Atlantic Dms - Springfield Blvd

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm Systems - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 41886 Based on staff interviews, the facility did not ensure that its fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance, and testing must be readily available. 9.6.1.3, 9.6.1.5 Upon request for Fire Alarm System Testing and Inspection Reports on 10/28/2024 at approximately 10:08 AM, the facility could not provide them. Therefore, it was determined that the Fire Alarm System initiating devices were not tested as required by NFPA 72. Staff A (AVP of Support Services) and Staff B (Chief Technician) were interviewed on 10/28/24 at approximately 01:58 PM, revealing that testing and Maintenance of the Fire Alarm System documents were unavailable at the facility.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 41886 Based on a staff interview, the facility did not ensure that its automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems. System design, maintenance, inspection, and testing records shall be maintained securely and readily available. Upon request for Sprinkler system inspection, Testing, and maintenance Reports on 10/28/24 at approximately 10:10 AM, the facility could not provide them. Therefore, it was determined that the initiating devices of the sprinkler System were not tested as required by NFPA 25. An interview of the AVP of Support Services (Staff A) and Chief Technician (Staff B) on 10/28/24 at approximately 2:00 PM revealed that the facility’s Testing and Maintenance of the sprinkler System documents were unavailable.”

“Maintenance, Inspection & Testing - Doors CFR(s): This Standard is not met as evidenced by: 41886 Based on observations and staff interviews, the facility did not have a maintenance and testing program for Fire Door Assemblies in accordance with NFPA 80 Standards for Fire Doors and Other Openings Protectives. Observation during a facility tour on 10/28/24 at approximately 11:35 AM identified that the 90-minute fire-rated door to the elevator control room stairs did not have a label on the frame and was not self-closing properly due to the non-functioning self-closure device. Also, the fire-rated door located in the exit corridor next to the dietitian room did not have a label on its door frame. Upon request for Fire and Smoke Barrier Door Assemblies Testing and Inspection Reports, the facility could not provide them. During the interview of the AVP of Support Services (Staff A) and Chief Technician (Staff B) on 10/28/24 at approximately 2:05 PM, it was revealed that the facility was not aware of the requirement and, therefore, did not have a vendor contract or trained personnel to perform the inspection.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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 the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID 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: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 26190 Based on interview, review of the facility’s “Emergency Management Plan, “the facility failed to include a documented facility/community-based risk assessment This failure had the potential to hinder the facility’s ability to prepare and respond to potential emergent situations, as well as protect the welfare and safety of patients and staff, placing all 93 in-center hemodialysis patients served by this facility at risk for a negative outcome. Findings include: A review of the facility’s “Emergency Preparedness” binder revealed a facility-based risk assessment could not be located. During an interview on 07/10/24 at 1:10 PM with the Facility Administrator, he/she was not aware that a facility-based risk assessment was completed for the facility. During an interview on 07/10/24 at 1:15 PM with the Administrative Support, he/she was not aware that a facility-based risk assessment needed to be completed/utilized as part of the facility’s emergency preparedness plan.”

“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: 26190 Based on interview and “Emergency Preparedness Plan” review, the facility failed to ensure it identified or participated in a tabletop exercise and/or community-based full-scale exercise within the last two years to evaluate the effectiveness of the “Facility Emergency Management Plan.” The failure to participate in a tabletop exercise and/or community-based exercise had the potential to negatively impact the facility’s ability to assess staff knowledge, emergency response skills, and readiness in an emergency. This failure could potentially affect all staff and the 93 patients receiving in-center hemodialysis at this facility. Findings include: Review of the facility’s “Emergency Preparedness” binder did not produce a full scale or tabletop emergency preparedness exercise completed by the facility. During an interview on 07/10/24 at 1:10 PM with the Facility Administrator, confirmed there were not any facility emergency preparedness exercises available for review. The Facility Administrator explained he/she had been the Facility Administrator at this facility since June 2024 and did not know why the emergency preparedness exercises had not been completed. Review of the facility’s “Emergency Preparedness” binder did not produce a policy that addressed the when, how and/or completion of emergency preparedness exercises.”

