Davita Orchard Park Dialysis

“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: 40430 Based on policy review, observation, and interview, staff do not follow standard infection control practices and wear personal protective equipment, per policy. Specifically, staff do not properly wear face masks and eye protection when performing procedures during which spurting or spattering of blood, contact with hazardous chemicals, or contact with contaminated equipment might occur. This practice places patients and staff at risk for potential infection. Findings Include: Review on 06/28/24 of policy “Infection Control for Dialysis Facilities”, last revised April 2023, revealed appropriate personal protective equipment (gowns, gloves, eye protection, face shield) will be worn whenever there is potential for contact with body fluids, hazardous chemicals, contaminated equipment, and environmental surfaces such as patient care areas. Observations on the treatment floor revealed the following staff wore their face mask located below their nose and/or did not wear eye protection while initiating dialysis, stripping machines of used blood lines and dialyzers and/or while cleaning the machines and stations following patient treatments as follows: - On 06/26/24 at 10:30 AM at Station #13: Staff (M), Patient Care Technician, wore their mask below their nose while initiating treatment for fistula (surgically created access for dialysis) Patient #3. At 11:05 AM, at Station #23: Staff (R), Registered Nurse, was wearing prescription eyeglass that did not have side eye shields while initiating treatment for central venous catheter Patient #2. At 11:15 AM at Station #14: Patient Care Technician, wore their mask below their nose while initiating treatment for fistula (surgically created access for dialysis) Patient #4. At 11:00 AM at Station #5, at 02:05 PM at Station #2, and 03:10 PM at Station #1: Staff (L), Patient Care Technician did not wear eye protection when stripping machines of blood lines/dialyzers and while cleaning the machines and stations following patients’ treatments. - On 06/27/24 at 09:25 AM at Station #4 revealed Staff (L), Patient Care Technician, did not wear eye protection when stripping machines of blood lines/dialyzers and while cleaning the machines and stations following patients’ treatments. Interview on 06/28/24 at 01:30 PM with Staff (G), Facility Administrator, and Staff (T), Regional Coordinator, verified these findings.”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 40430 Based on policy review, observation, and interview the facility did not ensure that clean supplies were stored in a manner to avoid contamination with spurting or spattering of blood or fluids. This has the potential for cross-contaminating clean patient supplies. Findings Include: Review on 06/28/24 of policy “Infection Control for Dialysis Facilities”, last revised April 2023, revealed if a common supply cart is used to store clean supplies in the patient treatment area, this cart is to remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Clean areas should be clearly designated for the preparation, handling, and storage of unused supplies and equipment. Observations on 06/26/24 to 06/28/24 from 08:40 AM to 03:15 PM in the treatment area revealed clean supplies including 24 central venous catheter treatment termination kits, blood pressure cuffs and a blue facility blanket were stored in the splash zone, on the counter, directly behind Station #1. Interview on 06/28/24 at 01:30 PM with Staff (G), Facility Administrator, and Staff (T), Regional Coordinator, verified these findings.”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 34528 Based on interview, policy review, and document review, the facility does not identify by staff name those staff who are audited monthly during infection control audits from January 2024 to May 2024. This practice does not verify if all staff are audited annually. Findings Include: Interview on 06/26/24 at 3:30 PM with Staff (J), Licensed Practical Nurse, stated the names of staff audited for hand hygiene are not documented on the audit tool. Staff (J) stated identifying the staff that have been audited from month to month would be based on memory. Review on 06/27/24 of policy “Infection Control For Dialysis Facilities”, last revised April 2023, revealed no reference to annual infection control audits for staff. Review on 06/28/24 of Patient Care Technician and Nurse Annual Skills check lists, dated 10/01/22, revealed Patient Care Technician and Nurse skills include demonstration on appropriate hand hygiene as evidenced by appropriate handwashing technique per procedure and demonstrating appropriate use of alcohol-based hand rubs per procedure. Review on 06/28/24 of the Monthly Infection Control Audit document, dated January 2024 completed by Staff (J), Licensed Practical Nurse, revealed Hand Hygiene Observation took place for one Patient Care Technician and two Licensed Practical Nurses. The names of the staff observed were not documented. Review on 06/28/24 of the Monthly Infection Control Audit document, dated February 2024, revealed Hand Hygiene Observation took place for two Patient Care Technicians and one Registered Nurse. The names of the staff observed were not documented and the name of the observing staff was not documented. Review on 06/28/24 of the Monthly Infection Control Audit document, dated March 2024, revealed Hand Hygiene Observation took place for two Patient Care Technicians, three Licensed Practical Nursed, and one Registered Nurse. The names of the staff observed were not documented and the name of the observing staff was not documented. Review on 06/28/24 of the Monthly Infection Control Audit document dated April 2024 completed by Staff (J), Licensed Practical Nurse revealed Hand Hygiene Observation took place for two Patient Care Technicians and one Registered Nurse. The names of the staff observed were not documented. Review on 06/28/24 of the Monthly Infection Control Audit document dated May 2024 completed by Staff (J), Licensed Practical Nurse revealed Hand Hygiene Observation took place for two Patient Care Technicians and one Registered Nurse. The names of the staff observed were not documented. Interview on 06/28/24 with Staff (G), Facility Administrator verified findings.”

