Usrc West Cheektowaga

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 40430 Based on observation, policy review, and interview, facility nursing staff did not implement generally accepted infection control practices. Specifically, patient’s bloodlines (tubing or catheter used during dialysis, and are attached to the patient and the dialysis machine) were draped, resting on, or drooped into non biohazardous waste containers located in the dialysis stations, during their hemodialysis treatment (treatment that helps your body remove extra fluid and waste products from your blood). Findings Include: Observations on 07/23/24 revealed the following: at 11:00 AM at Station #9, Patient #3’s bloodlines were drooping into the non-biohazardous waste container during their treatment. At Station #3, Patient #4’s bloodlines were draped along the side, touching the outside, of the non-biohazardous waste container during their treatment. At 11:30 AM at Station #1, Patient #5’s venous (venous bloodline- returns clean blood to the patient) bloodline was drooping into, and the arterial bloodline (arterial bloodline-removes blood to be cleaned from the patient) was resting on the edge, of the non-biohazardous waste container during their treatment. At Station #12, Patient #6’s venous line was drooping into, and the arterial line was draped along the side, touching the outside, of the non-biohazardous waste container during their treatment. Observation on 07/24/24 at 11:10 AM at Station #2, revealed Patient #17’s bloodlines were draped along the side, touching the outside, of the non-biohazardous waste container during their treatment. Observations on 07/25/24 at 08:45 AM revealed at Station #1, Patient #26’s venous bloodline was draped into the non-biohazardous waste container during their treatment and at Station #8, Patient #27’s venous bloodline was resting on the top edge of the non-biohazardous waste container during their treatment. Observations on 07/23/24, 07/24/24, and 07/25/24 from 08:45 AM to 03:00 PM, in the treatment area, revealed the non-biohazardous waste containers contained items such as dirty gloves, used treatment supplies, used disinfectant wipes, medication/water cups, and other non-biohazardous waste items. Review on 07/25/24 of policy, “Infection Control and Precautions for All Patients”, revised July 2023, revealed the purpose of the policy is “to educate staff on general guidelines in the prevention of infection within the dialysis facility.” The policy did not discuss ensuring bloodlines are not in contact with contaminated areas/items during treatment. Interview on 07/25/24 at 01:30 PM with Staff (L), interim Facility Administrator, and Staff (Q), Clinical Specialist, verified these findings.”

“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: 40430 Based on observation, policy review, and interview, the facility failed to ensure that staff followed standard infection control practices regarding the use of gloves and hand hygiene. Findings Include: Observation on 07/23/24 at 02:00 PM at Station #12, revealed Staff (N), Patient Care Technician, while discontinuing treatment for Patient #6, pushed in the leg and footrest of the chair with gloved hands. Staff (N) then disconnected Patient #6’s bloodlines and removed dialysis needles. Staff (N) did not change their gloves and perform hand hygiene. Observation on 07/24/24 at 09:10 AM at Station #2, revealed Staff (B), Patient Care Technician, removed the bloodlines from Patient #18’s machine, changed gloves but did not perform hand hygiene prior to taping Patient #18 fistula needle sites. With the same pair of gloves, Staff (B) readjusted the blood pressure cuff and touched the dialysis machine to take a blood pressure for Patient #18. Staff (B) removed their gloves, without performing hand hygiene, and applied a new pair of gloves. Staff (B) was then observed removing the blood pressure cuff, removed their gloves, but did not perform hand hygiene. Staff (B) exited the station to walk Patient #18 to the scale to discharge Patient #18 from the unit. At 09:20 AM Staff (B) entered Station #1 for Patient #19 and put on new gloves. Staff (B) but did not perform hand hygiene prior to donning (applying) clean gloves. Staff (B) rinsed back Patient #19, disconnected the bloodlines, changed gloves, but did not perform hand hygiene prior