Fmc Avantus Irving Place Dialysis Center

“Vertical Openings - Enclosure CFR(s): NFPA 101 Vertical Openings - Enclosure 2012 EXISTING Vertical openings shall be enclosed or protected per 8.6, unless one of the following conditions exist: 1. Unenclosed vertical openings per 8.6.9.1 are permitted. 2. Unenclosed openings which do not serve as a required means of egress are permitted. 3. Exit access stairs may be unenclosed if they meet the following conditions: Two stories or less a. Building is protected throughout by a supervised sprinkler system per 9.7.1.1(1). b. Total travel distance to outside does not exceed 100 feet. Three stories or less a. Occupant load per story does not exceed 15 people. b. Building is sprinkler protected throughout per 9.7.1.1(1). c. Building contains an automatic smoke detection system per 9.6. d. Activation of the sprinkler system or smoke detection system notifies all occupants of the building. e. Total travel distance to outside does not exceed 100 feet. Floors that are below the street level and are used for storage or any use other than a business occupancy, shall not have any unprotected openings to the business occupancy floors. 21.3.1, 39.3.1.1, 39.3.1.2 This Standard is not met as evidenced by: 36207 Based on observation and staff interviews, the facility did not ensure that the enclosure of the vertical openings was maintained for their complete integrity by having appropriately sealed penetration. Findings Include, During the facility tour on 10/23/2024 between 11:00 a.m. and 12:30 p.m., an unsealed hole almost six (6) inches in diameter was noted in Stairwell A, on the 6th floor. This observation was made in the presence of Staff A (Director of Operation), Staff B (Home Therapy RN), and C (Biomed Equipment Technician). Upon interview on 10/23/24 at 1:45 PM, staff member C acknowledged the finding.”

“Portable Fire Extinguishers CFR(s): NFPA 101 Portable Fire Extinguishers Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers. 20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10 This Standard is not met as evidenced by: 36207 Based on observations and staff interviews, the facility did not maintain the portable fire extinguisher per NFPA 10, 6.1.3.3.2, 2010 edition. Failure to maintain the fire extinguisher will delay the fire extinguishing process in case of fire. Findings Include, During the facility tour on 10/23/2024 between 11:00 a.m. and 12:30 p.m., it was noted that a fire extinguisher installed in a recessed cabinet in the main weighting area did not have a sign conspicuously marking its location at the time of inspection. These observations were made in the presence of Staff C (Biomed Equipment Technician). Upon interviewing Staff C on 10/23/24 at 1:45 PM, the finding was acknowledged. .”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 21.3.7.5, 21.3.7.6, 8.5 This Standard is not met as evidenced by: 36207 Based on observation and staff interviews, the facility did not ensure that the rated smoke barrier walls were maintained for their complete integrity by having appropriately sealed penetration. Findings Include, During the tour of the facility on 10/23/2024 between 11:30 am, 3 unsealed penetrations were observed on the extension of the 1 hour wall above the ceiling of the 2-leaf door between doors 601 and 602. This observation was made in the presence of Staff A (Director of Operation) and Staff B. (Home Therapy RN) and C (Biomed Equipment Technician). Upon interview on 10/23/24 at 1:45 PM, staff member C acknowledged the finding.”

“Maintenance, Inspection & Testing - Doors CFR(s): This Standard is not met as evidenced by: 36207 Based on observations, document reviews, and staff interviews, the facility did not inspect and test the fire door assembly annually, according to the NFPA 80, 2010 edition. Failure to maintain fire doors could negatively impact the closing of fire doors in case of fire. Findings include, During the facility tour on 10/23/2024 between 11:00 a.m.and 12:30 p.m., it was noted that the 45-minute fire rated 2-leaf doors between doors 601 and 602 had 4 penetrations. During the document review on 10/23/2024 at 1:30 p.m., it was noted that there were no written inspection records for testing of the fire door assembly available for review. An interview with staff C (Biomed Equipment Technician) on 10/23/24 at 1:45 PM, confirmed this finding. He further stated that he was not aware of the requirement.”

“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 121 in-center patients. Findings include: Observation on 05/09/24 at 1:40 PM revealed Patient (P) 10 at Station 13 applied pressure to the left upper arm access site until bleeding had stopped. When finished the patient removed his/her glove and Patient Care Technician (PCT) 1 assisted the patient to the scale to retrieve his/her weight. The patient did not wash or sanitize hands and PCT1 did not instruct or encourage the patient to wash or sanitize hands. During an interview on 05/09/24 at 1:55 PM, PCT1 confirmed P10 did not wash or sanitize hands after holding access site and that he/she did not instruct or encourage the patient to wash hands. PCT1 stated it was important to prevent cross contamination. During an interview on 05/10/24 at 11:05 AM the Clinic Manager confirmed it was the facility policy that patients wash or sanitize hands after holding access sites to prevent cross contamination. Review of the facility policy titled, “Hand Hygiene,” revised 11/06/23 indicated, “ ...Gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids, such as when self-cannulating or holding access sites post treatment to achieve hemostasis. To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed.””