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 26190 Based on interview, review of the facility’s “Emergency Management Plan,” and policy review, the facility failed to provide emergency preparedness orientation and training for six (Patient (P)1, P3, P6, P7, P8, P9) of nine sampled residents. Failure to ensure patients are adequately trained to respond to emergencies could result in a delayed or inappropriate response for all 93 in-center hemodialysis patients receiving care at this facility. Findings include: Review of the resident record, provided by the facility revealed the following: P1 was admitted to the facility on 04/15/24 with one of his diagnoses being End Stage Renal Disease (ESRD). P3 was admitted to the facility on 05/02/24 with one of his diagnoses being ESRD. P6 was admitted to the facility on 09/02/15 with one of her diagnoses being ESRD. P7 was admitted to the facility on 04/12/24 with one of her diagnoses being ESRD. P8 was admitted to the facility on 05/13/21 with one of his diagnoses being ESRD. P9 was admitted to the facility on 05/17/22 with one of her diagnoses being ESRD. Review of P1’s medical record information, provided by the facility, indicated there was no documentation of P1 receiving education on emergency preparedness. Review of P3’s medical record information, provided by the facility, indicated there was no documentation of P3 receiving education on emergency preparedness. Review of P6’s medical record information, provided by the facility, indicated there was no documentation of P6 receiving education on emergency preparedness. Review of P7’s medical record information, provided by the facility, indicated there was no documentation of P7 receiving education on emergency preparedness. Review of P8’s medical record information, provided by the facility, indicated there was no documentation of P8 receiving education on emergency preparedness. Review of P9’s medical record information, provided by the facility, indicated there was no documentation of P9 receiving education on emergency preparedness. During an interview on 07/10/24 at 12:05 PM, the Social Worker (SW), stated he/she provided education to patients regarding emergency preparedness on the following topics: heat awareness, hurricanes, and winter storms. The SW explained he/she did not always document the education provided in the patient’s electronic medical record (EMR). During an interview on 07/10/24 at 1:10 PM the Facility Administrator, stated the staff member who provided a patient’s emergency preparedness education should document in the patient’s EMR that the education was completed. A review of the facility’s “Emergency Preparedness” binder did not indicate a policy regarding documentation of patients’ emergency preparedness education. A review of the facility’s policy titled, “Disaster Plan,” dated 07/01/09, indicated, “ ...Objectives: ...3. To provide a basis for emergency preparedness training for all ...patients ...VII. Patient Preparedness 0. Provide patients with a copy of the Dialysis Center’s Preparedness Plan. Information to be reviewed quarterly ...” A review of the facility’s undated policy titled, “Disaster Plan, “d indicated, “ ...Policy Statement: ...This program is undertaken with the intent of fulfilling responsibilities to ...patients. Objectives: 1. To inform and train ...patients to maximize their personal safety by reacting appropriately during a disaster ...6. To provide a basis for emergency preparedness training for all ...patients ...” A review of the facility’s policy titled, “General Patient Care Requirements,” dated 03/29/18 indicated, “ ...2. Every patient will have the following screening/planning completed on admission and on the schedule outlined below: ...6. Emergency Preparedness: ...Patients ...will be instructed at least yearly in the Dialysis Unit Emergency Preparedness Plan ...””

“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: 28297 Based on observation, interview, and policy review, the facility failed to ensure patients washed or sanitized hands after holding access sites (A vascular access is created so that blood can be drawn from the body and run through a dialysis machine, where excess fluid and toxins are removed from the blood. (i) The filtered blood then flows back through the access into the body) for one of three survey days. The failure for patients to wash or sanitize hands after holding access site had the potential for cross contamination and could affect 93 in-center patients. Findings include: Observation on 07/08/24 at 12:15 PM revealed the patient at Station 15 applied pressure to the left lower arm access site until bleeding had stopped. When finished the patient removed his/her glove and the patient’s transportation assistant assisted the patient to the wheelchair and the scale to retrieve his/her weight. The patient did not wash or sanitize hands and Patient Care Technician (PCT) 1, who was near the scale did not instruct or encourage the patient to wash or sanitize their hands. During an interview on 07/08/24 at 12:15 PM, PCT1 acknowledged the patient did not wash or sanitize hands after holding their access site and he/she did not instruct or encourage the patient to prevent cross contamination. During an interview on 07/10/24 at 1:10 PM the Facility Administrator confirmed patients should wash or sanitize hands after holding access sites at the end of treatment to prevent cross contamination of blood borne pathogens. Review of the facility’s policy titled, “Handwashing Procedure,” revised 07/14/17, indicated, “ ...Hand hygiene with either hand washing, or alcohol-based rub (may be done more frequently than the times mentioned below): upon arrival on duty, before and after each patient contact, after handling of equipment. Supplies, or environmental surfaces at the patient station, after removal of gloves ...””