to removing Patient #19’s dialysis needles. Observation on 07/24/24 at 12:35 PM at Station #9, revealed for Staff (J), Registered Nurse, with gloved hands, set up and initiated intradialytic parenteral nutrition (IDPN-intravenous method of providing supplemental nutrients during dialysis) via infusion pump for Patient #11. Staff (J), without removing gloves or performing hand hygiene, entered Station #10 and reset a machine alarm and readjusted/reconnected the blood pressure cuff for Patient #14. Staff (J) then touched the dialysis machine with the same gloved hands to retake the Patient #14’s blood pressure. Staff (J) returned to Station #9 to type on the dialysis machine keyboard for Patient #11. Wearing the same gloves, Staff (J) exited Station #9 and entered the medication preparation area to retrieve drawn up/labelled medication for Patient #14. Wearing the same gloves, Staff (J) entered Station #10 and administered intravenous and oral medication to Patient #14 and proceeded to touch the dialysis machine keyboard in Station #10. Staff (J) then removed their gloves but did not perform hand hygiene and proceeded to the medication preparation area to retrieve drawn up/labelled medication. At 12:40 PM Staff (J) entered Station #7 and administered intravenous and oral medication to Patient #15 not wearing gloves. Staff (J) touched Patient #15’s dialysis machine to reset an alarm. At 12:41 PM Staff (J) exited Station #7, without performing hand hygiene or applying gloves, to enter Station #10 and reset a dialysis machine alarm with ungloved hands. Without performing hand hygiene Staff (J) exited Station #10 and entered the medication preparation area to retrieve drawn up/labelled medication. Without performing hand hygiene, Staff (J) entered Station #3 and administered intravenous and oral medication to Patient #15 without wearing gloves. Review on 07/25/24 of policy, “Infection Control and Precautions for All Patients,” revised July 2023, revealed “staff will perform hand hygiene using soap and water or antibacterial hand sanitizer before/after all patient contact and before and after applying gloves. After contact with integrated keyboard or chairside computer, regardless of whether contact occurred through gloved or ungloved hands. Staff must remove gloves and perform hand hygiene between each patient or station.” Review on 07/25/24 of policy, “Preparation and Administration of IV (intravenous)/SubQ (subcutaneous)/IM (intramuscular) Medications,” revised February 2023, revealed “gloves must be worn during medication administration.” Interview on 07/25/24 at 01:30 PM with Staff (L), Interim Facility Administrator, and Staff (Q), Clinical Specialist, verified these findings.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 16136 Based on policy review, observation and interview, the facility does not ensure the labeling of two containers of bleach solution or that blood clamps are fully submerged in a disinfectant solution. Failure to label two solution containers and fully submerge the blood clamps may result in patient harm. Findings Include: Review on 07/23/24 of policy, “Disinfection and Cleaning of Dialysis Machine Equipment,” revised July 2023, revealed “that when preparing 1:100 bleach solution, label bleach container with the concentration, date, time and initials of the individual mixing the bleach solution. Disinfect non-disposable medical equipment (e.g. scissors, hemostats in open position and clamps), between uses by fully submerging items and soaking in a 1:100 bleach solution for at least five minutes”. Observation on 07/23/24 at 11:50 AM revealed, two of two containers containing a 1:100 bleach solution, located in the clean area across from station #1 and station #4, did not have a label indicating the contents or the concentration of the containers. Interview on 07/23/24 at 11:55 with Staff (J), Register Nurse, verified this finding. Observation on 07/24/24 at 01:35 PM revealed the dirty clamps that were present in the 1:100 bleach solution across from station #1 were not fully submerged in the bleach solution. It was noted that three clamps were only partially in the bleach solution. Interview on 07/24/24 at 01:40 PM with Staff (L), Interim Facility Administrator, verified this finding.