Unity Dialysis at Chili

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 40430 Based on policy review, document review, observation, and interview, the facility did not comply with emergency preparedness requirements. Specifically, the facility did not include demographic and emergency contact information in the emergency preparedness plan. Findings include: Review of the policy “Dialysis-Comprehensive Emergency Management,” revised April 2025, revealed a list of immediately available emergency equipment at the facility. The policy did not address the requirement for patient/staff/evacuee demographic and/or emergency contact information. Review of the document “Comprehensive Emergency Management Plan, Annex 11, Evacuation Plan,” revealed the charge nurse will assign non-clinical staff to bring the evacuation box to the staging area. An access associate will be responsible for collecting patient order books, patient demographic books, and lists for transportation. Observation on 02/06/26 at 10:00 AM of the evacuation box located in the charting room, just off of the patient care area, revealed a list of contents, however, the list did not include patient demographic books, transportation contact lists, or patients/staff/evacuee’s emergency contact information. Observation and interview on 02/06/26 at 10:15 AM with Staff (B) revealed they were unable to locate the patient demographic books, transportation contact lists, and patient/staff/evacuees emergency contact information to be utilized during an emergency evacuation. Staff (B) reported the required information was not available in the facility evacuation box. Staff (B) and Staff (C) verified these findings. Interview on 02/06/26 at 10:40 AM with Staff (G), Staff (I), and Staff (E), also verified this 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 policy review, observation, and interview, nursing staff do not follow standard infection control practices regarding the use of gloves and hand hygiene. Findings include: Review of the policy “Dialysis Infection Prevention Protocols (Supplemental) Policy,” revised March 2025, indicated personnel must wear disposable gloves for all patient and machine contact. All personnel must scrupulously practice hand washing. Hand hygiene must be performed upon entering and exiting patient station, after all patient contact, when removing gloves and whenever hands are soiled. Review of the policy “Initiation and Termination of Dialysis with a Hemodialysis Catheter Policy,” revised April 2024, indicated to perform hand hygiene and apply clean gloves, discontinue the dialysis treatment (return blood from the machine back to the patient), check blood pressure, and if stable perform hand hygiene and apply a new pair of clean gloves before cleansing the catheter ports and disconnecting the dialysis tubing. Observation on 02/02/26 at 10:45 AM at Station #9 for Patient #4 revealed Staff (Q) removed their gloves, exited Station #9 but did not perform hand hygiene before applying a clean glove to their right hand to reset a machine alarm at Station #11 for Patient #19. Observation on 02/06/26 at 09:40 AM at Station #9 for Patient #7 revealed Staff (U) discontinued Patient #7 dialysis treatment. After returning Patient #7 blood from the hemodialysis machine and touching the machine to check Patient #7 blood pressure, Staff (U) did not remove gloves, perform hand hygiene, and put on a new pair of clean gloves before cleaning the catheter ports and disconnecting the dialysis tubing. Interview on 02/06/26 at 10:45 AM with Staff (G), Staff (I), and Staff (J), verified these findings.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 40430 Based on policy review, observation, and interview, the facility does not ensure adequate separation between clean and dirty supplies/equipment. Specifically, the centrifuge (device used to separate the contents of blood in blood tubes for diagnostic tests) and rack to hold blood filled lab specimen tubes were on the same nursing station/supply countertop directly next to clean supplies. Findings include: Review of the policy “Infection Prevention-Storage of Clean and Sterile Patient Care Supplies in Clinical Areas,” revised April 2025, indicated clean and sterile supplies must be stored in a manner to prevent contamination. Clean and dirty items should never be stored in the same location. Observations on 02/02/26 from 10:00 AM to 01:30 PM, and 02/06/26 from 09:30 AM to 10:40 AM in the patient care unit revealed the centrifuge located across from Stations 12-16, was labeled with a red biohazard sticker (used to indicate items contain disease causing agents that can be transmitted to individuals), and a red rack to hold blood filled lab specimen tubes, were on same nursing station/supply countertop, directly next to clean supplies including several boxes of gloves, gauze, surgical face masks, disinfectant wipes, tubing used to deliver dialysis treatments, and normal saline (solution used during dialysis treatments) bags. Interview on 02/06/26 at 10:45 AM with Staff (G), Staff (I), Staff (J), and at 11:00 AM with Staff (E), 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, nursing staff did not ensure patient care supplies were stored in a manner to avoid contamination. Specifically, gloves are being placed in staff uniform pockets. Findings include: Review of the policy “Infection Prevention-Storage of Clean and Sterile Patient Care Supplies in Clinical Areas,” revised April 2025, indicated clean supplies must be stored in a manner to prevent contamination. Clean and dirty items should never be stored in the same location. The policy did not include guidance on not storing patient care supplies in uniform pockets per regulations. Observation on 02/02/26 at 10:45 AM at Station #9 for Patient #4 revealed Staff (Q) removed gloves from their white personal protective equipment (PPE) gown pocket to reset a machine alarm and assist Patient #4 unpack their personal belongings. After initiating Patient #4 treatment, Staff (Q) removed their gloves, performed hand hygiene, then removed several clean gloves from the box and placed more gloves in their PPE gown pocket. Interview on 02/06/26 at 10:45 AM with Staff (G), Staff (I), and Staff (J), verified these findings.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 40430 Based on policy review, observation, and interview, nursing staff do not properly handle and/or dispose of potentially infectious waste. Findings include: Review of the policy “Dialysis-Initiation and Termination of Hemodialysis with Fistula/Graft (surgically created access used to deliver dialysis treatment to patients) Procedure,” revised November 2025, indicated after the termination of the dialysis treatment, remove needles and dispose into the needle disposal container. Observation on 02/02/26 at 11:10 AM at Station #10 for Patient #10 revealed Staff (T) removed two needles from Patient #10’s fistula and placed the needles on the chairside table while they applied gauze and held pressure to the previous needle sites. Interview on 02/06/26 at 10:45 AM with Staff (G), Staff (I), and Staff (J), verified this finding.”

“QAPI-ONGOING;USES INDICATORS=IMPROVEMENT CFR(s): 494.110(a)(1) The program must include, but not be limited to, an ongoing program that achieves measurable improvement in health outcomes and reduction of medical errors by using indicators or performance measures associated with improved health outcomes and with the identification and reduction of medical errors. This Standard is not met as evidenced by: 34528 Based on policy review, document review and interview the facility does not have a monthly benchmark to measure mortality in their Quality Assessment (QA) program. Findings include: Review of the policy “Quality Assessment and Performance Improvement Program (QAPI) Policy,” last reviewed October 2022, revealed QAPI meetings will be held monthly and include the guidelines for the meeting will follow the Centers for Medicare and Medicaid Services (CMS) Measure Assessment Tool (MAT). Review of the CMS “MAT (Version 2.5),” Health Outcomes section related to mortality revealed the following indicator: patient survival uses a measure of a standard mortality ratio of 1.0 as average, > 1.0 is worse than average, and <.1.0 is better than average. Review of the online “Quality Tracking Dashboard” revealed one mortality in August 2025, no mortalities in September 2025, one mortality in October 2025, one mortality in November 2025, and no mortalities in December 2025. The mortality indicator does not include a standard mortality ratio measurement as a benchmark. Interview on 02/06/26 at 10:00 AM with Staff (H) revealed the CMS MAT standardized mortality ratio is not used in QAPI mortality review and they have not developed their own indicator measurement.”