Ray Yasui Dialysis Center

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 37237 Based on observation, interview and review of personnel files, it was determined the facility failed to ensure: 1. 1 of 8 clinical staff (Staff #2) had current BLS documentation. 2. All staff received annual EP training. 3. The tools necessary for a patient to disconnect themselves from the dialysis machine in the event of an emergency were available. Findings: 1. Review of the personnel audit worksheet completed by the CM and the Providence Hood River Memorial Hospital HR Team revealed Staff #2’s last “CPR Expiration Date” was listed as 01/31/2020. Review of “Student and Group Transcript Report” for Staff #2, revealed no CPR or BLS training was listed. 2. Review of the personnel audit worksheet completed by the CM and the Providence Hood River Memorial Hospital HR Team revealed 15 of 16 staff (Staff #s 1-11 and 13-16) lacked Emergency Preparedness training during the last 12 months. 3. During observation of the facility on 11/13/2023 beginning at 1230, none of the treatment stations contained a packet with the tools necessary for a patient to disconnect from dialysis during an emergency. During interview with the CM on 11/15/2023 beginning at 1550, the above findings were confirmed.”

“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: 37237 Based on observation and interview, it was determined the facility failed to ensure staff did not keep drinks in the treatment area. Findings: Observation of the nursing stations throughout the treatment area on 11/13/2023 beginning at 1230 revealed 3 covered beverage containers were in use and were sitting out on counters throughout the treatment area. During interview with the CM and the Providence Hood River Memorial Hospital’s CEO, on 11/13/2023 beginning at 1330, they stated that a Providence policy allowed beverage containers at nursing stations as long as the container had a lid. This regulation stipulates that staff members should not eat or drink in the dialysis treatment area. This tag was also cited during the last recertification survey during March of 2019 for beverage containers in the treatment area.”

“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: 37237 Based on observation, interview and the review of documentation, it was determined the facility failed to ensure that the biohazard waste bins kept on the treatment floor were clearly labeled. Findings: During observation of the facility on 11/13/2023 beginning at 1230, the three black bins used to dispose of infectious used blood lines lacked visible labels that clearly identified the bins as biohazard waste collection bins. Review of the facility policy, “Bloodborne Pathogens Exposure Control Plan,” dated as last revised 11/2023 stipulated on page 6, “Labels: the following are labeled with Red/Red-Orange color-coding and/or biohazard labels ... Regulated medical waste.” During interview with the CM on 11/14/2023 at 1030, the above findings were confirmed. The stated the biohazard waste bags are collected each evening by the hospital’s facilities staff.”

“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: 37237 Based on observation, it was determined that the facility failed to ensure the appropriate cleaning and disinfection of contaminated surfaces, medical devices and equipment. Findings: During observation of the treatment floor on 11/13/2023 beginning at 1225, a staff member was assessing patients entering the treatment floor from the waiting room. The SA surveyor observed five patients individually enter the treatment floor and receive an assessment that included the staff member utilizing a stethoscope they had hanging around their neck to auscultate breath sounds of the patient. After listening to breath sounds of the patient, the staff member placed the stethoscope around their neck and escorted the patient to the scale. The staff member returned and proceeded to assess the next four patients in the same manner. The staff member failed to clean and disinfect the stethoscope in between patients. During observation of the treatment floor on 11/15/2023 beginning at 1230, a PCT and RN used the Hoyer lift to move a patient from a wheelchair to their treatment chair. Once the patient was settled in the treatment chair, the Hoyer lift was moved to the common area. The Hoyer lift was not disinfected. Within 5 minutes of being replaced in the common area, another PCT and RN used the same Hoyer lift to move another patient from a wheelchair into their treatment chair. The Hoyer lift was wiped down with disinfectant and replaced in the common area. During an interview with the CM on 11/13/2023 at 1530, the above finding were confirmed.”

