] 6, 12, 15, 16, 21) of 12 (P6, P12-22) patients. This deficient practice could possibly lead to infection in this immunocompromised (a condition where the immune system is not working properly, making it difficult to fight off infections) population. The findings are: A. Record review of the facility’s policy titled “Hand Hygiene” dated 11/06/2023, revealed the following: -“Policy” stated “Decontamination using alcohol-based hand rub or by washing hands with antimicrobial soap and water ‘When ... Before and after direct contact with patients; Entering and leaving the treatment area; Before performing any invasive procedure such as vascular access cannulation [placing needles into a surgically made connection between a vein and artery which is used to connect patient to dialysis machine] or administration of parenteral medications; After contact with body fluids or excretion [body waste products], mucous membranes [the thin skin that covers the inside surfaces of parts of the body such as the nose and mouth and produces mucous to protect them], non-intact skin, and wound dressings if hands are not visibly soiled; After contact with inanimate [not organic] objects near the patient; When moving from a contaminated body site to a clean body site on the same patient; After contact with the dialysis wall box, concentrate, drain, or water lines; After contact with other objects within the patient station or treatment space.’ -“Procedure for Decontaminating Hands with Alcohol based hand rubs” Step 1. If gloves are worn, remove and discard in appropriate waste container. Expose the skin for decontamination. 2. Apply alcohol-based hand rub to the palm in one hand using the amount recommended by the product manufacturer . . . 3. Rub hands together covering all surfaces of the hands and fingers until hands are dry.” B. During an observation of P12 on 01/22/2025 at 2:04 PM, S [staff] 11, clinical, did not remove gloves, did not perform hand hygiene, and did not place clean gloves after reinfusion of extracorporeal circuit (The path the hemodialysis patient’s blood takes outside of the body. It typically consists of plastic tubing, a hemodialysis machine, and a dialyzer) while performing discontinuation of dialysis with Central Venous Catheter (CVC: a catheter that is inserted through the chest wall and ends at the entrance of the heart, used as an access point for dialysis treatment). C. During an observation of P6 on 01/22/2025 at 8:50 AM, S7, clinical, did not remove gloves, did not perform hand hygiene, and did not place clean gloves after removing and discarding an old CVC dressing and prior to disinfecting of CVC connections. D. During an observation of P21 on 01/22/2025 at 9:52 AM, S12, clinical, did not remove gloves and did not perform hand hygiene after initiation of dialysis treatment using an AV fistula (a surgical connection made between an artery and vein to allow for a stronger connection to the hemodialysis machine). E. During an observation of P16 on 01/22/2025 at 11:58 AM, S8, clinical, discontinued the needles from AV access and did not perform hand hygiene after removing gloves. S8 picked up a clean glove, and without placing hand inside the glove, touched the machine’s monitor, and then threw the glove away. S8 did not perform hand hygiene after touching the monitor with the ungloved hand. F. During an observation of P15 on 01/22/2025 at 12:10 PM, S13, clinical, did not perform hand hygiene after glove removal after P15 was stabilized and discharged.”

“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: 51995 Based on observation and interview, the facility failed to ensure appropriate infection control measures were taken to prevent intravascular catheter-related infections for 1 (P[patient] 20) of 12 (P6, P12-22) patients observed. This is evidenced by neither patient nor staff washing the skin over an AV access site (a surgical connection made between an artery and vein to allow for a stronger connection to the hemodialysis machine) with soap and water prior to treatment. This deficient practice could lead to infection or other complications of vascular accesses which may restrict a patient’s ability to receive care. The findings are: A. During an observation of P20 on 01/22/2025 at 1:41 PM at station 14, P20 arrived at the station experiencing shortness of breath, using a cane to help walk while wearing a large coat. P20 sat in dialysis chair and removed the coat. S (staff) 10, clinical, did not verbally confirm that vascular access was cleansed upon arrival. S10 proceeded with aseptic cleaning and accessing the vascular site with no complications. B. During an interview on 01/22/2025 at 1:51 PM, S10 confirmed that she did not verify with P20 to confirm of proper washing of the AV access site was performed. C. During an interview on 01/22/2025 at 1:51 PM, P20 confirmed that he walked straight over to the dialysis chair and did not wash his AV access as expected upon arrival.”

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 47302 Based on record review, observation, and interview the facility failed to ensure that the water softener was maintained. This deficient practice could lead to equipment failure and water impurities which could affect all patients that receive dialysis in the facility. The findings are: A. Record review of the facility’s policy titled, “Water Softener” dated 05/03/2023 under, “Monitoring of Water Softener Operational Performance” stated, “At a minimum, facility staff will monitor and document water softener(s) for the following each operational day: - Check brine tank daily to be sure the tank is at least half filled with salt, adding salt pellets if necessary.” B. During an observation on 01/22/2025 at 10:45 AM in the water treatment room the salt level in the water softener brine tank was less than half full and below the water line. C. During an interview on 01/22/2025 at 12:40 PM with S(Staff)3, non-clinical, it was confirmed that salt needed to be added to the brine tank.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 47302 Based on record review and interview the facility failed to sustain the prescribed dose of dialysis for 2 (P[patient]6 and P7) of 11 (P1-P11) patients reviewed for adherence to orders. This deficient practice may lead to patient’s not achieving adequacy from their dialysis treatments. The findings are: A. Record review of the facility’s policy titled, “Pre-Treatment Safety Checks Procedure” dated 02/06/2023 under “After Patient is Seated” stated, “The clinician initiating treatment must verify the prescribed set up matches the patient: - Patient’s identity per policy - Prescription - Dialyzer - Dialysate composition - Dialysate flow rate - Time - Goal set - Needle size - Temperature” B. Record review of the facility’s policy titled, “Patient Assessment and Monitoring” dated 05/01/2023 on page 6 stated “Check machine settings and measurements: - Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. . .” C. Record review of P6’s hemodialysis orders and treatment sheets revealed the following: 1. The BFR (blood flow rate; the speed that the patient’s blood is moving through the dialysis tubing) was ordered to run at 350 (the rate that was ordered for the BFR). 2. Treatment sheet for 01/13/2025 revealed that the BFR was running at 300 from 11:33 AM to 12:31 PM. No evidence regarding why the prescribed blood flow was not met. 3. Treatment sheet for 01/15/2025 revealed that the BFR was running at 400 for the patient’s whole treatment. No evidence was found that the order was changed nor was it documented why the prescribed blood flow was not met. 4. Treatment sheet for 01/22/2025 revealed that the BFR was running at 300 from 11:05 AM to 1:59 PM. No evidence was found regarding why the prescribed blood flow was not met. D. Record review of P7’s hemodialysis orders and treatment sheets revealed the following: 1. The BFR was ordered to run at 450. 2. Treatment sheet for 01/09/2025 revealed that the BFR was running at 400. No evidence was found that the order was changed nor was it documented why the prescribed blood flow was not met. 3. Treatment sheet for 01/14/2025 revealed that the BFR was running at 400. No evidence was found that the order was changed nor was it documented why the prescribed blood flow was not met. 4. Treatment sheet for 01/16/2025 revealed that the BFR was running at 400. No evidence was found that the order was changed nor was it documented why the prescribed blood flow was not met. 5. Treatment sheet for 01/18/2025 revealed that the BFR was running at 350. No evidence was found that the order was changed nor was it documented why the prescribed blood flow was not met. E. During an interview on 01/23/2025 at 1:00 PM with S(staff)1, non-clinical confirmed the BFR noted on the orders should be followed. S1 explained that if there is a change from the order for any reason it should be documented on the treatment sheet.”