“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: 40430 Based on observation, policy review, and interview, nursing staff did not follow facility policy while performing central venous catheter care for four of four catheter patients (Patients #22, #23, #24, and #27). Failure to follow central venous care policy places patients at increased risk for infection. Findings Include: Review on 06/28/24 of the policy “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure,” last revised October 2023, revealed that upon completion of dialysis staff are to discard the existing barrier and place a new clean moisture proof barrier under the catheter to prevent contamination prior to aseptically disconnecting the blood lines from the catheter ports. Observation on 06/27/24 at 09:50 AM at Station #7 for Patient #22 revealed Staff (H), Registered Nurse, discontinued treatment via central venous catheter. Staff (H) did not place a new clean moisture proof barrier under the catheter ports prior to disconnecting the blood lines from catheter ports and continuing with post treatment catheter care as follows: At 09:55 AM at Station #9 for Patient #23 and at 10:15 AM at Station # 8 for Patient #24 revealed Staff (K), Licensed Practical Nurse, discontinued treatments via central venous catheters. Staff (K) did not place a new clean moisture proof barrier under the catheter ports prior to disconnecting the blood lines from the catheter ports and continuing with post treatment catheter care. Observation on 06/28/24 at 09:40 AM at Station #17 for Patient #27 revealed Staff (H), Registered Nurse, discontinued treatment via central venous catheter. Staff (H) did not place a new clean moisture proof barrier under the catheter ports prior to disconnecting the blood lines from catheter ports and continuing with post treatment catheter care. Interview on 06/28/24 at 01:30 PM with Staff (G), Facility Administrator, and Staff (T), Regional Coordinator, verified these findings.”

“HOT H20 DISINF SYS-MONITORING CFR(s): 494.40(a) 6.3.4 Bacterial control devices 6.3.4.3 Hot water disinfection systems: monitoring Hot water disinfection systems should be monitored for temperature and time of exposure to hot water as specified by the manufacturer. Also, hot water disinfection should be performed at least as often as recommended by the manufacturer. The temperature of the water should be recorded at a point farthest from the water heater-that is, where the lowest water temperature is likely to occur ...and measured each time a disinfection cycle is performed. A record that verifies successful completion of the heat disinfection should be maintained. Successful completion is defined as meeting temperature and time requirements specified by the equipment manufacturer. This Standard is not met as evidenced by: 16136 Based on document review and staff interview, the facility does not document the hot water temperature at the furthest point from the hot water heater for six of six months during 2024 (January -June 2024). Failure to record the disinfection water temperature may result in inadequate disinfection of the water system. Findings Include: Review on 06/27/24 at 12:00 PM of the Daily Water Treatment Log- Cold Water Plant (CWP) revealed the log did not provide evidence that the staff responsible for performing daily water readings on the Cold Water Plant log documented the time/temperature when hot water disinfection was performed nightly from January 2024 to June 2024. This time/temperature must be recorded where the lowest water temperature is likely to occur and to verify that a successful completion of the heat disinfection has been obtained per manufacturer recommendations. Interview on 06/28/24 at 01:20 PM with Staff (E), Biomed Tech, revealed that the staff have not been trained on how to obtain this information from the Cold Water Plant and have not documented daily water readings on the Cold Water Plant log the time/temperature of when hot water disinfection was performed nightly.