“IC: HBV: TEST ALL,REV RESULTS/STATUS B4 ADMIT CFR(s): 494.30(a)(1)(i) Routine Testing for Hepatitis B The HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) of all patients should be known before admission to the hemodialysis unit. Routinely test all patients [as required by the referenced schedule for routine testing for Hepatitis B Virus]. Promptly review results, and ensure that patients are managed appropriately based on their testing results. This Standard is not met as evidenced by: 47148 Based on interview and review of documentation, it was determined that the facility failed to ensure that all patients were tested to determine their HBV serological status (i.e. HBsAg, total anti-HBc and anti-HBs) for 10 of 22 patients. Findings: Review of immunization records for 22 hemodialysis patients dated 11/14/2023, revealed 2 patient records failed to show documentation of a HBsAg and 3 patient records failed to show documentation of total anti-HBc. Further review of the immunization records revealed 7 Hepatitis B susceptible patients lacked documentation of monthly HBsAg testing as required. During interview on 11/15/2023 at 1530, the CM confirmed the above findings.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 47148 Based on interview and review of documentation, it was determined the facility failed to ensure that all susceptible patients and staff members were offered vaccination against Hepatitis B. Findings: Review of the immunization records for Hepatitis B revealed 7 of 22 patients’ information lacked documentation of complete vaccination series, booster shots and/or that vaccinations were offered and refused. Review of the facility policy, “Hemodialysis Orders - Standing Orders,” dated as “Revised 11/26/2019” stipulated, “If HbsAB negative and HbsAG negative, administer Hep B vaccine series according to manufacturer’s recommendations ... If titer <10 give booster x 1.” During an interview on 11/15/2023 at 1530, the CM confirmed the above 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: 37237 Based on observation, it was determined that the facility had failed to maintain a safe and functional treatment environment. Findings: Observation of the treatment floor on 11/13/2023 beginning at 1230 revealed the following: - The following items could not be effectively cleaned for infection control purposes: * The desk adjacent to the patient scale had a strip of missing laminate along one of the edges that exposed the substrate underneath. * The laminate above one of the wall boxes had a chip with a green substance used to repair the chip. The green substance only partially filled the area, exposing some of the substrate underneath. * The patients’ bathroom walls had multiple areas of chipped and bubbling paint and multiple holes that had been improperly filled in. The bathroom’s floor and a portable toilet seat with a paper seal around it had evidence of liquid fecal matter that had not been cleaned. * The walls and the window frame in the isolation room had chipped paint that exposed the substrates underneath. * There were other multiple areas with chipped paint and laminate throughout the treatment area. * Wooden counter tops around the treatment floor were scratched, had holes and dings, areas where the sealer had worn off, partially peeled off pieces of tape and multiple items taped to the tops of the counters. - Many of the water connections in the chases throughout the treatment floor had an accumulation of built-up white precipitate material around them. - In the dirty linen supply room, the emergency eyewash station covers were open, leaving the nozzles exposed to dirt and contamination. * The eyewash station located in the water room was had white precipitate built-up on the metal arms and both outside and inside the green plastic nozzle housing. Multiple nozzle holes were partially obstructed with the participate. - Items were stored inside the sink cabinets. One cabinet had a jug of bleach and one had 9 jugs of citric acid stored underneath and three spray bottles of vinegar stored underneath.”