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 40430 Based on observation, policy review, and interview nursing staff do not ensure compliance with current aseptic techniques related to safe injection practices, medication preparation/administration, nor that medications are drawn up per facility policy. Findings Include: Observations on 07/23/24 at 11:15 and on 07/24/24 at 09:00 AM, in the medication fridge, revealed a syringe with two milliliters of clear solution with a label of “Hepatitis 40 milligrams.” There were no staff initials, date, time, or patient name on the label. This was verified with Staff (J), Registered Nurse. Observation on 07/23/24 at 11:30 AM, at the medication preparation area, Staff (J), Registered Nurse, removed the plastic cap protecting the rubber stopper of an unopened vial of Venofer (intravenous iron supplement used for iron deficiency anemia) and did not wipe/disinfect the rubber top of the vial with an alcohol pad prior to withdrawing medication from the vial. Staff (J) then withdrew Epogen (intravenous medication used to treat anemia) from a multidose vial and did not wipe/disinfect the rubber top of the vial with an alcohol pad. At 11:38 AM at Station #3 for Patient #4 Staff (J) administered the Epogen via the medication port on the normal saline (intravenous solution used in preparation and delivery of hemodialysis). Staff (J) did not wipe the medication port with an alcohol pad. Observations on 07/24/24, revealed the following: at 12:20 PM in the medication preparation area, Staff (J), Registered Nurse withdrew Epogen from a multidose vial utilizing two separate syringes. Staff (J) did not wipe/disinfect the rubber top of the vial with an alcohol pad prior to reentering the multidose vial with the second syringe. Staff (J) removed the plastic cap protecting the rubber stopper of an unopened vial of Venofer and did not wipe/disinfect the rubber top of the vial with an alcohol pad prior to withdrawing the medication from the vial. At 12:25 PM in the medication preparation area, Staff (J) withdrew Epogen from a multidose vial utilizing two separate syringes and did not wipe/disinfect the rubber top of the vial with an alcohol pad for either entry into the vial. At 12:35 PM at Station #10, Staff (J) administered Epogen via the medication port on the normal saline line to Patient #14. Staff (J) did not swab the injection port with an alcohol pad prior to administration. At 12:40 PM at Station #7 for Patient #15 and at 12:42 PM at Station #3 for Patient # 15, Staff (J) administered Epogen via the medication port on the normal saline and did not swab the injection port with an alcohol pad prior to administration. Review on 07/25/24 of policy, “Guidelines for Administration of Medication,” revised April 2024, revealed staff are to “label pre drawn medications with patients name, medication name, dose, date, time, and preparer’s initials.” Review on 07/25/24 of policy, “Preparation and Administration of IV (intravenous)/SubQ (subcutaneous)/IM (intramuscular) Medications”, revised February 2023, revealed staff are to “remove the plastic cap protecting the rubber stopper of a vial for an unopened vial and wipe the rubber top of the vial with an alcohol pad. Rubber tops of previously opened multidose vials are to be wiped with an alcohol pad. Wipe the medication port on the normal saline line prior to inserting the needle into the port for administration.” Interview on 07/25/24 at 01:30 PM with Staff (L), interim Facility Administrator, and Staff (Q), Clinical Specialist, verified these 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, medical record review, policy review, and interview, nursing staff did not follow facility policy while performing central venous catheter care for six of six catheter patients (Patient #5, Patient #12, Patient #13, Patient #24, Patient #25, and Patient #28 ) and the facility does not ensure a registered nurse assesses the central venous catheter insertion site each hemodialysis treatment for three (Patient #1, Patient #4, and Patient #9) of three patients reviewed. Findings Include: Observations on 07/23/24 revealed Staff (J), Registered Nurse, while discontinuing treatment, did not replace the under pad, with a new under pad, beneath the catheter prior to disconnecting the blood lines at 01:30 PM at Station #1 for catheter Patient #5 and at 02:52 PM at Station #10 for Patient #12. Observations on 07/24/24 