Davita Rogue Valley Dialysis

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm Systems - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 42986 Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facility Administrator that the facility failed to test and maintain fire alarm in accordance with NFPA 72. This resulted in the potential for system and device failure during fire emergencies (LSC 21.3.4, 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72). Findings include: 1. On 6/13/2024, during record review between 12:15 pm and 1:15 pm. the facility failed to provide documenation for monthly and quarterly fire alarm inspection and testing. Facility staff indicated they were unaware of the this requirement and did not have access to NFPA 101 or 72. 2. On 6/13/2024, during record review between 12:15 pm and 1:15 pm, the facility failed to provide documenation for the required semi-annual inspection, testing and maintenance of the fire alarm system. The annual inspection, testing and maintenance was conducted in April 2022. Surveyor was accompanied by the Facility Administrator who acknowledged the existence of these conditions.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 42986 Based on observations, record review and interview during the survey, it was determined through on-going dialog with the Facility Administrator that the facility failed to ensure the sprinkler system was continuously maintained & in reliable operating condition. This resulted in the potential for system failure during fire emergencies (LSC 21.3.5, 39.3.5, 9.7.5, 9.7.7, 9.7.8, NFPA 13, NFPA 25). Findings include: 1. On 6/13/2024, during record review between 12:15 pm to 1:15 pm, the facility failed to provide documenation for monthly and quarterly inspection, maintenance, and testing of the fire sprinkler system. Surveyor interviewed staff and the staff were not aware of any requirements other than the annual and 5 year internal pipe inspection. SEE NOTE* 2. On 6/13/2024, during record review between 12:15 pm to 1:15 pm, the facility failed to provide documentation for the annual fire inspection, testing, and maintenance of the fire sprinkler system. The last testing documenation was dated 12/29/2022. 3. On 6/13/2024, during record review between 12:15 pm to 1:15 pm, the facility failed to provide documenation of the required annual forward flow test. SEE NOTE* Surveyor was accompanied by the Facility Administrator who acknowledged the existence of these conditions. * NOTE: This was a repeat deficiency from the survey completed on 11/20/2020.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 21.3.7.5, 21.3.7.6, 8.5 This Standard is not met as evidenced by: 42986 Based on observations and interview during the survey, it was determined through on-going dialog with the Facility Administrator that the facility failed to maintain minimum smoke barrier fire resistance ratings in universe smoke compartments throughout the building. This resulted in the potential for the spread of fire/smoke to other smoke compartments (LSC 21.3.7.3, 21.3.7.6, 8.3). Findings include: 1. On 6/13/2024, at 1:36 pm, there was an opening/penetration in the ceiling of the Janitors Closet that was greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility. 2. On 6/13/2024, at 1:37 pm, there was an opening/penetration in the ceiling of the Electrical Room that was greater than 1/4 inch that would allow for the spread of smoke or fire to other areas of the facility. Surveyor was accompanied by the Facility Administrator who acknowledged the existence of these conditions.”

“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: 1. On 6/13/2024, during record review between 12:15 pm and 1:15 pm, facility documentation presented to the surveyor showed incomplete fire drill forms for the facility. 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. SEE NOTE* 2. On 6/13/2024, during record review between 12:15 pm and 1:15 pm, facility documentation, policy review and interviews with staff identified that the facility failed to properly conduct fire drills by transmission of a fire alarm signal as required in NFPA 101.21.7.1.4. Facility policy indicated that activation of fire alarm system is “SIMULATED unless required by State regulations”. The requirement is required by NFPA 101. SEE NOTE* Surveyor was accompanied by the Facility Administrator who acknowledged the existence of these conditions. * NOTE: This was a repeat deficiency from the survey completed on 11/20/2020.”