“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: 37237 Based on interview and the review of documentation, it was determined that the facility failed to ensure that all equipment was maintained and operated in accordance with the manufacturer’s recommendations. Findings: Review of the facility’s RN daily logs revealed the lab refrigerator on the treatment lacked daily temperature readings. During interview with the CM on 11/15/2023 at 1550, they stated that the lab fridge isn’t used and daily temperature readings are not taken. They further stated, the fridge does have a thermometer inside, but it is not used due the adjacent hospital doing the dialysis center’s lab draws. They stated it may be better not to have the fridge on the floor if it’s not used.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 47148 Based on interview and review of documentation, it was determined that the facility failed to offer pneumococcal vaccination to patients based on assessment of status as required by facility policy and CDC guidelines. Findings: Review of the immunization history section of 22 patient medical records revealed 16 patient medical records failed to reflect that the pneumococcal vaccination had been offered to those patients as recommended. Examples include but are not limited to: * One patient had documentation of receiving PPSV23 on 10/19/2006. No other documentation as to subsequent pneumococcal vaccine given, offered or refused was noted. * One patient, with an age <65 years old, had documentation of receiving the PCV13 on 09/28/2016. According to facility policy, as well as CDC guidelines, this patient should have received a pneumococcal vaccine in 2021. Review of the facility policy, “Hemodialysis Outpatient Orders,” dated “12/27/2019” stipulated, “Immunizations: ... Pneumovax vaccine every 5 years as needed.” The CDC guidelines for pneumococcal vaccination schedules for adults at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html included: * Adults 19 through 64 years old who have only received PCV13, the CDC recommends: “Give 1 dose of PCV20 or PPSV23 ... The PCV20 dose should be given at least 1 year after PCV13.” * Adults 19 through 64 years old who have received PCV13 and 1 dose of PPSV23, the CDC recommended either: “Give 1 dose of PCV20 at least 5 years after the last pneumococcal vaccine ... Give a second dose of PPSV23 at least 8 weeks after PCV13 and 5 years after PPSV23 if they have an immunocompromising condition ...” * Adults 65 years or older who have only received PPSV23 the CDC recommended: “Give 1 dose of PCV15 or PCV20 ...The PCV15 or PCV20 dose should be administered at least 1 year after the most recent PPSV23 vaccination ... Regardless of if PCV15 or PCV20 is given, an additional dose of PPSV23 is not recommended since they already received it.” * Adults 65 years or older who have only received PCV13, the CDC recommended either: “Give 1 dose of PCV20 at least 1 year after PCV13 ... Give 1 dose of PPSV23 at least 1 year after PCV13.” During interview on 11/15/2023 at 1530, the CM confirmed the above findings.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 21.7.1.4 through 21.7.1.7 This Standard is not met as evidenced by: 42986 Based on observations, interviews and record review during the survey, it was determined through on-going dialog with the Facility Administrator that the facility failed to provide fire drills for all staff affecting the entire building. This resulted in the potential for inadequate staff knowledge during fire emergencies, potentially exposing patients to smoke and fire in the facility (LSC 21.7.1., 21.7.2, 21.7.2.2, 21.7.2.3). Findings include: On 11/15/2023, during record review between 12:15 pm and 1:30 pm, facility documentation presented to the surveyor showed incomplete fire drill forms for the facility for 2022 and 2023. Fire drill forms were missing items such as but not limited to the number of simulated occupants evacuated from the affected smoke compartment, time to complete the simulated evacuation from the affected smoke compartment to an unaffected smoke compartment, specific type of fire simulated, specific location of simulated fire and staff performance during the drill. Surveyor was accompanied by the Facility Adminsitrator who acknowledged the existence of these conditions.”

“Maintenance, Inspection & Testing - Doors CFR(s): This Standard is not met as evidenced by: 42986 Based on record review and interview during the survey, it was determined through on-going dialog with the Facility Administrator that the facility failed to ensure Maintenance, Inspection & Testing - Doors, Fire doors assemblies are maintained, inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. This resulted in the potential for the fire doors to fail during a fire event. 21.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) Findings include: 1. On 11/15/2023, at 11:35 am, the fire rating label on the fire door frame for the doors entering into the facility from the corridor was painted. Surveyor could not determine that the door assembly fire rating was maintained. 2. On 11/15/2023, at 11:35 am, the fire rating label on the fire door entering into the patient care area was painted. Surveyor could not determine that the door assembly fire rating was maintained. Surveyor was accompanied by the Facility Administrator who acknowledged the existence of these conditions.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for four continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked and readily identifiable. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 42986 Based on observations, record review and interviews it was determined through on-going dialog with the Facility Administrator that the facility failed to properly maintain the generator for the entire facility. This resulted in the potential for the lack of emergency electrical power (LSC 21.2.9, 7.9, NFPA 110, NFPA 99, 6.4.4, 6.5.4, 6.6.4, NFPA 111). Findings include: On 11/15/2023, during record review between 12:15 pm and 1:30 pm, the facility did not have current documentation for the required 3-yr. 4-hr. load bank test. The last 3-yr. 4-hr. load bank test on the generator was conducted on 1/31/2019 and was past due since 1/31/2022.. Surveyor was accompanied by the Facility Administrator who acknowledged the existence of these conditions.”