revealed the following: at 11:10 AM at Station #12, Staff (J) did not replace the under pad, with a new under pad, beneath the catheter prior to disconnecting the blood lines for Patient #13. At 02:50 PM at Station #5, Staff (J) initiated treatment via central venous catheter for Patient #28. Staff (J) did not remove Patient #28’s old exit site dressing and/or lift the dressing to assess the site and condition of the catheter before the initiation of treatment. This finding was verified with Staff (J) who stated they change the dressing at the end of the dialysis treatment. Observations on 07/25/24 revealed the following: at 10:05 AM at Station #7, Staff (G), Registered Nurse, while discontinuing treatment, did not replace the under pad, with a new under pad, beneath the catheter prior to disconnecting the blood lines for catheter Patient #25. At 10:20 AM at Station #5, Staff (O), Licensed Practical Nurse initiated treatment via central venous catheter for Patient #24. Staff (O) did not remove gloves and perform hand hygiene after removing Patient #24 old dressing and continuing with exit site inspection and care. Review on 07/24/24 of the treatment flowsheets for central venous catheter Patient #1 dated 06/29/24, 07/02/24, 07/04/24, 07/06/24, 07/12/24, 07/16/24, 07/20/24, and 07/23/24; Patient #4 dated 06/29/24, 07/02/24, 07/04/24, 07/09/24, 07/11/24, 07/16/24, 07/18/24, and 07/23/24; and Patient #9 on 07/16/24, 07/18/24, 07/20/24, and 07/23/24 revealed no documentation that a registered nurse assessed the catheter insertion site. Review on 07/25/24 of the policy, “Accessing and De-Accessing the Dialysis Catheter,” revised June 2024, revealed staff are to” replace under pad beneath the catheter prior to rinsing back the patient’s blood and disconnecting the bloodlines from the catheter.” Review on 07/25/24 of the policy, “Dialysis Catheter Dressing Change Procedure,” revised February 2023, revealed “that sterile gauze dressing will be changed every treatment. Remove and discard old exit site dressing. Remove gloves, perform hand hygiene and don (apply) clean gloves. If unable to perform catheter dressing change before initiation of treatment, apply clean gloves to lift the dressing to assess the site and condition of the catheter and then recover until dressing is changed. Care of catheters will include an accurate assessment of the insertion site for signs/symptoms of infection.” Interview on 07/25/24 at 01:30 PM with Staff (L), Interim Facility Administrator, and Staff (Q), Clinical Specialist, verified these findings.”

“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 (clean sink drainage, eye wash station accessibility, emergency access to patient toilet room, marked exit door does not latch and janitor’s door propped open). Failure to maintain safety within the clinic area may result in harm to the patients and staff. Findings Include: Observations on 06/26/24 at 10:55 AM in the clinic area, revealed that the patient handwash sink, adjacent to the floor scale, does not drain properly. It was observed that the sink was activated for 30 seconds and took two minutes and thirty seconds to drain. Interview on 07/23/24 at 02:15 PM with Staff (E), Bio Medical Technician, verified this finding. Observations on 07/23/24 at 12:02 PM and on 07/24/24 at 10:10 AM revealed the eye wash station, in the clinic area, across from Station #4, was obstructed by two regulated medical waste bins. Interview on 07/23/24 at 12:05 with Staff (N), Patient Care Tech, and on 07/24/24 at 10:15 AM with Staff (E), Biomed Technician, verified this finding. Observation on 07/24/24 at 12:45 PM revealed emergency access was not provided for the patient toilet room, which is located in the clinic, adjacent to the regulated medical waste room. It was also observed at 12:55 PM, in the clinic area, the fire exit door, adjacent to the storage area, does not latch when closed. Interview on 07/24/24 at 12:47 PM and at 01:05 PM with Staff (P), Biomed, verified these findings. Observation on 07/24/24 at 01:25 PM revealed that the one-hour fire door entering the janitor’s closet was propped open. It was also observed that ceiling tiles above the mop sink were broken and warped, and dust and debris was present on the exhaust vent. Interview on 07/24/24 at 01:30 PM with Staff (E), Biomed Technician, verified this finding.”