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 28297 Based on observation, interview, and review of facility policy, the facility failed to ensure staff wore Personal protective equipment (PPE) appropriate for two of three survey days. The failure to wear PPE appropriately had the potential for staff to be exposed to Bloodborne Pathogens (infectious microorganisms in human blood that can cause disease in humans. These pathogens include, but are not limited to, hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV)) and this could affect 93 in-center patients. Findings include: 1.Observation on 07/09/24 at 1:55 PM revealed Patient Care Technician (PCT) 2 discontinuing the treatment at Station 24 for Patient (P) 9 via a fistula (a connection between an artery to a vein in to allow for hemodialysis). PCT 2 had on a yellow disposable gown. The gown was not closed at the top and during the disconnection process the grown fell off the shoulders and exposed her close under the gown. During an interview on 07/09/24 at 2:10 PM PCT2 confirmed that his/her gown was not closed at the top of the neck and did migrate down and had the potential to exposure him/her to blood exposure. 2.During an observation on 07/10/24 at 11:15 AM Registered Nurse (RN) 1 was at Station 20 administering medication to (P13 into the venous port of extracorporeal circuit. RN1 did not have a protective eye and face shield during medication administration. During an interview on 07/10/24 at 11:20 AM RN1 confirmed he/she did not have appropriate face and eye protection during medication administration as required but should have to prevent cross contamination of blood. During an interview on 07/10/24 at 1:10 PM the Facility Administrator confirmed that he/she observed RN1 administer medications without protective face covering and that it was required to prevent exposure to bloodborne pathogens. The Facility Administrator confirmed that staff should wear Personal Protective Gowns appropriately to prevent potential exposure to blood on personal clothes. Review of the facility policy titled, “Infection Control Practices in the Dialysis Facility,” revised 07/23/19, indicated, “ ...Staff members will wear impermeable gown (covers arms, torso, and at least mid-thigh), gloves, and face mask/shield (covers all mucous membranes) to protect themselves and prevent soiling of clothing when performing procedures during which exposure to blood might occur ...””

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 28297 Based on interview, facility document review, and policy review, the facility failed to complete infection control audits for six of six months reviewed for isolation practices and two of six months reviewed for other infection control audits (hand hygiene, initiation and termination of treatment and catheter care) as required. The failure to complete infection control audits as required had the potential for missed opportunities to capture breaches in infection control practices and could affect 93 in-center patients. Findings include: Review of six months of infection control audits from January 2024 through June 2024, provided by the Facility Administrator, revealed the facility did not have evidence that they completed facility infection control audits including hand hygiene, initiation and termination of treatment and catheter care for March 2024 and June 2024. In addition, there were no infection control audits for the care of Hepatitis B patients. The facility has had positive Hepatitis B patients in the past six months. During an interview on 07/10/24 at 1:10 PM the Facility Administrator stated the infection control audits could not be found for March or June 2024 and there were no infection control audits for the care of Hepatitis B patients. The Facility Administrator confirmed audits of these practices should be conducted monthly to capture breeches in practice so that they could be corrected in a timely manner. Review of the facility’s policy titled, “Infection Control Practices in the Dialysis Unit,” revised 07/23/19, indicated, “ ...Infection Control Practices will be monitored for effectiveness and results presented at the monthly Quality Assurance Performance Improvement Meetings ...””

