Davita Salem Dialysis

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 31224 Based on interview and review of documentation, it was determined the facility failed to participate in an exercise of choice (a table-top exercise or workshop) drill to test the emergency plan at least annually per facility policy. Findings: Review of the facility’s EP binder revealed it lacked documentation that the facility participated in a table-top exercise or workshop during the last 12 months. During interview on 02/07/2024 at 1330, the SMCS confirmed the facility failed to participate in a table-top exercise or workshop during the past 12 months.”

“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: 31224 Based on interview and review of documentation, it was determined the facility failed to ensure that all patients were tested for the Hepatitis B surface antigen (HBsAg) as required to manage care appropriately for 1 of 75 patients (Patient #21). Findings: Review of the “Vaccinations and Surveillance Report,” dated 02/05/2024, revealed a patient (Patient #21) had negative monthly HBsAg tests through 11/2023, but then ceased. Patient #21’s HBcAb was positive and a HBsAb was greater than 10. Review of the facility policy titled,”HEPATITIS B SURVEILLANCE, VACCINATION, INFECTION CONTROL MEASURES AND ISOLATION GUIDANCE,” last dated 10/2023, stipulated under “ROUTINE SURVEILLANCE TESTING” that patients with a negative HBsAg, positive HBcAb, and a HBsAb greater than 10 was to receive “Monthly antigen and annual antibody” surveillance testing. During interview on 02/08/2024 at 1000, the CC confirmed Patient #21 should have received monthly HBsAg testing and that the test was missed for 12/2023 and 01/2024.”

“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: 31224 Based on observation and interview, it was determined the facility failed to ensure the dialysis facility was maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. Findings: 1. During the flash tour on 02/05/2024 started at 1045, the fire extinguishers near the water room, staff restroom, PD exam room #2, and lobby were tagged and showed they were serviced in November of 2023. Since then, the monthly inspection record had no inspections documented. During interview on 02/05/2024 at 1300, the Regional Biomed stated clinic staff were responsible to check the fire extinguishers as part of the monthly OSHA checks. During interview on 02/06/2024 at 1510, the GFA reported clinic staff thought an outside contractor was conducting the monthly checks of the fire extinguishers and confirmed they were not done. 2. Additional observations during the flash tour on 02/05/2024 included the following: - A chair at station 13 had an approximately 2 inch crack in the seat upholstery that revealed the fibers underneath which could not be effectively cleaned for infection control purposes. - An open vial of Heparin that lacked the date and time opened, and initials of the staff who opened the vial. - An open vial of Lidocaine that lacked the date and time opened, and initials of the staff who opened the vial. - A bottle of WaterCheck Chloride or Peroxide Reagent Test Strips that expired 12/2023. - The wall box at station 7 contained a black substance extending approximately 4 inches on each side of the drain. The wall box and surrounding wall were splattered with a dried brown colored substance. - The hemostats in a bleach tub were closed, which does not allow the bleach to contact all surfaces for disinfection. - A box of Nitroglycerin Sublingual tablets expired 09/2023. During interview on 02/05/2023 at 1450, the GFA confirmed the findings.”