“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 two of two facility systems are maintained (electrical 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 07/24/24 at 11:10 AM of the Building Fire Alarm Installation and Testing Reports from 2023 and 2024 revealed that the facility has 17 horn/strobe devices. Additional review of this report did not provide evidence that a load voltage test had been performed on the batteries fire alarm control panel (FACP) for two of two inspections in 2023 (03/01/23 and 08/23/2023). Interview on 07/24/24 at 11:30 AM with Staff (P), Biomed, revealed that 24 horn/strobe devices were located in the facility and verified these findings. Review on 07/24/24 at 11:10 AM of the Building Fire Alarm Installation and Testing Reports from 2023 and 2024 did not provide evidence that the locking mechanism, on the door in the marked egress pathway, would release / unlock upon loss of power controlling the locking mechanism or upon activation of the fire alarm system. Interview on 07/25/24 at 03:20 PM with Staff (M), Regional Director, verified this finding. Interview on 07/24/24 at 03:00 PM with Staff (P), Biomed, revealed that the facility has not performed inspections on the fire doors and that the facility was not aware that fire door inspections are required annually. Fire doors must be inspected annually per NFPA 80 (National Fire Protection Association), 2010 edition, to ensure that the door, frame, hardware, and glazing are installed properly and will continue to function as intended if a fire or emergency occurs. Review on 07/25/24 at 11:10 AM of the requested documentation, on 07/23/24 at 10:35 AM for the 2023 and 2024 semi-annual and annual testing, of the Ground Fault Circuit Interrupters (GFCI), was not provided to verify that these outlets had been tested. It was observed on 07/24/24at 02:15 PM, that two GFCI outlets are located a each dialysis station. The GFCI’s must be tested every six months in patient care areas and annually in non-patient care areas to ensure the devices are inactivated at a maximum of 10 mA (milliamperes) (a unit for measuring electrical current). Interview on 07/25/24 at 11:15 with Staff (E), Biomed Technician, and at 03:20 PM with Staff (M), Regional Director, 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 policy review, document review and staff interview, the facility does not ensure that the dialysis machines are chemically disinfected weekly. Failure to chemically disinfect the dialysis machines may cause the machine to malfunction during patient treatment. Findings Include: Review on 07/25/24 of policy, “Machine Disinfection - Fresenius”, revised February 2023, states that “All machines including back up machines must go through weekly bleach disinfection.” Review on 07/25/24 at 01:00 PM of the Machine Disinfect Log from January 2024 through July 2024 revealed the following: dialysis machines #1 through #15 were not disinfected the weeks of 01/21/24, 01/28/24, 02/18/24,03/10/24, /04/14/24, 04/21/24 and 06/09/24. Interview on 07/25/24 at 01:30 PM with Staff (E), BioMed Technician, verified this finding.”

“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: 40430 Based on observation, policy review, and interview, staff do not ensure all hemodialysis access sites are visible throughout the patient treatment. Findings Include: Observations on 07/23/24 from10:55 AM to 11:16 AM and from 01:30 PM to 02:00 PM at Station #9 revealed fistula (surgically created access site used for dialysis) Patient #3’s bloodline connections were covered by their blanket. Observation on 07/23/24 from 10:55 AM to 01:30 PM at Station #3 revealed central venous catheter (temporary access site for dialysis) Patient #4’s bloodline connections were covered by their blanket. Observation on 07/25/24 11:55 AM at Station #10 revealed fistula Patient #3 bloodline connections were covered by their blanket. Review on 07/25/24 of policy, “Intradialytic Monitoring of Patient,” revised September 2020, revealed “staff will ensure patient’s access, blood lines and face are visible at all times.” Interview on 07/25/24 at 01:30 PM with Staff (L), Interim Facility Administrator, and Staff (Q), Clinical Specialist, verified these findings.