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 16136 Based on observation, policy review and staff interview, the facility does not ensure that individual acid jugs were correctly labeled and that there was adequate separation between the cases of acid concentrate in the supply room. Failure to label the acid concentrate jugs and to provide adequate separation may result in the dialysis patients receiving an incorrect acid solution. Findings Include: Observation on 06/26/24 at 10:35 AM revealed three open one-gallon acid jugs located on the metal cart adjacent to Station # 12. One acid jug of 2.0 K 3.0 Ca was dated 06/21 but did not have teammate initials, one acid jug of 3.0 K 3.0 Ca was dated 06/23/24 but did not have teammates initials and one acid jug of 3.0 K 3.0 Ca was not dated and did not have teammate initials. Review on 06/28/24 at 10:00 AM of policy “Acid Concentrate System, Incoming Acid Concentrate and Supply Log and Use of Acid Gallon Concentrate Containers”, last reviewed April 2019, revealed that “upon opening an acid gallon concentrate container, label container with date opened and initials of teammate”. Observation on 06/26/24 at 11:13 AM in the supply room revealed one case (4 one-gallon jugs) of acid concentrate, 2.0 K 3.0 Ca was stored in front of two one-gallon jugs of 3.0 K 3.0 Ca acid concentrate without separation between the different acid concentrations. The labeling on the wall indicated that at this location, acid concentrate, 3.0 K 3.0 Ca, was to be stored. Review on 06/27/24 of policy “Look Alike, Sound Alike Product Storage and Labeling”, last reviewed April 2019, revealed that if products or containers look alike or sound alike should have dividers between the different solutions if the shelving is shared, brightly colored labels for the different solutions. Interview on 06/26/24 at 10:55 AM with Staff (G), Facility Administrator, verified this finding.”

“MICROB MONITOR-SAMPLE BEFORE DISINFECT CFR(s): 494.40(a) 7.2 Microbial monitoring methods 7.2.1 General: samples before disinfect Samples should always be collected before sanitization/disinfection of the water treatment system and dialysis machines. This Standard is not met as evidenced by: 16136 Based on policy review, document review, and staff interview, staff did not document the time that monthly water cultures are obtained for two of two months (April 2024 and May 2024), when cultures were collected prior to monthly water loop disinfection and that water cultures were collected within 72 hours of water loop disinfection. A time is needed to ensure the water culture sample is collected prior to the water loop disinfection and to ensure that water cultures are collected per facility policy. Findings Include: Review on 06/27/24 of policy “Water Culture”, last revised April 2024, revealed that routine water cultures are collected monthly within 72 hours prior to the scheduled disinfection of the distribution system. Review on 06/27/24 of the water cultures results dated January 2024 through June 2024 and the Scheduled Routine Disinfection log dated January 2024 through June 2024 revealed that for April 2024 and May 2024, staff did not document the time of obtaining the water culture or the time the water loop was disinfected. It was not possible to verify that the water culture samples were collected prior to water loop disinfection. Interview on 06/28/24 at 11:20 AM with Staff (E), Biomed Tech, verified this finding.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 16136 Based on observation and staff interview, the facility does not ensure adequate safety within the clinic area (sharps containers location, supply storage and electrical cord location). Failure to maintain safety within the clinic area may result in harm to the patients and staff. Findings Include: Observations on 06/26/24 revealed at 10:25 AM at the patient care sink revealed an electrical cord used for the grinder pump (a pump that grinds wastewater and pumps to a septic system) was lying on the bottom of the cabinet where the pump is located. It was noted that there was evidence that a water leak from the plumbing had occurred in this cabinet. Observation on 06/26/24 at 10:45 AM in the medication prepare area revealed a sharp’s container was overfilled and was not secured. Observation on 06/26/24 at 11:05 AM in the supply room revealed five cases of saline (12 bags of 1000 milliliter /case), three cases of Citeron - non-woven sponges, and two boxes of specimen shipping boxes supplies were stored on the floor. Observation on 06/27/24 at 12:10 PM in the exam room revealed a sharp’s container was overflowing and not secured. Interview on 06/26/24 at 11:22 AM with Staff (E), Biomed Tech, and Staff (G), Facility Administrator, and on 06/27/24 at 12:20 PM With Staff (G), Facility Administrator verified these findings.