“PE-COMFORTABLE TEMPERATURE CFR(s): 494.60(c)(2) The dialysis facility must: (i) Maintain a comfortable temperature within the facility; and (ii) Make reasonable accommodations for the patients who are not comfortable at this temperature. This Standard is not met as evidenced by: 28297 Based on observation, interview, and policy review, the facility failed to ensure the patient treatment area was at a comfortable temperature for patient comfort for two of three survey days. The failure to maintain a comfortable temperature for patients had the potential for patient to cover accesses and complain about being cold while on treatment. The deficient practice had the potential to affect 93 in-center patients. Findings include, 1. Observation and interview on 07/08/24 at 11:55 AM revealed Patient (P) 4 left access site was covered. When asked, the patient stated it was cold and pointed to a vent in the ceiling that was blowing on him/her. During an interview on 07/08/24 at 11:55 AM Patient Care Technician (PCT) 1 stated P4 covers his/her access because of complaints of being cold. PCT1 stated P4’s chair had been moved to not be under the vent. 2. Observation and interview on 07/09/24 at 12:30 PM, P11 at Station 3 catheter site were covered. The patient was shivering. The patient stated he/she knew it was supposed to be uncovered however, P11 complained of the facility being cold. During an interview on 07/09/24 at 12:30 PM, PCT3 confirmed the patient access should not be covered but patients complain of being cold. 3. Observation and interview on 07/09/24 at 12:35 PM, P12 at Station 16 left arm access was covered. P12 complained of being cold. During an interview on 07/10/24 at 11:40 AM Registered Nurse (RN) 2 confirmed patients complain frequently of being cold and cover their access sites. RN 2 stated they tell patients all the time to uncover their access sites, but they still cover them because they are cold. During an interview on 07/10/24 at 1:10 PM the Facility Administrator stated the temperature should be comfortable for the patients and acknowledged that a new plan needed to be implemented to ensure temperatures are documented and patient are comfortable. During an interview on 07/10/24 at 1:30 PM the Biomedical Technician stated they were required to check the temperature regularly and document however currently there were no documented temperature logs, and he/she was unable to verify the temperature with an independent method. Review of the facility’s policy titled, “Treatment Room Temperature Comfort,” revised July 1, 2009, indicated, “The Dialysis Center will maintain a comfortable temperature in the Treatment Room for the patients. Procedure: 1. The thermostats in the treatment room will be set between 70-72 degrees. 2. Thermostat readings will be recorded in a temperature maintenance log on a daily basis. 3. Patients will be advised to bring a blanket and/or head covering for their own comfort during the dialysis treatment. 4. Patients will be informed that their vascular access site, bloodline connections and face must be visible throughout the treatment. 5. Accommodations will be made when possible, to move the patients to a more comfortable location in the room based on the location of vents.””

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 28297 Based on observation, interview, and policy review, the facility failed to ensure the patient access sites were uncovered for two of three survey days. If access sites are covered there is an increased risk for adverse events, and this could potentially affect 93 in-center patients. Findings include, 1.Observation and interview on 07/08/24 at 11:55 AM revealed P4 left access site was covered. When asked, the patient stated it was cold and pointed to a vent in the ceiling that was blowing on him/her. PCT 1 ask P4 to uncover their access. During an interview on 07/08/24 at 11:55 AM Patient Care Technician (PCT) 1 stated P4 covers his/her access because of complaints of being cold. 2. Observation and interview on 07/09/24 at 12:30 PM P11 at Station 3 catheter site were covered. The patient was shivering. The patient stated he/she knew it was supposed to be uncovered however, P11 complained of being cold. PCT 3 instructed the patient to uncover their access. During an interview on 07/09/24 at 12:30 PM, PCT3 confirmed the patient access should not be covered but patients complain of being cold. 3. Observation and interview on 07/09/24 at 12:35 PM P12 at Station 16 left arm access was covered. P12 complained of being cold. During an interview on 07/10/24 at 11:40 AM Registered Nurse (RN) 2 confirmed their access site was covered because the patient was cold. RN2 stated they tell patients all the time to uncover their access sites, but they still cover them because they are cold. During an interview on 07/10/24 at 1:10 PM the Administrator stated that patient access sites must be uncovered to ensure patient safety from potential blood loss. Review of the facility policy titled “Assessment and Monitoring of Patients while receiving chronic outpatient Hemodialysis,” issued July 1, 2009 , indicated, “ ...All patients must have access and dialysis connections visible at all times during treatment so that staff may monitor for accidental dislodgement of needles, or disconnection of lines. Patients will be educated on this requirement and education will be reinforced as necessary. Every effort will be made to provide an environment that allows for the access site and line connections to be visible as well as patient modesty. Any patient non-compliance with this requirement will be referred to the Interdisciplinary Team to address.””