“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: 37898 Based on observation and interview, it was determined that the facility failed to ensure that all equipment was maintained in accordance with manufacturer’s recommendations and facility policy. Findings: 1. Review of the facility log titled “Weekly Eyewash and Drench Shower/Hoses Inspection” for 2023 and 2024 revealed: - The log sheets for January, February, March, June, August, September, and October 2023 were blank. - The April 2023 log lacked entries for 04/01, 04/08, 04/15. - The May 2023 log contained entries for only 05/03 and 05/10. - The July 2023 log lacked an entry for the water room eyewash on 07/17. The log lacked any entry for 07/31. - The December 2023 log contained entries for only 12/04. - The 2024 log binder lacked sheets and/or entries for January and February. Review of facility policy 4-08-09 titled “Eyewash Station/Sink/Drench Shower/Hose Checks,” last revised October 2019, stipulated “Plumbed eyewash stations/sinks/drench showers/hoses are to be activated weekly to flush the line and verify proper operation. Self-contained stations are to be inspected according to the manufacturers’ specifications. NOTE: Plumbed single and/or combination units shall be activated weekly for a period long enough to verify operation and that flushing fluid is available.” During interview on 02/07/2024 at approximately 1100, the SMCS confirmed that the eyewash stations should be checked and documented weekly. 2. Review of the facility log titled “Oxygen Concentrator Filter Weekly Cleaning Log” for 2023 and 2024 revealed: - The 2023 yearly log for “Serial #1” contained entries for only 04/01, 04/08, 04/15, 04/22, 04/29, 05/03, 05/10, 07/03, 11/02, 11/07, 11/14, 11/20, and 12/05. - The 2023 yearly logs for Serial #s 2-11 contained entries for only 04/01, 04/08, 04/15, 04/22, 04/29, 05/03, 05/10, and 07/03. - The 2024 log binder lacked sheets and/or entries for January and February. Review of facility policy 1-02-04 titled “Use of Oxygen Concentrators,” last revised October 2023, stipulated “Follow Manufacturer Instructions for Use regarding any additional cleaning/maintenance of the device and document on the Oxygen Concentrator Filter Cleaning Log, as applicable.” Review of the “DeVilbiss 5 Liter Oxygen Concentrator Instruction Guide,” presented by the SMCS as applying to all facility concentrators, stipulated “Air Filter and Oxygen Outlet Connector ... The air filter and connector should be cleaned at least once a week.” During interview on 02/07/2024 at approximately 1100, the SMCS confirmed that the oxygen concentrator air filters should be cleaned and documented weekly.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 31224 Based on interview and record review, it was determined the facility failed to ensure necessary services outlined in the patient plan of care was provided for 1 of 20 patients reviewed (Patient #2). Findings: Review of Patient 2’s Patient Note dated 01/10/2024 revealed the following order for Venofer (a medication used to treat iron deficiency anemia), “100 mg venofer [sic] per ICHD treatment for x5 treatments (End at 1/20/24) (loading dose) and than [sic] switch back to 50 mg x1 a week.” Review of Patient 2’s Treatment Details Reports dated 01/11/2024 through 01/20/2024 revealed Patient 2 received 100 mg of Venofer as ordered. However, review of Treatment Details Reports dated 01/23/2024 through 02/03/2024 revealed there was no order for 50 mg of Venofer entered or administered. During interview on 02/07/2024 at 1030, the FA verified the 50 mg order for Venofer was not reinstated and Patient 2 did not receive the medication as ordered.”