“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 were offered vaccination against Hepatitis B and/or routine surveillance testing was completed. Findings: Review of the facility’s “Vaccinations and Surveillance Report,” created “06/11/2024,” that included documentation of Hepatitis B vaccination status of 163 patients revealed 34 patients who were tested and determined to be susceptible to hepatitis B, lacked documentation of receiving the vaccine series, the vaccine series was incomplete or the vaccine series was incorrectly administered. Review of an Excel spreadsheet provided by the facility that is utilized by the RN who oversees vaccinations and comparing that to the “Vaccinations and Surveillance report” revealed the following examples but were not limited to: * Six (6) patients were given a hepatitis B vaccine or booster when their “Hep B Surveillance Status” stipulated “Immune” status. * Five (5) patients lacked documentation of lab results after being administered a vaccine or booster. * Eleven (11) patients lacked documentation of monthly HBsAg lab results as required per routine surveillance guidance. * Two (2) patients lacked documentation of annual HBsAb lab results as required per routine surveillance guidance. * One (1) patient had documentation on the Excel spreadsheet of receiving “1 of 4” vaccines on “6/10/24” however, the “Vaccinations and Surveillance Report” failed to reveal this documentation. Review of the facility’s policy, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance dated as “April 2024” stipulated, “All patients will be routinely tested ... (refer to Routine Surveillance Testing Table).” The table provided guidance of when surveillance testing was to be conducted per CDC guidelines. Patients with a susceptible status indicated that monthly antigen surveillance testing be conducted. Patients with an immune susceptible status indicated that annual antibody surveillance testing be conducted. During an interview with the MCS on 06/11/2024 at approximately 1510, they 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: 47148 Based on observation, interview and review of documentation, it was determined the facility failed to maintain a safe and functional treatment environment. Findings: Observations of the facility on 06/11/2024 beginning at 0850 revealed: * An opened MDV of Tubersol, (for tuberculosis testing) had “opened 5/2/2024” handwritten on the box. The 28-day BUD for the opened solution would have been 05/30/2024 and the vial removed from use. * An opened MDV of Heparin (an anticoagulant) lacked a BUD. * An opened MDV of Heparin (an anticoagulant), found in a drawer and available for use, had “4/1/24” written on the label. The 28-day BUD for the opened Heparin solution would have been 04/29/2024 and the vial removed from use. * Five vials of Vancomycin (an antibiotic) that expired 06/01/2024 were available for use. * Three bleach tubs had the lids off and propped beside the tubs. * The velcro of the blood pressure cuffs throughout the facility was so filled with debris, they could not be cleaned effectively for infection control purposes. * An IV pole had blue tape wrapped around a section of one of the support legs. The IV pole could not be cleaned effectively for infection control purposes. Observations of the facility on 06/13/2024 at 1330 revealed: * An opened MDV of Tubersol, (for tuberculosis testing) had “open 5/1/24” handwritten on the box. The 28-day BUD for the opened PPD solution would have been 05/29/2024 and the vial removed from use. Review of the facility policy “1-06-01” titled, “Medication Policy,” dated as “October 2023” stipulated: * “Medications containing a preservative must be discarded 28 days after opening or accessed.” * “All medications in the facility are checked monthly for expiration dates ... Medications are ordered and replaced prior to expiration.” Review of the facility policy “1-05-08,” titled “Bleach Policy,” dated as “April 2019” stipulated “Bleach solution needs to be covered with a secure lid and the solution should not be placed in the splash zone. NOTE: Without a secure lid, the bleach solution is open to air causing the solution to degrade over time and become less effective.” The above findings were confirmed during interview with the MCS, DO and FA on 06/11/2024 at 1600.”

“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: 37237 Based on observation and interview, it was determined the facility failed to maintain the building in which dialysis services were provided was constructed and maintained to ensure the safety of the patients, the staff and the public. Findings: Observations of the facility on 06/11/2024 beginning at 0850 revealed: * The lids were hanging off the eyewash station outside the water room leaving the nozzles uncovered and exposed to dirt and contaminants. * A second eyewash station had one of the lids hanging off, leaving the nozzle uncovered and exposed to dirt and contaminants. * The nozzle holes of a third eyewash station were dirty, surrounded and/or filled with black debris and/or a white precipitate. * Two cupboard doors had handles that were not completely attached. * One treatment chair had a tear in the upholstery on one of the arms that exposed the foam underneath. * Areas where the material used to fill and seal floor seams were detaching, leaving gaps in the floor that could not be effectively cleaned for infection control purposes. * Areas where the floor and wall adjoin had large cracks. The cracks were up to 3 - 4 feet in length. This compromised surface integrity could not be cleaned effectively. * The cabinetry around multiple concentrate boxes was damaged, showing water damage to the exposed substrate underneath, and/or chipped and missing laminate. * Multiple areas of chipped/missing paint with exposed sheetrock throughout both the in-center and home program areas, including patient bathrooms. * The material used as a backsplash around the nurses’ stations and around the facility was porous and this compromised surface integrity could not be cleaned effectively. * The facility failed to label a sink located on the treatment floor as clean or dirty. The above findings were confirmed during interview with the MCS, DO and FA on 06/11/2024 at 1600.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 37237 Based on observation and interview it was determined the facility failed to display the current State Agency and ESRD network mailing addresses and telephone complaint numbers as part of their grievance process. Findings: Observation of the Home Program area on 06/11/2024 at approximately 1020, revealed the facility failed to have information posted providing the mailing addresses and contact information for the applicable ESRD Network and the State survey agency as well as the complaint telephone numbers for each. Interview with DO, MCS and FA on 06/11/2024 at approximately 1600, they confirmed the finding.”