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 40430 Based on policy review, medical record review, and interview, pre and post treatment nursing assessments were not completed timely, as required, by a registered nurse for four of 6 patients (Patient #3, Patient #4, Patient #6, and Patient #10). Findings Include: Review on 07/25/24 of policy, “Pre-Treatment Assessment of Patient,” revised January 2020, revealed “pre dialysis nursing assessment will occur within the first hour of patient contact or per stricter state regulations.” This policy did not include guidance to staff regarding New York State regulation 757.3 (b) (1) requiring a registered nurse pre-treatment assessment/documentation in the medical record within 45 minutes of the initiation of treatment for catheter patients and 60 minutes for non-catheter patients. Review on 07/25/24 of policy, “Post Dialysis Assessment of Patient,” revised January 2020, revealed “the patient is assessed post treatment to address any identified issues prior to discharging a patient. Post dialysis assessment includes, but is not limited to, sitting and standing blood pressure.” Review on 07/24/24 of fistula Patient #3 flowsheets, dated 06/29/24 to 07/23/24, revealed on 07/11/24 there is no post treatment standing blood pressure or a reason why it could not be obtained. Mobility was documented as ambulatory. Review on 07/24/24 of catheter Patient #4 flowsheets, dated 06/29/24 to 07/23/24, revealed on 07/02/24 at 11:24 AM, treatment was initiated by a patient care technician. At 02:14 PM, the registered nurse pre assessment was signed off as completed. On 07/18/24 there is no post treatment standing blood pressure or a reason why it could not be obtained. Mobility was documented as ambulatory. Review on 07/24/24 of fistula Patient #6 flowsheets, dated 06/25/24 to 07/23/24, revealed on 07/02/24 at 10:24 AM, treatment was initiated by a patient care technician. At 11:54 AM, the registered nurse pre assessment was signed off as completed. On 07/23/24 at 01:53 PM, treatment was discontinued by a patient care technician. At 08:22 PM, the registered nurse post assessment was signed off as completed. Review on 07/24/24 of fistula Patient #10 flowsheets, dated 06/28 /24 to 07/22/24, revealed on 06/28/24 at 06:01 PM, treatment was discontinued by a patient care technician. On 07/01/24 at 02:31 PM, the registered nurse post assessment was signed off as completed. On 07/15/24 at 03:43 PM, treatment was initiated by a patient care technician. At 06:22 PM, the registered nurse pre assessment was signed off as completed. On 07/17/24 at 02:23 PM, treatment was initiated by a patient care technician. At 04:24 PM, the registered nurse pre assessment was signed off as completed. At 07:44 PM, the post assessment was signed off as completed. On 07/22/24 at 02:43 PM, treatment was initiated by a patient care technician. At 04:42 PM, the registered nurse pre assessment was signed off as completed. Interview on 07/25/24 at 01:30 PM with Staff (L), Interim Facility Administrator, and Staff (Q), Clinical Specialist, verified these findings.”

“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, and interview the facility does not ensure that the dialysis prescription is followed, per physician order, for 5 (Patient #1, Patient #3, Patient 4, Patient #6, and Patient #10) of 6 patients reviewed. Findings Include: Review on 07/25/24 of policy, “Initiation of Dialysis Treatment,” revised August 2020, revealed staff are “to verify all prescribed orders are followed. If unable to follow any part of the patient’s prescription notify the charge nurse and document notification. Charge nurse will document any follow up or new orders. Prescription orders include, but are not limited to, blood flow is at prescribed rate, and correct dialysate flow rate.” Review on 07/24/24 of catheter Patient #1 last 10 treatment flowsheets, dated 06/27/24 to 07/23/24, revealed on 07/02/24 and 07/13/24, the prescribed blood flow rate of 400 milliliters per minute (ml/min) was not maintained. There was no documentation in the medical record to indicate why the blood and/or dialysate flow rates were not followed as ordered. Review on 07/24/24 fistula Patient #3 last 10 treatment flowsheets, dated 06/29/24 to 07/23/24, revealed on 07/11/24, the prescribed blood flow rate of 450 ml/min was not maintained. There was no documentation in the medical record to indicate why the blood and/or dialysate flow rates were not followed as ordered. Review on 07/24/24 catheter Patient #4 last 10 treatment flowsheets, dated 06/29/24 to 07/23/24, revealed on 07/09/24 and 7/20/24, the prescribed dialysate flow