322547-Kidney Care Center-Hobbs

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to ensure a process of emergency preparedness collaboration with the local emergency preparedness (EP) agency to confirm it is aware of the facility’s needs in the event of an emergency. This deficient practice could lead to the delays in meeting the facility’s needs in an emergency which could impact all patients receiving care at this facility. The findings are: A. Record review of document “Letter to Local Emergency Agency,” not dated, states “Contact [local emergency agency] at least annually.” No record noted of previous letters sent or received. B. During an interview with S (staff) 1, clinical, it was confirmed that the “Letter to Local Emergency Agency” has not been sent or communicated to local emergency command center in the past year.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(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:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to include policies and procedures in the Emergency Preparedness (EP) describing the facility ’ s role in providing care and treatment at alternative sites under a 1135 waiver. This deficient practice could have an impact on all patients who are receiving services with this facility by not establishing roles to protect all patients and their health information in the event of an emergency. The findings are: A. Based on a record review of the facility’s EP, undated, revealed the EP did not contain any facility roles under a waiver declared by the secretary. B. During an interview on 01/30/2025 at 9:15 AM S (Staff)1, clinical, confirmed that facility roles, under a waiver declared by the secretary, was not part of the facility’s EP.”

“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 ensure that the developed communication plan for the Emergency Preparedness Plan (EP) was updated every two years. This deficient practice could lead to delays in contacting appropriate Emergency Preparedness (EP ) services if the numbers have changed, which could impact all patients receiving care at this facility. The findings are: A. Record review of the facility’s policy “Emergency preparedness,” dated 07/01/2015, reflects emergency numbers. There was no evidence that this document was updated in the last two years. B. During an interview with S (Staff)1, clinical, on 01/30/2025 at 9:15 AM, S1 was unable to provide proof that emergency contacts have been updated in the last two years.”

“Information on Occupancy/Needs CFR(s): §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(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: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: 51995 Based on record review and interview, the facility failed to ensure the emergency preparedness communication plan contained information about the facility’s occupancy, needs, and its ability to aid their local emergency operations center (EOC). This deficient practice could impact all patients, for communication and assistance can be delayed in an emergency. The findings are: A. Record review of the facility’s document titled “Letter to Local Emergency Agency,” not dated, found in EP plan, stated “Contact [local emergency agency] at least annually.” No record noted of previous letters sent or received. B. During an interview on 01/30/2025 at 9:15 AM with S (staff)1, clinical, it was confirmed that the “Letter to Local Emergency Agency” has not been sent or communicated to the local EOC in the past year.”

“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 V113 Based on record review and observations, the facility failed to ensure staff practiced proper hand hygiene and glove use practices prior to performing patient care for affected 4 (P[patient] P4, P8, P9, P10) of 9 (P4, P8-15) patients observed. 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 “Infection Control for Dialysis Facilities” last reviewed 09/30/2024, under “Staff member hygiene,” it states “1. Hand hygiene is to be performed upon entering the facility, prior to gloving, after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, before touching clean areas such as supplies and before leaving the patient care area.” B. Record review of the facility’s policy titled “Pre-dialysis Central Venous Catheter (CVC: a temporary vascular access that enters through the chest wall and ends at the entrance of the heart) Dressing change,” last reviewed 09/24/2024, under “Procedure” stated “. . . 6. Carefully remove dressing. Discard the soiled gloves. 7. Apply clean gloves . . .” C. During an observation on 01/29/2025 at 11:56 AM at station 8, P8 received Central venous catheter (CVC) exit site care (cleaning of the chest wall and catheter connections of CVC) by S (Staff)2, clinical. S2 did not remove gloves, nor was hand hygiene performed after removing the old CVC dressing and prior to aseptic cleansing (Disinfection of chest wall and catheter tubing). D. During an observation on 01/29/2025 at 10:29 AM of P4 at station 13, S5, clinical, did not remove gloves after ending the dialysis treatment (disconnecting patient from dialysis machine). E. During an observation on 01/29/2025 at 11:21 AM of P9 at station 3, S3, clinical, did not perform hand hygiene prior to placing gloves on hands and prior to accessing a fistula (a surgical access connecting an artery and vein). F. During an observation on 01/29/2025 at 9:55 AM at station 6, S4, clinical, returned P10’s blood back from hemodialysis machine. S4 removed their gloves but did not perform hand hygiene. Additionally, S4 did not perform hand hygiene after dirty gloves were removed and after removing needles from P10’s access. G. Record review of the facility’s policy titled “Arteriovenous Fistula (AFV) and arteriovenous graft (AVG) Vascular access care,” dated 09/20/2024, revealed that no mention of glove removal and hand hygiene during the cannulation process (insertion of needles into vascular access and connected to dialysis machine). H. Record review of facility’s document titled “Audit tool: Arteriovenous fistula/graft cannulation observed,” dated 01/24/2024, revealed expectation of proper procedure as: “Hand hygiene performed ([by] staff). New, clean gloves worn. Skin antiseptic (a solution that prevents the growth or action of germs on the skin) applied appropriately. Skin antiseptic allowed to dry. No contact with fistula/graft site (after antisepsis [cleansing of skin to kill harmful germs]). Cannulation performed aseptically. Connect to blood lines aseptically. Gloves removed. Hand hygiene performed” I. During an observation on 01/29/2025 at 11:21 AM at station 3 of P9, S 3, clinical, had not performed hand hygiene prior to placing clean gloves while S3 was preparing to cannulate an AFV for P9. An antiseptic swab was applied to P9’s AFV. S3 then palpated over the cleaned AFV with a gloved finger. S3 did not reapply any antiseptic to the access after palpation and proceeded to cannulate the site. After accessing the site, taping the needles in place, and removing the tourniquet (elastic band placed above an AFV or AVG to assist with access), S3 did not remove gloves; Nor did S3 perform hand hygiene. S3 proceeded to touch patients ’ dialysis monitor with the same gloves that they wore during cannulation.”

“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: 51995 Based on record review, observation, and interview the facility failed to ensure that proper cleaning and disinfection of contaminated surfaces, medical devices, and equipment was performed. This deficient practice could lead to an increase in transmission (the act or process of sending or passing on) of dangerous germs for all patients. The findings are: A. Record review of the facility ’ s document titled “Audit tool: Hemodialysis station routine disinfection observations,” dated 01/08/2025, revealed expectations of routine disinfection are to include “All supplies removed from station and prime bucket emptied. . . disinfectant applied to all surfaces and prime bucket” B. During an observation on 01/29/2025 at 10:47AM at station 13, S (staff)6, clinical, did not fully recline the dialysis chair. Due to the chair not being fully reclined, S6 did apply disinfectant between the bottom cushion and the lower back of the chair. C. During an observation on 01/29/2025 at 11:15AM at station 3, it was observed that S7, clinical, did not empty, clean, or disinfect the prime waste container. D. During an interview on 01/29/2025 at 11:15AM at station 3 with S7, clinical, confirmed that the prime waste container was not emptied, cleaned or disinfected.”