“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: 47148 Based on interview, review of patient medical records and review of documentation, it was determined that the facility failed to ensure: 1. VS checks and patient visualizations were completed regularly and on time for 12 of 16 patients (Patient #s 1, 3, 4, 5, 6, 7, 9, 12, 13, 14, 15 and 16). 2. Patients received their hemodialysis treatments as prescribed for 3 of 16 patients (Patient #s 3, 6 and 7). Findings: 1. Review of patients’ treatment flowsheets, “Treatment Details Reports,” revealed two sections titled “Intradialytic Vitals Stat Line.” The first section included a brief table of times and dialysis machine readings, at mostly routine times. The second section included more detailed entries. The second section entry was documented by PCTs/RNs and time stamped when staff did the actual patient evaluation, face and access visualization and heparin documentation. Patient 1 Patient visualization and vital sign checks were late and/or missed for 11 of 13 treatments. Review of the 05/10/2024 “Intradialytic Vitals Stat Line” section of the “Treatment Details Reports” revealed: * The PCT documented treatment start time as 1032. * The PCT documented visualization/heparin checks and comments at 1032, 1101, 1152, 1205, 1254, 1302, 1437 (91 minutes later), 1438, 1439 and 1440. The system continued to automatically document at 1029, 1031, 1101, 1132, 1202, 1231, 1301, 1331, 1332, 1402 and 1415. * Treatment end time was documented by the system at 1418 and by the PCT at 1440. * The staff failed to visualize the patient for periods up to an hour and missed numerous checks throughout the patient’s treatment. * The prescription for “Heparin Pork-Hourly Rate” was “Order stop time for hourly dose before end of treatment ... 90 minutes.” The heparin infusion was started at 1032 and ended at 1453. Review of the 05/20/2024 “Intradialytic Vitals Stat Line” section of the “Treatment Details Reports” revealed: * The PCT documented treatment start time as 1019. * The PCT documented visualization/heparin checks and comments at 1019, 1138 (19 minutes later), 1205, 1302 (57 minutes later), 1402 (60 minutes later), 1404 and 1429. The system continued to automatically document at 1016, 1031, 1101, 1131, 1201, 1231, 1301, 1331, 1401 and 1407. * Treatment end time was documented by the system at 1407 and by the PCT at 1429. * The staff failed to visualize the patient for periods up to and over an hour and missed numerous checks throughout the patient’s treatment. * The prescription for “Heparin Pork-Hourly Rate” was “Order stop time for hourly dose before end of treatment ... 90 minutes.” The heparin infusion was started at 1016 and ended at 1429. Review of the 06/03/2024 “Intradialytic Vitals Stat Line” section of the “Treatment Details Reports” revealed: * The PCT documented treatment start time as 1009. * The PCT documented visualization/heparin checks and comments at 1010, 1228 (138 minutes later), 1229, 1308, 1401 (53 minutes later) and 1402. The system continued to automatically document at 1009, 1031, 1102, 1132, 1201, 1231, 1301, 1332, 1353 and 1355. * Treatment end time was documented by the system at 1355 and by the PCT at 1402. * The staff failed to visualize the patient for periods up to and over 1 hour and missed numerous checks throughout the patient’s treatment. * The prescription for “Heparin Pork-Hourly Rate” was “Order stop time for hourly dose before end of treatment ... 90 minutes.” The heparin infusion was started at 1032 and ended at 1453. * Similar findings were identified for 05/13/2024, 05/15/2024, 05/17/2024, 05/24/2024, 05/29/2024, 05/31/2024, 06/07/2024 and 06/10/2024. * Similar findings were identified for Patient #s 3, 4, 5, 6, 7, 9, 12, 13, 14, 15 and 16. 