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 26190 Based on record review, and interviews, the facility failed to complete an initial comprehensive assessment conducted by all members of the interdisciplinary team (IDT - a registered nurse [RN], a physician treating the patient for end stage renal disease [ESRD], a social worker, and a dietitian) within 30 calendar days or 13 hemodialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) treatment sessions after admission, for one of nine sampled patients (Patient (P) 5) new to dialysis and admitted to the facility within the last 90 days. Failure to complete an initial comprehensive assessment performed by all members of the IDT within 30 calendar days or 13 hemodialysis treatment sessions after admission for patients new to dialysis, provided opportunities for areas of concern to be unidentified and unaddressed related to the plan of care, and had the potential to negatively impact the care and well-being of the 93 patients receiving dialysis treatments at this facility. Findings include: Review of the medical record, provided by the facility, revealed P5 was admitted to the facility on 12/07/23 with one of her diagnoses being End Stage Renal Disease (ESRD). Review of the medical record information, provided by the facility, indicated P5 did not receive a initial comprehensive assessment following his/her admission to the facility on 12/07/23. The first and only comprehensive assessment that was completed was dated 02/21/24 and was marked as the 90-day assessment. During an interview on 07/10/24 at 1:10 PM with the Facility Administrator, he/she confirmed that the staff was unable to locate an initial comprehensive assessment for P5. The Facility Administrator stated the facility’s interdisciplinary team (IDT-physician, nurse, social worker and dietician) was responsible for completion of the patients’ initial comprehensive assessments. The Facility Administrator stated he/she was not the Facility Administrator at the facility when P5 was admitted to the facility, but it was ultimately the responsibility of the Facility Administrator to ensure initial comprehensive assessments were completed for all of the facility’s newly admitted patients. Review of the facility’s policy titled, “General Patient Care Requirements,” dated 03/29/18, indicated, “ ...1. Comprehensive Patient Care: The care of every ESRD patient of the center is developed under the continuing supervision of the professional team of the dialysis center. The team consists of the patient’s nephrologist, nurses, nutritionist and social worker. a. A Comprehensive Interdisciplinary Patient Assessment will be completed on all patients to evaluate the patient’s immediate and long term needs and prescribe a planned regimen for adequate dialysis, medications, diet, special procedures recommended for the health and safety of the patient and plans for continuing care for the optimum health and safety of the patient ...It will be completed within 30 days or 13 treatments of the initiation of dialysis at the center ...””

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- (1) At least annually for stable patients; This Standard is not met as evidenced by: 26190 Based on record review, interview and policy review, the facility failed to ensure a comprehensive re-assessment with a revision of the plan of care was completed at least annually for one of nine sampled patients (Patient (P) 9). The failure to complete an annual assessment as required had the potential for missed opportunities for improvement in health outcomes and could affect 93 in-center patients. Findings include: Record review, provided by the facility, revealed P9 was admitted to the facility on 05/11/22 with one of his/her diagnoses being End Stage Renal Disease (ESRD). Review of the medical record information provided by the facility indicated P9 did not receive an annual comprehensive assessment which was due during May of 2024. The most recent comprehensive assessment was completed on 05/10/23 which was an annual assessment. During an interview on 07/10/24 at 1:10 PM with the Facility Administrator, she confirmed that the facility’s staff was unable to locate a more recent annual comprehensive assessment for P9. The Facility Administrator stated the facility’s medical team (physician, nurse, social worker and dietician) was responsible for completion of the patients’ comprehensive assessments, but it was ultimately the responsibility of the Facility Administrator to ensure annual comprehensive assessments were completed in a timely manner for the facility’s patients. Review of the facility’s policy titled, “General Patient Care Requirements,” dated 03/29/18 stated, “ ...1. Comprehensive Patient Care: The care of every ESRD patient of the center is developed under the continuing supervision of the professional team of the dialysis center. The team consists of the patient’s nephrologist, nurses, nutritionist and social worker ...b. Every patient will have a comprehensive Patient Assessment and Care Plan completed ...at least annually ...””

