Taos Home Dialysis

“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: 47302 Based on record review and interview the facility failed to provide information in the emergency plan that outlined what their patient population would need in an emergency. This deficient practice can affect all patient’s and lead to lack of planning for specific patient in the event there is an emergency that limits access to the facility. The findings are: A. Record review of the facility’s emergency plan revealed that the plan did not address the specific needs of the facility’s patient population. B. During an interview on 07/22/2025 at 2:00 PM with S(Staff)1, clinical, it was confirmed that the emergency preparedness plan did not address the specific needs of the facility’s patient population.”

“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: 47302 Based on record review and interview the facility failed to identify what the facility’s role would be under an 1135 waiver (allowed modification of regulatory requirements) as an alternate care site. This deficient practice could lead to lack of planning if an 1135 waiver were enacted and affect all patients in an emergency. The findings are: A. Record review of the facility’s emergency plan revealed that the plan did not address what the role of the facility would be under an 1135 waiver. B. During an interview on 07/22/2025 at 2:00 PM with S(Staff)1, clinical, it was confirmed that the emergency preparedness did not contain what the role of the facility would be under an 1135 waiver.”

“Primary/Alternate Means for Communication CFR(s): §403.748(c)(3), §416.54(c)(3), §418.113(c)(3), §441.184(c)(3), §460.84(c)(3), §482.15(c)(3), §483.73(c)(3), §483.475(c)(3), §484.102(c)(3), §485.68(c)(3), §485.542(c)(3), §485.625(c)(3), §485.727(c)(3), §485.920(c)(3), §486.360(c)(3), §491.12(c)(3), §494.62(c)(3). [(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: (3) Primary and alternate means for communicating with the following: (i) [Facility] staff. (ii) Federal, State, tribal, regional, and local emergency management agencies. *[For ICF/IIDs at §483.475(c):] (3) Primary and alternate means for communicating with the ICF/IID’s staff, Federal, State, tribal, regional, and local emergency management agencies. This Standard is not met as evidenced by: 47302 Based on record review and interview the facility failed to have a primary and an alternate means of communication in their Emergency Preparedness Plan. This deficient practice could lead to an inability to coordinate care for all patients in the event of an emergency. The findings are: A. Record review of the facility’s Emergency Preparedness Plan undated under the section “Communication Plan,” revealed there wasn’t any primary and alternate means of communication in the event of an emergency. B. During an interview on 07/22/2025 at 2:00 PM with S(Staff)1, clinical, it was confirmed that the emergency preparedness did not contain a primary and alternate means of communication.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 47302 Based on record review, observation and interview the facility failed to ensure that the arterial drip chambers [small, transparent container that holds blood coming from the patient’s artery before it is filtered by the dialysis machine] were filled approximately ¾ full for all patients during hemodialysis (process of cleaning the blood for patients that have kidney failure) treatments for 3 (P[patients]1, P6, and P8) of 8 (P1, P2, P6, P7, P8, P9, P10 and P11) patients receiving hemodialysis treatments. This deficient practice could lead to the risk of air embolism, (a condition where air bubbles enter the bloodstream, and may cause serious health issues like heart of brain damage) blood clotting, and inefficient blood flow which can compromise patient safety and dialysis effectiveness for all patients receiving hemodialysis treatments at the facility. The findings are: A. Record review of the facility’s Hemodialysis Operator’s Manual titled, “2008T Hemodialysis Machine Operator’s Manual” dated 2024 in Chapter 2 under “Daily Preparation for Treatment” it stated, “9. Fill the arterial drip chamber to an acceptable level. using the [up] key (level adjust) on the blood pump ...” B. During an observation on 07/23/2025 at 8:30 AM, the arterial drip chamber for P1 was less than half full. C. During an observation on 07/23/2025 at 8:30 AM, the arterial drip chamber for P6 was less than half full. D. During an observation on 07/23/2025 at 8:30 AM, the arterial drip chamber for P8 was less than half full. E. During an interview on 07/23/2025 at 8:30 AM with S(staff)1, clinical, it was confirmed that the drip chambers should be filled at least ¾ full.”