“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 policy review, the facility failed to ensure staff wore Personal Protective Equipment (PPE), (Personal protective equipment, commonly referred to as “PPE”, is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) appropriately for one of three days of the survey. The failure to wear PPE appropriately had the potential for staff to be exposed to “other potential infectious material (OPIM)” that could affect 121 in-center patients. Findings include: Observation on 05/08/24 at 10:45 AM, Registered Nurse (RN) 2 was at Station 5 initiating the treatment via Central Venous Catheter (CVC- a plastic tube inserted into a vein that is used for hemodialysis) for Patient (P) 2. RN2 did not have a face shield or eye protection. During an interview on 05/08/24 at 11:10 AM, RN2 acknowledged he/she forgot to apply eye protection during initiation of the dialysis treatment but should have to prevent any potential blood splatter to expose her eyes. During an interview on 05/08/24 at 11:30 AM, RN2 acknowledged he/she did not have on face shield during initiation of dialysis via a CVC because he/she forgot. Review of the facility’s policy titled, “Personal Protective Equipment,” revised 11/06/23, indicated, “ ...Personal protective equipment including a full-face shield or mask and protective eyewear with full side shield, fluid -resistant gowns, and gloves, must be wom to protect employees from blood or other potentially infectious materials (OPIM). PPE is used to protect employees who are occupationally exposed to blood or OPIM 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).””

“PA-TRANSPLANTATION REFERRAL CFR(s): 494.80(a)(10) The patient’s comprehensive assessment must include, but is not limited to, the following: (10) Evaluation of suitability for a transplantation referral, based on criteria developed by the prospective transplantation center and its surgeon(s). If the patient is not suitable for transplantation referral, the basis for nonreferral must be documented in the patient’s medical record. This Standard is not met as evidenced by: 30177 Based on interview and policy review, the facility did not have the selection criteria for two of two kidney transplant centers on file and available to patients. The failed practice did not ensure the facility had available the current selection guidelines and criteria for commonly referred transplant centers. This failure created a missed opportunity for patients to be informed and have knowledge of the transplant center’s current selection criteria and had the potential to negatively affect the 121 in-center hemodialysis patients and the 19 patients receiving home peritoneal dialysis care at this facility. Findings include: In an interview on 05/09/24 at 3:30 PM, the Social Worker was asked which two kidney transplantation centers patients at this facility are commonly referred to. The Social Worker stated that the majority of his/her patients are referred to “named facility” and “named facility.” When asked if the selection criteria for both “name kidney transplant centers” were available, he/she replied, “No.” The Social Worker was asked if he/she had access to the “name facilities” selection criteria. The Social Worker replied, “I can call the kidney transplant centers.” In a follow-up interview with the Social Worker on 05/09/24 at 4:15 PM, he/she stated that they were unable to retrieve the kidney transplantation center’s selection criteria. A review of the facility’s policy titled “Transplant Responsibilities and Guidelines,” revised in 03/02/20, revealed, “The facility will obtain the selection criteria from every transplant center to which it refers patients ... Each dialysis clinic is required to maintain a file that lists the selection criteria for each transplant program that it refers patients to for transplant evaluation. The facility may use the Request Letter for Transplant Criteria for Selection template to obtain the selection criteria from each program that it refers patients to for consideration of transplantation... The Social Worker will perform or coordinate the following to ensure the selection criteria from every transplant center is obtained and staff are aware of the selection criteria ... Every transplant center has its own acceptance criteria for candidacy, protocol for evaluation, and contraindications to transplantation.””

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 30177 Based on interview, document review, and review of facility policies, the staff failed to implement their grievance process in that the facility failed to inform six of ten sample patients (Patient (P)1, P3, P6, P7, P8, and P9) with updates periodically on his/her unresolved grievance’s progress and failed to report to P1, P3, P6, P7, P8, and P9 when a resolution was attained or considered attained by the facility. This failure to inform patients of grievance progress and resolution not only infringed upon the patient’s rights but also hindered the facility from responding to patients when grievances remained in progress or were resolved. Such a failure had the potential to deprive the patient of the opportunity to make informed decisions about his or her care, thereby potentially affecting the 121 in-center hemodialysis patients at this facility and the 19 patients receiving home peritoneal dialysis. Findings include: A review of an untitled document, which the Clinical Manager described as the “Patient’s Grievance Log,” revealed that P1, P3, P6, P7, P8, and P9 voiced concerns that were not immediately resolved as the facility’s expectations defined. In an interview with the Social Worker on 05/08/24 at 3:30 PM, the Social Worker was asked if P1, P3, P6, P7, P8, and P9’s grievances were immediately resolved. He/she replied, “No.” The Social Worker was then asked how the facility defines “Immediately Resolved.” The Social Worker replied, “Immediately resolved means the grievance was resolved on the same day.” The Social Worker stated, “I can take the report, but I do not resolved the grievances. I thought it was the Clinical Manager’s responsibility to resolve the grievances.” In an interview on 05/08/24 at 3:45 PM, the Clinical Manager was asked if he/she provided P1, P3, P6, P7, P8, and P9 or the patient’s representative with updates periodically on the grievance progress when the grievances were not immediately resolved. The Clinical Manager replied, “No.” The Clinical Manager was then asked if he/she reported to P1, P3, P6, P7, P8, and P9 when a resolution was attained or considered attained by the facility. The Clinical Manager replied, “No.” A review of the facility’s policy titled “Patient Grievance Procedure,” revised on 04/04/14, revealed, “The Clinical Manager reports back to the patient when a resolution is attained or considered attained by the facility. When the grievance cannot be immediately resolved, the Clinical Manager must periodically update the patient/representative on progress.””