Pnrs-North Coast Dialysis Clinic

“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 and interview, it was determined the facility failed to ensure the facility’s emergency evacuation kit contained updated staff contact information and patient contact and medication information. Findings: Observation of the in-center emergency evacuation kit on 01/07/2025 beginning at 1110 revealed the information on the “Emergency Disaster Patient Contact List” was last updated on 01/19/2024. During interview with the FA on 01/07/2025 at 1530, they confirmed the contact list had not been updated quarterly.”

“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: 31224 Based on interview and review of documentation, it was determined that the facility failed to ensure that all susceptible patients were offered the Hepatitis B vaccination or Hepatitis B vaccine boosters as required to appropriately manage care for 3 of 67 patients (Patient #s 7-9). Findings: Review of the “Hepatitis B Summary Report,” created 01/07/2025, reflected: * Patient #7 was admitted to the facility during 10/2024. The following laboratory results, dated 10/3/2024, revealed: HBsAg “negative,” anti-HBs less than 10 mIU/mL, and anti-HBc “negative.” This indicated they were susceptible to Hepatitis B. There was no documentation to show Patient #7 was offered or received the Hepatitis B vaccine. * Patient #8 was admitted to the facility during 12/2023 and received the series of Hepatitis B vaccines. On 09/24/2024, Patient #8’s anti-HBs laboratory results were <10, that indicated they were susceptible to Hepatitis B. There was no documentation to indicate whether a second Hepatitis B vaccine series was offered or administered. * Patient #9 was admitted to the facility during 10/2024. The following laboratory results, dated 10/11/2024, revealed: HBsAg “negative,” anti-HBs less than 10 mIU/mL, and anti-HBc “negative.” This indicated they were susceptible to Hepatitis B. There was no documentation to show Patient #9 was offered or received the Hepatitis B vaccine. Review of the facility policy titled, “Patient Vaccination for Hepatitis B,” dated 02/07/2022 stipulated: * “The Hepatitis B vaccine shall be offered to all susceptible patients including peritoneal and home hemodialysis patients.” * A protective antibody response is 10 or more milliinternational units (mIU) per milliliter (anti-HBs [greater than or equal to] 10 mIU/mL). Review of the facility policy titled, “CMAB Recommended Evaluation and Immunization Against Hepatitis B Infection 1.0,” dated 05/16/2022 stipulated: * A new dialysis patient with laboratory results of HBsAg “negative,” anti-HBs less than 10 mIU/mL, and anti-HBc “negative” and had no known history of Hepatitis B vaccination would be offered the vaccine, the consent or refusal documented in the patient’s records. If the patient consented to receiving the vaccine, the Hepatitis B vaccine series would be administered. * If a patient was “Previously vaccinated for Hepatitis B with one (1) completed series, and anti-HBs level less than 10 mIU/mL” then “Administer (4-dose) Heplisav-B vaccine series.” During interview on 01/08/2025 at approximately 1100 AM, the CN II verified the above findings.”

“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: 37237 Based on observation, interviews, and review of documentation it was determined that the facility failed to ensure that medications were prepared and stored correctly. Findings: Observation of the treatment floor on 01/07/2024 beginning at 1110 revealed: * A box of pneumococcal vaccines, “Pneumovax23,” with 9 vials that expired on 05/06/2024 was available for use in the medication refrigerator. * An opened MDV of heparin available for use lacked an opened date and/or a beyond use date. * Two pre-filled syringes of heparin with preprinted patient labels attached were dated 01/07/2024 and stored in a drawer. Both syringes lacked the time and initials of the staff who prepared the medication. Review of the facility policy titled, “Medication Preparation and Administration” dated “02/06/2023” stipulated: * “All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of the patient, date, time and initials of the person who prepared the medication” * “When preparing medications if the vial is not used immediately in its entirety, the nurse or PCT must place the date and time the vial was opened on the medication label along with their initials” * “All medications will be kept in a locked cabinet except when in use.” During interview with the FA on 01/07/2025 at 1530, the above findings were confirmed.”

“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 and interview, it was determined the facility failed to ensure expired medical supplies were not available for use. Findings: Observation of the facility on 01/07/2024 beginning at 1110 revealed: * Two 250 mL bags of 0.9% NS that expired 10/2024. * Glucometer control solutions 1 and 2 that expired 12/02/2022. * Embrace PRO glucometer test strips that expired 03/29/2023. * Twelve BD 50 mL Luer-Lok Tip syringes that expired 10/31/2024. The FA confirmed the above findings on 01/07/2024 at 1530.”