“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: 31224 Based on interview, review of patient medical records and review of documentation, it was determined that the facility failed to ensure that patients received appropriate and timely hemodialysis treatment and monitoring for 8 of 14 patients (Patients #1, 2, 4, 5, 6, 10, 12, 13, and 14). Findings: 1. Review of Patient #2’s treatment sheets dated 01/04/2024 through 02/08/2024 revealed Patient #2 had diastolic blood pressure (the bottom number) readings greater than 90 mm Hg noted by the PCT on the following treatment dates. There was no documentation to indicate the blood pressure was rechecked and/or the licensed nurse was notified: - 01/09/2024 - 01/11/2024 - 01/13/2024 - 01/16/2024 - 01/23/2024 - 01/25/2024 Review of facility policy 1-03-08 titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” with a last revision date of October 2023, stipulated “Abnormal findings ...will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy)... Abnormal Findings...Sitting diastolic BP greater than 90 mm Hg...” During interview on 02/07/2024 at 1100, the SMCS confirmed the above findings. Similar findings were noted for Patients #s 4, 5, 10, 12, 13, 14. 2. Review of Patient #1’s treatment sheets dated 01/05/2024 through 02/02/2024 revealed: - On 01/29/2024 treatment was started at 1620. The first intradialytic data collection/assessment was documented 113 minutes later at 1813. The only other intradialytic data collection/assessment was documented 111 minutes later, when treatment was terminated, at 2004. Review of Patient #6’s treatment sheets dated 01/03/2024 through 02/05/2024 revealed: - On 02/05/2024 treatment was started at 1558. The first intradialytic data collection/assessment was documented 140 minutes later at 1818. Documentation by the RN at 1818 included “... the cycler wasn’t turned on; so no other blood pressures were taken.” Review of facility policy 1-03-08 titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” with a last revision date of October 2023, stipulated “Intradialytic Data Collection/Assessment ... a. Vital signs and treatment monitoring ... i. For non-nocturnal treatments is completed at least every thirty (30) minutes ... b. At a minimum, obtain and document the following: i. Blood pressure, ii. Heart or pulse rate, iii. Blood and dialysate flows, arterial and venous pressures, iv. Fluid removal and/or replacement, v. Vascular access visible and line connections intact, vi. Patient subjective statement(s) i.e., patient report on overall health, any complaints.” During interview on 02/07/2024 at 1040, the FA confirmed the findings. 3. Review of Patient #2’s dialysis orders and treatment sheets dated 01/04/2024 through 02/03/2024 revealed the BFR settings were changed from the dialysis order without documentation to state why the order was changed and/or the licensed nurse was notified of the change during 9 of 13 treatments. For example, on 01/20/2024, the BFR was ordered to run at 450 mL/min, however BFR values ranged from 310-400 mL/min without documentation to show the reason for the change and/or the licensed nurse was notified. Review of facility policy 1-03-08 titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” with a last revision date of October 2023, stipulated “If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” During interview on 02/07/2024 at 1030, the FA confirmed the above findings. 4. Review of Patient #6’s dialysis orders and treatment sheet dated 02/05/2024 revealed: - The “Treatment Time” ordered was 240 minutes. “Intradialytic Vitals Stat Line” documentation indicated treatment started at 1557 and ended at 1918; a total of 201 minutes, 39 minutes less than ordered. The “Close Treatment Reason” indicated “Patient Choice (AMA, transportation, weather, has other appt).” A “Treatment Nurse Assessment” documented “tx time shortened by 43 min due to getting on tx late and pt refusing to stay whole tx.” Patient #6’s medical record failed to include an AMA form signed by the patient for the shortened treatment on 02/05/2024. Review of facility policy 1-01-09 titled “Prescribed Treatment Time Not Met,” with a last revision date of October 2023, stipulated “1. The Registered Nurse (RN) will verify that a patient signs the ‘Early Termination of Treatment Against Medical Advice’ form any time the patient requests to terminate their treatment earlier than the prescribed run time ... 4. A copy of the ‘Early Termination of Treatment Against Medical Advice’ form signed by the patient, if shortened voluntarily by patient, will be kept in the patient’s health record.” During interview on 02/07/2024 at 1040, the FA stated the patient frequently arrives late for treatment and refuses to stay for a full treatment. They confirmed that the patient should have been asked to sign an AMA form and the form should have been included in the patient’s health record.”