rate of 600ml/min was not maintained. There was no documentation in the medical record to indicate why the blood and/or dialysate flow rates were not followed as ordered. Review on 07/24/24 fistula Patient #6 last 10 treatment flowsheets, dated 06/25/24 to 07/23/24, revealed on 07/11/24, the prescribed blood flow rate of 450 ml/min was not maintained. There was no documentation in the medical record to indicate why the blood and/or dialysate flow rates were not followed as ordered. Review on 07/24/24 of fistula Patient #10’s last 10 treatment flowsheets, dated 06/28 /24 to 07/22/24, revealed on 07/01/24 and 07/03/24, the prescribed dialysate flow rate of 800 ml/min was not maintained. On 07/19/24, the prescribed blood flow rate of 500ml/min was not maintained. There was no documentation in the medical record to indicate why the blood and/or dialysate flow rates were not followed as ordered. Interview on 07/25/24 at 01:30 PM with Staff (L), Interim Facility Administrator, and Staff (Q), Clinical Specialist, 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 policy review, medical record review, and interview the facility does not ensure patients are seen by a provider monthly, as required, for 3 of 6 patients (Patient #1, Patient #10, and Patient #22) reviewed. Findings Include: Review on 07/25/24 of policy, “Medical Staff and Advanced Practice Providers,” revised on April 2023, revealed “responsibilities of the medical staff physician include, but are not limited to, ensuring documented evaluation monthly by physician or advanced practice provider with reference to overall renal care.” Medical record review on 07/25/24, from June 2023 to June 2024, revealed no documented evidence of monthly provider notes for the following: Patient #1 for November 2023, December 2023, January and February 2024; Patient #10 for April, May, and June 2024; and Patient #22 for September 2023, October 2023, February 2024, March 2024, and May 2024. Interview on 07/25/24 at 01:30 PM with Staff (L), Interim Facility Administrator, and Staff (Q), Clinical Specialist, verified these findings.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 34528 Based on policy review, document review and interview the facility did not document analysis for 2 of 5 adverse events. Findings Include: Review on 07/25/24 of policy, “Occurrence/Incident Reports Including Close Call/Near Miss”, last revised February 2024, revealed “the facility administrator or designee or the medical director will review and document an analysis of patient history and specific circumstances to identify potential interventions to prevent recurrence”. Review on 07/25/24 of incident reports dated 04/20/24 (Infiltration) Patient #30 and 06/25/24 (infiltration) Patient #29 revealed no documentation by an facility administrator or Medical director. There was no documentatinon of an analysis of patient history and specific circumstances to identify potential interventions to prevent recurrence. Interview on 07/25/24 at 09:45 with Staff (L), Facility Administrator, verified findings.”

“QAPI-INDICATOR-PT SATIS & GRIEVANCES CFR(s): 494.110(a)(2)(viii) The program must include, but not be limited to, the following: (viii) Patient satisfaction and grievances. This Standard is not met as evidenced by: 34528 Based on policy review, document review and interview the facility did not ensure 1 of 1 grievances documented from January 2024 to June 2024 were identified in Quality. Findings Include: Review on 07/25/24 of policy, “Introduction to Quality Assessment and Performance Improvement” (QAPI), last revised January 2020, revealed “US Renal Care at the direction of the Chief Medical Officer and with approval of the corporate leadership, evaluate and set company-wide goals for critical outcomes to be reviewed by the facility QAPI team monthly. These are based on current literature, Measures Assessment Tool (MAT) as well as network goals”. Review on 07/25/24 of Centers for Medicare & Medicaid Services MAT goals Version 2.5 revealed goals include Patient Satisfaction and grievances. Review on 07/25/24 of Complaint/Grievance Form dated 03/05/24 revealed Patient #7 made a complaint regarding Response/Care delay and Clinical Staff. Review on 07/25/24 of March 2024 Facility Quality Management Meeting revealed no official grievances in March. Interview on 07/25/24 at 02:30PM with Staff (L) Facility Administrator and Staff (Q) Clinical Specialist verified findings.”