2. Review of Patient # 3’s dialysis orders and treatment sheets dated 05/092024 through 06/09/2024 (13 treatments) reflected the following: * The physician order for Max UFR on 05/05/2024 was 13.0 mL/kg/hr. * The Max UFR exceeded 13.0 mL/kg/hr for 6 of 13 treatments with no documentation to reflect why the physician orders were not followed. Examples included: - On 05/09/2024, the actual UFR was 14.0 mL/kg/hr. - On 05/14/2024, the actual UFR was 16.5 mL/kg/hr. - On 05/18/2024, the actual UFR was 18.3 mL/kg/hr. * Similar findings were noted on treatment flowsheets dated 05/28/2024, 06/01/2024 and 06/08/2024. * Similar findings were identified for Patient #s 6 and 7 Review of the facility policy, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated April 2024, stipulated: * “Patient identity, prescription, and machine settings are verified by teammate prior to initiation of treatment ... Prescription components include but are not necessarily limited to... UFR and Max UFR ...” * “Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: * “Vital signs and treatment monitoring ... are completed at least every 30 minutes.” * “At a minimum, obtain and document the following ... Blood pressure ... Heart or pulse rate ... Blood and dialysate flows, arterial and venous pressures ... Fluid removal and/or replacement ... Vascular access visible and line connections intact ... Patient subjective statement(s) i.e., patient report on overall health, any complaints.” During interview with the MCS on 06/13/2024 at approximately 1530 the above findings were confirmed.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 47148 Based on interview, review of clinical records, and review of facility documentation, it was determined the facility failed to ensure: 1. Clinical records were accurate for all patients with a history of pneumococcal vaccination administration. 2. Clinical records were accurate for 12 of 20 patients (Patient #s 1, 3, 4, 5, 6, 7, 9, 12, 13, 14, 15 and 16) whose treatment sheets were reviewed. Findings: 1. Review of the Vaccination and Surveillance Report for pneumococcal vaccinations for 163 patients revealed that for 51 patients with a history of pneumococcal vaccinations, the exact vaccine provided was often not available. The vaccine history simply stated Pneumococcal Vaccine” and did not specify whether the vaccine administered was PCV13, PCV15, PCV20, or PPSV23. As a result, staff were not able to determine what follow-up vaccines would be required, if applicable. Review of the facility policy titled “Pneumococcal Vaccination for Adult Hemodialysis Patients,” dated as “October 2023”, included obtaining patient vaccination history and vaccination guidance based on which vaccine(s) was administered (PCV 13, PCV 15, PCV 20, or PPSV 23). During interview with the FA and MCS on 06/13/2024 at approximately 1555, the above findings were confirmed. The MCS stated that the ability to document the specific vaccine given had been initiated by the IT department prior to the initiation of this survey. 2. Review of Patient #1’s treatment sheets revealed entries during treatment were time stamped at conspicuously equal intervals on the short treatment review form that did not appear to reflect the time the task was completed. For example: * On 5/10/2024, RN/PCT documentation under “Intradialytic Vital Stat Line” for VS, BFR/DFR, AP, VP, UFR, volume remaining, access visualization, face visualization and the heparin pump were time stamped at 1029, 1031, 1101, 1132, 1202, 1231, 1301, 1331, 1332, 1402 and 1415, giving the appearance that checks were done at these times and that no checks by the RN/PCT were missed. This documentation did not match the information on the long treatment review form that showed when the RN/PCT actually documented when they evaluated the patient. The actual time stamps were 1032, 1101, 1152, 1205, 1254 (49 minutes later), 1302, 1437 (91 minutes later), 1438, 1439 and 1440, with no documentation to show a RN/PCT check was conducted for the 1231, 1331, 1402 and 1415 timeframes. Similar findings were noted for the 11 of 13 treatments. Similar findings were noted in the treatment sheets for Patient #s 3, 4, 5, 6, 7, 9, 12, 13, 14, 15 and 16. Review of the facility policy, “CWOW-Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated as “April 2024” stipulated vital signs and treatment monitoring was “completed at least every thirty (30) minutes.” During interview on 06/13/2024 at 1530, the MCS confirmed the above findings. Refer to findings cited at Tag V503 under CFR §494.80 (a)(2) - Standard: Evaluation of the appropriateness of the dialysis prescription that reflects how this discrepancy resulted in a situation where missed vital signs and patient safety checks could go unidentified and for missed RN/PCT checks and missed vital signs.”