“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: 31224 Based on interview, review of clinical records, facility documentation, and CDC recommendations, it was determined the facility failed to comprehensively assess or offer pneumococcal or Hepatitis B vaccines for 53 of 75 ICHD patients (Patient #s 1-5, 7, 8, 22, 24, 27-63) reviewed. Findings: 1. Review of the ICHD hepatitis B Vaccinations and Surveillance Report, dated 02/05/2024, revealed the following: * 1 of 75 patients (Patient #23) had received one series of hepatitis B vaccines in 2022, but did not achieve an immune response. * 1 of 75 patient’s (Patient #25’s) lab results indicated they were susceptible to Hepatitis B, however there was no documented history of the vaccine being administered or refused. * 4 of 75 patients (Patient #s 5, 22, 24, and 26) had immunity, but there was no vaccine history documented. 2. Review of the facility policy titled, “HEPATITIS B SURVEILLANCE, VACCINATION, INFECTION CONTROL MEASURES AND ISOLATION GUIDANCE,” dated 10/2023, stipulated the following: * “Documentation of the following will remain in the patient’s current active medical record... If a patient has received the hepatitis vaccination series, a copy of the vaccination record.” * If the patient’s lab results indicated they were susceptible to Hepatitis B, “Offer vaccination series.” * “Test all vaccinated patients for HBsAb... If hepatitis B surface antibody (HBsAb) is less than 10 mIU/mL, consider the patient susceptible, revaccinate with an additional full series, and retest for HBsAb one (1) or two (2) months after the last dose of the second series.” 3. Review of the ICHD Pneumococcal Vaccinations and Surveillance Report, dated 02/05/2024, revealed the following: * 2 of 75 patients (Patient #s 13 and 63) missed three opportunities to receive the pneumococcal vaccine in 10/2023, but no subsequent attempts to vaccinate these patients were documented. * 4 of 75 patients (Patient #s 14, 39, 41, and 44) had refused the vaccine greater than one year ago and there was no documented attempt to reassess the patient’s willingness to receive the vaccine. * 6 of 75 patients (Patient #s 8, 21, 25, 36, 43, and 55) had no documented history of being offered or receiving a pneumococcal vaccine. * 41 of 75 patients (Patient #s 1-5, 7, 8, 22, 24, 27-35, 37, 38, 40, 42, 45-62) had a history of either PCV13, PPSV23, or “Pneumococcal Vaccination.” As a result, staff were not able to determine what follow-up vaccine would be required, if applicable. 4. The CDC recommends pneumococcal vaccination for adults 19 to 64 with chronic renal failure and for all adults 65 and older. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html 5. Review of the facility policy titled “PNEUMOCOCCAL VACCINATION FOR ADULT HEMODIALYSIS PATIENTS,” dated October 2023, included vaccination guidance based on which vaccine was administered (PCV13, PCV15, PCV20, or PPSV23). * For patients who had received only PPSV23, a dose of PCV20 or PCV15 could be administered at least one year after the most recent PPSV23 vaccine. * For no previous vaccine, a patient may receive PCV20 or PCV15 and PPSV23 at least one year later “(minimal interval is 8 weeks and can be considered in adults with an immunocompromising condition.)” 6. The CDC recommends hepatitis B vaccination for all adults 19-59 years old and adults age 60 years or older with risk factors for hepatitis B infection, including chronic renal failure. https://www.cdc.gov/vaccines/vpd/hepb/index.html 7. Review of the facility policy titled “HEPATITIS B SURVEILLANCE, VACCINATION, INFECTION CONTROL MEASURES AND ISOLATION GUIDANCE,” dated October 2023, stipulated: * “HBV serological status (i.e., the results of Hepatitis B Surface antigen [total anti-HBc or HBcAb], and Hepatitis B Surface Antibody (anti-HBs or HBsAb]) of all patients should be known before admission to the hemodialysis facility.” * “Results [of routine surveillance testing] will be reviewed promptly to verify that patients are managed appropriately based on their testing results.” * “Results from Hepatitis B surface antigen drawn within 30 days is required prior to first treatment date.” * Susceptible patients should be offered the vaccination series during admission screening. * “An order will be obtained for hepatitis B vaccination. The patient is provided the Vaccination Information Sheet (VIS) and a consent form...The patient will consent to the vaccination or will decline...” 8. An interview was conducted on 02/08/2024 at 1000 with the CC, FA, and SMCS. The CC confirmed they were responsible for ensuring the ICHD patients were assessed and provided the opportunity to receive the pneumococcal and hepatitis B vaccines. The CC and SMCS confirmed the above findings and reported vaccine information in the reports was often incomplete since not all data transferred to the new EHR in the fall of 2022, over one year prior to the date of this survey. The CC reported that they did not have access to the old EHR or to Oregon’s statewide immunization registry, nor did they inherit a system to assess and track patients’ immunization needs when they started the position in 8/2023.”