“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 medical records, and review of documentation, it was determined that the facility failed to ensure that patients received hemodialysis treatments as prescribed and that VS monitoring was completed according to facility policy for 3 of 4 in-center hemodialysis patients reviewed (Patient #s 1, 3 and 4). Findings: Patient #1 Review of Patient #1’s dialysis orders and treatment flowsheets dated 12/10/2024-01/06/2025 (16 treatments)revealed: * Physician orders included running a 1 K+ dialysate for the first two hours of treatment on Mondays and Wednesdays. * There was no documentation to indicate a 1 K+ dialysate was run for 3 of 16 treatments dated 12/16/2024, 12/18/2024, and 12/23/2024. * During treatment on 12/27/2024, Patient #1 BP readings were elevated with SBP measuring from 166 to 206 and DBP measuring from 106 to 124. There was no documentation to indicate the PCT notified the RN of the elevated BPs or that the RN addressed the elevated the BPs when they documented monitoring the patient. The RN documented, “Pt tx terminated early at pt request d/t severe headache.” Patient #3 Review of Patient #3’s dialysis orders and treatment flowsheets dated 12/10/2024-01/04/2025 (8 treatments)revealed: * Physician orders included running a “1 K bath for the first 2 hours of treatment on first treatment day of the week.” - There was no documentation that a 1K+ bath was run for 7 of 8 treatment dates. The only documentation of a 1K+ bath was on 12/14/2024. * Physician orders included a DFR of 600 mL/min. The DFR was changed without documentation to indicate why the physician orders were not followed in 3 of 8 treatments. - The treatment flowsheet dated 12/30/2024 revealed the RN set the DFR to 800 mL/min for the duration of the treatment with no documentation by the PCT or RN as to why the physician orders were not followed. -Similar findings were identified for treatment dates 12/23/2024 and 12/19/2024. * VS and/or patient safety checks were not conducted at a minimum of every 30 minutes during 1 of 8 treatments. - The treatment flowsheet dated 12/30/2024 revealed the RN documented VS and patient safety checks at 0803. The next check was done at 0933, 90 minutes later. A PCT documented the next VS check at 1029, 54 minutes later. Patient #4 Review of Patient #4’s dialysis orders and treatment flowsheets dated 12/06/2024 through 01/06/2024 (14 hemodialysis treatments) revealed: * Physician orders included a BFR of 350 mL/min. * The BFR was changed without documentation to indicate why the physician orders were not followed in 3 of 14 treatments. * VS and/or patient safety checks were not conducted at a minimum of every 30 minutes during 4 of 14 treatments. Examples include, but were not limited to: * The treatment flowsheet dated 12/09/2024 revealed the PCT documented VS and patient safety checks at 0902. The next check was done at 0952, 50 minutes later. * The treatment flowsheet dated 12/16/2024 revealed the PCT documented VS at 0832. The next VS was documented at 0934, 62 minutes later. The RN documented the next VS at 1033, 59 minutes later. * The treatment flowsheet dated 12/17/2024 revealed the PCT set the BFR at 375 mL/min for the duration of the treatment with no documentation by the PCT or RN as to why the physician orders were not followed. - Similar findings were identified on 12/22/2024, 12/29/2024, 12/31/2024, and 01/06/2024. Review of facility policy titled “Patient Assessment and Monitoring,” dated 05/01/2023, stipulated: * “During Treatment ... Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations.” * “Report to the nurse ... Systolic blood pressures greater than 180 mm/Hg ... Diastolic blood pressure greater than 100 mmHg ...” * “Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow.” During interview on 01/09/2025 at 0930, the CN II confirmed the above findings.”

“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 and review of documentation, it was determined that the facility failed to offer the pneumococcal vaccine to patients based on assessment of status or assess prior refusal of vaccines as required by facility policy for 14 of 67 patients (Patient #s 7, 9, 10-20). Findings: Review of the “Pneumonia Vaccination Report,” printed on 01/07/2025, revealed: * Patient #s 7, 9, and 11-18 were eligible to receive the PCV20 vaccine, but there was no documentation to show it was offered or administered. * Patient #s 10, 19, and 20 had a history of declining the vaccine, but there was no documentation to show this was reevaluated annually. Review of the “Hepatitis B Summary Report,” printed on 01/07/2025, revealed Patient #10 had a history of declining the Hepatitis B vaccine, but there was no documentation to show this was reevaluated annually. Review of the facility policy titled, “Pneumococcal Vaccine for Adults,” dated 02/05/2024, stipulated: * “Pneumococcal vaccination is recommended for adults with chronic renal failure.” * “Patients should be offered pneumococcal vaccination on an annual basis, at minimum” for any patient who previously declined the vaccine. Review of the facility policy titled, “Patient Vaccination for Hepatitis B,” dated 02/07/2022, stipulated “Patients who are candidates for hepatitis [sic] B vaccine and decline, should be offered the Hepatitis B vaccine on an annual basis, at minimum.” During interview on 01/08/2024 at approximately 1100 AM, the CN II verified the above findings.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 37237 Based on interview, review of 2 of 6 patients’ plan of care (Patient #s 3 and 6) and review of documentation, it was determined that the facility failed to ensure that plans of care were signed by the patient and/or the patient’s designee or that a reason for refusal was documented. Findings: Review of medical records of Patient #3 included a Plan of Care dated 03/20/2024 that lacked the signature of the patient or patient’s designee. The Plan of Care also lacked documentation that showed if the patient chose not to sign the plan of care or why the signature was not provided. Review of the medical records of Patient #6 included a Plan of Care dated 05/20/2023. The patient signature was dated 03/24/2024, 10 months later. A Plan of Care dated 03/21/2024 lacked the signature of the patient or patient’s designee. The Plan of Care also lacked documentation that showed if the patient chose not to sign the plan of care or why the signature was not provided. Review of the facility policy, “Comprehensive Interdisciplinary Assessment and Plan of Care,” dated as 07/03/2023 stipulated, “The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record.” During an interview with the CN II on 01/09/2025 at 1030, the above findings were confirmed. Failure by the facility to ensure that patient or patient designee participated in the care plan meetings could result in a failure to design, implement, monitor and evaluate a treatment plan that could effectively meet the individualized care needs of the patient.”