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 16136 Based on observation, document review and staff interview, the facility does not ensure that four of four facility systems are maintained (generator, electrical, lighting, and fire alarm). Failure to maintain these systems may result in patient and staff harm in the event of an actual emergency. Findings Include: Review on 06/26/24 at 1:35 PM of the Weekly Generator Function Test log from 01/02/24 through 06/26/24 did not provide evidence that the generator was tested thoroughly weekly or monthly per manufacturer recommendations. The only documentation provided on this log was the time the test began and ended without a load on the generator. Review on 06/26/24 manufacturer recommendations revealed that inspection of the generator is to be performed weekly consisting of the following: checking the fuel level, checking the engine and coolant levels, checking the control panel and generator set for accumulation of dust, check the air restriction indicator and visually check for signs of leaks from the fuel system. Documentation was not provided to verify that the emergency generator was tested every 20-40 days at a load of 30% of the nameplate rating. This documentation must also include the time required to transfer the rated load from complete cold starts. Interview on 06/27/24 at 12:20 PM with Staff (E), Biomed Tech verified this finding. Review on 06/26/24 at 02:30 PM of the ground fault circuit interrupters (GFCI) Monthly Inspection Report for 2023 revealed no evidence of documentation that the GFCI were inactivated at a maximum of 10mA (milliamperes) (a unit for measuring electrical current). There is no documentation that the GFCI’s were tested every six months in patient care areas from 06/2023 to present. Interview on 06/28/24 at 09:10 AM with Staff (E), Biomed Tech, verified this finding. Review on 06/26/24 at 02:05 of the 90 Minute Functionality Test for the battery-operated emergency lights for 2022 and 2023, revealed no documented evidence that the battery-operated emergency light in the water room was tested annually. Interview on 06/28/24 at 01:00 PM with Staff (E), Biomed Tech, confirmed this finding. Observation on 06/28/24 at 10:00 PM revealed that one of three pull stations was obstructed. This pull station was located adjacent to the staff entrance and was obstructed by 12 plastic reusable regulated medical waste containers. Interview on 06/28/24 at 10:10 AM with Staff E, Biomed Tech, verified this finding.”

“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: 16136 Based on observation, document review and staff interview, the facility does not ensure that the water room or the dialysis machines (3 of 27) are maintained. Failure to maintain dialysis equipment may result in delayed patient treatment. Findings Include: Review on 06/27/24 at 08:30 AM, of the Daily Water Treatment Log - CWP from 12/04/23 through 06/01/24, indicated that item #26, gauge #9, ultrafilter, was not within the facility established parameters of a delta pressure less than or equal 20 psi (pounds per square inch) as follows: In December 2023, parameters ranged from 40-50 psi for18 of 18 days; in January 2024, parameters ranged from 30 - 50 psi for 19 of 26 days; in February 2024, parameters ranged from 22 - 80 psi for 22 of 25 days; in March 2024, parameters ranged from 60 - 80 psi for 26 of 26 days; in April 2024, parameters ranged from 60 - 80 psi for 24 of 26 days; and in May 2024, parameters ranged from 70 - 80 psi for 27 of 27 days. Interview on 06/27/24 at 11:40 AM with Staff (E), Biomed Tech, verified this finding. Observation on 06/27/24 at 12:00 PM revealed that dialysis machine #5 at Station #2, dialysis machine #10 at Station #3 and dialysis machine #14 at Station #10 were leaking when the machines were in the daily disinfect mode. Interview on 06/27/24 at 02:00 PM with Staff (E), Biomed Tech, revealed that the dialysis machines have two tubes (one acid and one bicarbonate), retainer tube /suction rod, per machine. Both tubes are replaced at the same time but are not replaced at any specified interval.”