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 26190 Based on record review, interview and policy review the facility failed to monitor a patient’s psychosocial status and provide social work interventions through utilization of a standardized mental and physical assessment tool (Kidney Disease Quality of Life (KDQOL)) at regular intervals. In a sample of nine patients, seven patients (Patient (P) 1, P4, P5, P6, P7, P8, P9) were deficient. Findings include: Review of the resident record, provided by the facility revealed the following: P1 was admitted to the facility on 04/15/24 with one of his diagnoses being End Stage Renal Disease (ESRD). P4 was admitted to the facility on 03/08/24 with one of his diagnoses being ESRD. P5 was admitted to the facility on 12/11/23 with one of her diagnoses being ESRD. P6 was admitted to the facility on 09/02/15 with one of her diagnoses being ESRD. P7 was admitted to the facility on 04/12/24 with one of her diagnoses being ESRD. P8 was admitted to the facility on 05/13/21 with one of his diagnoses being ESRD. P9 was admitted to the facility on 05/17/22 with one of her diagnoses being ESRD. Review of the medical record information, provided the facility, indicated P1’s KDQOL was completed on 06/12/24, but it was not signed/dated by the Social Worker (SW) and there were no interventions or plans for P1 documented by the SW. Review of the medical record information, the facility provided, indicated P4’s KDQOL was completed on 06/17/24, but it was not signed/dated by the SW and there were no interventions or plans for P4 documented by the SW. Review of the medical record information, the facility provided, indicated P5’s KDQOL was completed on 06/03/24, but it was not signed/dated by the SW and there were no interventions or plans for P5 documented by the SW. Review of the medical record information, the facility provided, indicated P6’s KDQOL was completed on 06/12/24, but it was not signed/dated by the SW and there were no interventions or plans for P6 documented by the SW. Review of the medical record information, the facility provided, indicated P7’s KDQOL was completed on 06/12/24, but it was not signed/dated by the SW and there were no interventions or plans for P7 documented by the SW. Review of the medical record information, the facility provided, indicated P8’s KDQOL was completed on 03/25/24, but it was not signed/dated by the SW and there were no interventions or plans for P8 documented by the SW. Review of the medical record information, the facility provided, indicated P9’s KDQOL was completed on 10/09/23, but it was not signed/dated by the SW and there were no interventions or plans for P9 documented by the SW. During an interview on 07/10/24 at 12:05 PM, the SW, stated he/she routinely completed the yearly KDQOLs on his/her patients, but completion of the 90-day KDQOL was not a done. The SW said over the past five years he/she discontinued giving the patients the KDQOL for them to complete themselves, instead he/she asked the patients the questions and he/she wrote down the answers. SW confirmed there were times he/she did not sign/date or document interventions/plans for patients on their KDQOL. During an interview on 07/10/24 at 1:10 PM with the Facility Administrator, stated he/she was not aware the KDQOLs forms were not being fully completed by the SW. A review of the facility’s policy titled, “KDQOL Policy,” dated 09/05/23, stated, “Policy: 1. KDQOL Assessment: All dialysis patients will undergo regular assessments using the KDQOL-36 questionnaire to monitor their quality of life ...3. Documentation: Results of the KDQOL assessments will be documented in the patient’s electronic health medical record (EHR). 4. Intervention: Based on the assessment results, appropriate interventions will be developed and implemented to address identified issues ...Purpose: ...This includes the implementation of the KDQOL instrument, ensuring that patients’ physical and mental well-being are regularly assessed and appropriate interventions are provided based on the assessment results ...3. Intervention: Care Plan Development: Develop a personalized care plan addressing the specific needs and concerns in the KDQOL-36 assessment ...””