“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: 40430 Based on policy review, medical record review, observation, and interview, the facility does not ensure that dialysate flow rates are maintained for three of six patients (Patient #10, Patient #13, and Patient #17), correct dialyzer is utilized for two of five patients (Patient #19, and Patient #25), and catheter ports are heparinized (anticoagulant solution to preserve catheter patency) per physician order for one of six patients (Patient #6). This practice can potentially lead to inadequate dialysis and/or adverse patient outcome. Findings Include: Review on 06/28/24 of policy “Pre-Intra-Post Treatment data collection, Monitoring and Nursing Assessment,” last revised April 2024, revealed that prescription components and machine settings are verified by the teammate prior to initiation of treatment. Prescription components include but are not necessarily limited to: dialyzer make and model, dialysate flow rate, and all accesses are evaluated. If the dialysis prescription is not being met (including dialysis flow rate), the reason will be documented, and the licensed nurse will be informed. Review on 06/28/24 of policy “Central Venous Catheter Care”, last revised October 2022, revealed catheters not in use will have locking solution (heparin solution that sits in the catheter ports to preserve catheter patency) changed every dialysis treatment. Review on 06/27/24 of treatment flowsheets for Patient #10, dated 06/03/24 to 06/26/24, revealed a prescribed dialysate flow rate of 700 milliliters per minute (ml/min) was not maintained on 06/03/24, 06/07/24, and 06/10/24. There was no documentation in the medical record to indicate why the dialysate flow rate was not maintained as ordered. Review on 06/27/24 of treatment flowsheets for Patient #13, dated 06/03/24 to 06/26/24, revealed the prescribed dialysate flow rate of 500 ml/min was not maintained on 06/17/24. There was no documentation in the medical record to indicate why the dialysate flow rate was not maintained as ordered. Review on 06/27/24 of treatment flowsheets for Patient #17, dated 05/28/24 to 06/27/24, revealed the prescribed dialysate flow rate of 800ml/min was not maintained on 06/01/24, 06/22/24, and 06/25/24. There was no documentation in the medical record to indicate why the dialysate flow rate was not maintained as ordered. Observation on 06/27/24 at 12:15 PM at Station #13 for Patient #19 revealed they were dialyzing utilizing an Optiflux F180 dialyzer (filter used for dialysis to clean blood). Review of the treatment flowsheet, dated 06/27/24, revealed the prescribed/ordered dialyzer was an Optiflux F200. Interview on 06/27/24 at 12:15 PM with Staff (H), Registered Nurse, verified Patient #13’s prescription and verified the finding. Observation on 06/27/24 at 12:20 PM at Station #14 for Patient # 26 revealed they were dialyzing utilizing an Optiflux F200 dialyzer. Review of the treatment flow sheet dated 06/27/24 revealed the prescribed/ordered dialyzer order was Optiflux F180. Interview on 06/27/24 at 12:20 PM with Staff (H), Registered Nurse, verified Patient #26’s prescription and verified the finding. Review on 06/28/24 of treatment flowsheets for Patient #14, dated 05/13/24 to 06/26/24, revealed Patient #14 had a fistula and central venous catheter. Fistula access was being utilized for dialysis treatments. Review of flowsheet, dated 05/24/24, revealed last date catheter used for dialysis was 04/09/24. Review of Nursing Progress note, dated 05/24/24, revealed nursing verified Patient #14 had their catheter removed on 05/24/24. Intracatheter heparin was not instilled, as ordered, on 05/13/24, 05/17/24, 05/20/24, and 05/22/24. There was no documentation in the medical record to indicate why intracatheter heparin was not instilled, as ordered. Interview on 06/28/24 at 01:30 PM with Staff (G), Facility Administrator, and Staff (T), Regional Coordinator, verified these findings.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 40430 Based on policy review, medical record review, and interview, nursing staff did not ensure vital signs and/or treatment monitoring were completed, per policy, for five of six (Patient #6, Patient #9, Patient #13, Patient #14, and Patient #17) patients reviewed. This practice has the potential for adverse patient outcome. Findings Include: Review on 06/28/24 of the policy “Pre-Intra-Post Treatment Data collection, Monitoring and Nursing Assessment,” last revised April 2024, revealed that patient data/vital signs will be documented by the patient care technician or a licensed nurse to include standing blood pressure measurements pre and post treatment (if patient is unable to stand, document reason in the patient electronic record or flow sheet). Intradialytic (during dialysis) vital signs and treatment monitoring checks are completed at least every 30 minutes. At minimum, obtain and document blood pressure, pulse rate, blood and dialysate flow rates, arterial and venous pressures (machine readings to indicate how well or safely the treatment is going), and fluid removal and/or replacement. Review on 06/27/24 of the treatment flowsheets for Patient #6, dated 06/05/24 to 06/26/24, revealed lack documented post treatment standing blood pressure on 06/17/24 and 06/21/24 or a reason why it could not be obtained. Mobility was documented ambulatory with cane. Review on 06/27/24 of the treatment flowsheets for Patient # Patient #14, dated 05/13/24 to 06/26/24, revealed lacked documented post treatment standing blood pressure on 05/29/24 or a reason why it could not be obtained. Mobility was documented ambulatory with no assistance needed. Review on 06/27/24 of the treatment flowsheets for Patient #6, dated 06/05/24 to 06/26/24, revealed on 06/21/24 treatment started at 11:28 AM and ended at 02:52 PM. Every 30-minute treatment monitoring checks did not include the minimum required data at 11:30 AM, 12:00 PM, 01:00 PM, 02:36 or 02:52 PM. There was no documentation in the medical records to indicate why the checks were incomplete or omitted. Review on 06/27/24 of the treatment flowsheets for Patient #9, dated 06/03/24 to 06/26/24, revealed on 06/10/24 treatment started at 10:43 AM and ended at 14:32 PM. Every 30-minute treatment monitoring checks were not completed between 10:49 AM and 11:44 PM. On 06/14/24 treatment started at 10:39 AM and ended at 02:48 PM. Every 30-minute treatment monitoring checks did not include the minimum required data at 11:08 AM, 11:38 AM, and 02:48 PM. There is no documented 30-minute treatment monitoring at 01:08 PM or 02:08 PM. There was no documentation in the medical records to indicate why the checks were incomplete or omitted. Review on 06/27/24 of the treatment flowsheets for Patient #13, dated 06/03/24 to 06/26/24, revealed on 06/21/24 treatment started at 10:35 AM and ended at 01:39 PM. Every 30-minute treatment monitoring checks did not include the minimum required data at 11:08 AM. There was no documentation in the medical records to indicate why the checks were incomplete or omitted. Review on 06/27/24 of the treatment flowsheets for Patient #17,dated 05/28/24 to 06/26/24, revealed on 06/20/24 treatment started at 10:16 AM and ended at 01:54 PM. Every 30-minute treatment monitoring checks were not completed between 10:18 AM and 11:44 AM. There was no documentation in the medical records to indicate why the checks were incomplete or omitted. Interview on 06/28/24 at 01:30 PM with Staff (G), Facility Administrator, and Staff (T), Regional Coordinator, verified these findings.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 40430 Based on medical record review, document review, and interview the facility does not ensure patients are seen by a provider, monthly, for three of five (Patient #6, Patient #10, and Patient #14) hemodialysis patients reviewed. Lack of assessment can potentially result in inadequate dialysis treatments. Findings Include: Review on 6/28/24 on medical records revealed no evidence of monthly provider notes for the following patients: Patient #6 for September 2023, January 2024, and February 2024; Patient #10 for January2024, February 2024, March 2024, April 2024, and May 2024; and Patient #14 for January 2024. Review on 06/28/24 of “Medical Staff Bylaws”, effective 06/30/21, revealed providers must ensure patients are rounded on in compliance with state and federal requirements. At minimum, in-center patients must be evaluated and examined by a nephrologist (doctor that specializes in treating kidney conditions) no less than once per month, in person, in the facility while the patient is on dialysis. Interview on 06/28/24 at 01:30 PM with Staff (G), Facility Administrator, and Staff (T), Regional Coordinator verified these findings. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY CONDUCTED 07/28/2017.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 34528 Based on policy review, document review, and interview the facility does not ensure incenter hemodialysis program and the home program quality indicators are measured, analyzed and tracked independently. Failure to separate data has the potential for missed opportunities to improve care and services. Findings Include: Review on 06/28/24 of policy “Continuous Quality Improvement Program”, last reviewed April 2021, revealed the facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include Hepatitis B. Review on 06/28/24 of the Incenter and Home Hemodialysis program quality meeting minutes from March to May 2024 revealed no evidence that Hepatitis B susceptibility rates were tracked separately for the Incenter Hemodialysis and Home Peritoneal Dialysis Program. Review on 06/28/24 of March 2024 Facility Health Record Quality meeting minutes for Incenter Hemodialysis revealed 29 patients (Incenter Hemodialysis/Peritoneal Dialysis) were susceptible to Hepatitis B. Review on 06/28/24 of April 2024 Facility Health Record Quality meeting minutes for Incenter Hemodialysis revealed 31 patients (Incenter Hemodialysis/Peritoneal Dialysis) were susceptible to Hepatitis B. Review on 06/28/24 of May 2024 Facility Health Record Quality meeting minutes for Incenter Hemodialysis revealed 30 patients (Incenter Hemodialysis/Peritoneal Dialysis) were susceptible to Hepatitis B. Interview on 06/28/24 with Staff (G), Facility Administrator verified findings.”