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 26190 Based on record review, interview and policy review the facility failed to ensure that a patient’s plan of care was signed by the patient or documentation of the patient’s declination to sign the plan of care in nine (Patient (P) 1, P2, P3, P4, P5, P6, P7, P8, P9) of nine sampled patients. The failure to give patients opportunities to be involved in their POC had the potential for missed opportunities for improved care. Findings include: Review of the resident record, provided by the facility revealed the following: P1 was admitted to the facility on 04/15/24 with one of his/her diagnoses being End Stage Renal Disease (ESRD). P2 was admitted to the facility on 04/03/23 with one of his/her diagnoses being ESRD. P3 was admitted to the facility on 05/02/24 with one of his/her diagnoses being ESRD. P4 was admitted to the facility on 03/08/24 with one of his/her diagnoses being ESRD. P5 was admitted to the facility on 12/11/23 with one of his/her diagnoses being ESRD. P6 was admitted to the facility on 09/02/15 with one of his/her diagnoses being ESRD. P7 was admitted to the facility on 04/12/24 with one of his/her diagnoses being ESRD. P8 was admitted to the facility on 05/13/21 with one of his/her diagnoses being ESRD. P9 was admitted to the facility on 05/17/22 with one of his/her diagnoses being ESRD. Review of the medical record information provided by the facility indicated P1’s Plan of Care was completed on 05/13/24, but it was not signed/dated by P1, or their representative or the patient’s declination to sign the care plan documented. Review of the medical record information provided by the facility indicated P2’s Plan of Care was completed on 05/10/23, but it was not signed/dated by P2, or their representative or the patient’s declination to sign the care plan documented. Review of the medical record information provided by the facility indicated P3’s Plan of Care was completed on 03/11/24, but it was not signed/dated by P3 or their representative or the patient’s declination to sign the care plan documented. Review of the medical record information provided by the facility indicated P4’s Plan of Care was completed on 03/11/24, but it was not signed/dated by P4 or their representative or the patient’s declination to sign the care plan documented. Review of the medical record information provided by the facility indicated P5’s Plan of Care was completed on 02/21/24, but it was not signed/dated by P5 or their representative or the patient’s declination to sign the care plan documented. Review of the medical record information provided by the facility indicated P6’s Plan of Care was completed on 09/16/23, but it was not signed/dated by P6 or their representative or the patient’s declination to sign the care plan documented. Review of the medical record information provided by the facility indicated P7’s Plan of Care was completed on 05/13/24, but it was not signed/dated by P7 or their representative or the patient’s declination to sign the care plan documented. Review of the medical record information provided by the facility indicated P8’s Plan of Care was completed on 09/16/23, but it was not signed/dated by P8 or their representative or the patient’s declination to sign the care plan documented. Review of the medical record information provided by the facility indicated P9’s Plan of Care was completed on 05/10/23, but it was not signed/dated by P9 or their representative or the patient’s declination to sign the care plan documented. During an interview on 07/10/24 at 12:05 PM the Social Worker (SW) stated many of the patients participate in their care plan meetings. SW said he/she did not document a patient’s participation in their care plan meeting in the patient’s electronic medical record (progress notes) or have the patient sign the care plan meeting signature sheet. During an interview on 07/10/24 at 1:10 PM with the Administrator, he/she confirmed that the facility’s staff was unable to locate documentation regarding the patients’ participation in their care plan meetings. Review of the facility’s policy titled, “General Patient Care Requirements,” dated 03/29/18, stated, “ ...1. Comprehensive Patient Care: The care of every ESRD patient of the center is developed under the continuing supervision of the professional team of the dialysis center. The team consists of the patient’s nephrologist, nurses, nutritionist and social worker ...d. Patients will have the right to attend an Interdisciplinary meeting with the Nephrologist, a Nursing representative, Dietician, and Social Worker at all Care Plan meetings. They may also bring a representative, or have a representative attend in his/her place ...8. All patients will be given the opportunity to participate in the planning of their medical treatment. Patients will be informed about and participate, if desired, in all aspects of his or her care ...””