Fmc Florence Oregon

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 37237 Based on interview and review of the facility’s emergency preparedness plan, it was determined the facility failed to update the EP plan annually. Findings: Refer to findings identified in Tag E039”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 37237 Based on interview and the review of emergency planning materials, it was determined the facility failed to ensure the emergency plan included an updated facility-based and community-based risk assessment, utilizing an all-hazards approach. Findings: Refer to findings identified in Tag E039.”

“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: 47148 Based on interview, review of patients’ medical records and review of documentation, it was determined the facility failed to ensure: 1. The Emergency Preparedness Plan was updated annually. 2. That a facility-based and community-based risk assessment, utilizing an all-hazards approach was completed annually. 3. That the facility participated in a full-scale exercise and conducted a tabletop exercise. 4. That the facility participated in quarterly fire drills. Findings: 1. The facility failed to provide documentation that it annually maintained and updated the facility’s Emergency Preparedness Plan. - The facility presented a binder identified as “Fresenius Kidney Care 8365 - Florence, Oregon Emergency Plan” with a date of “4/11/22.” * The facility was unable to provide confirmation if that was the most current date for the facility’s Emergency Preparedness Plan. * The facility provided documentation of Governing Body minutes dated “November 18, 2023” that revealed, “The Chairperson directed members to the facility’s Emergency Plan, Hazard Analysis, Community Wide Drill, and Table Top Drill, previously circulated on (ENTER DATE). The Governing Body resolved to readopt the plan.” It was unknown when the EP plan was presented to the Governing Body for approval. 2. The facility failed to annually maintain a current Hazard Vulnerability Assessment tool (HVA) that identified hazardous events that may affect clinic operations. - The clinic failed to provide documentation of a current, dated HVA tool. The facility provided a document titled, “HAZARD VULNERABILITY ASSESSMENT” that failed to reveal a date to indicate when it was completed. 3. The facility failed to provide documentation of participation of a full-scale exercise and a tabletop exercise during 2023. 4. The facility failed to provide any documentation of staff participation in fire drill exercises for the past four quarters (Q1, Q2, Q3 and Q4) and of patient participation in fire drills in Q1, Q3 and Q4. Review of the facility policy titled “Guidelines for Emergency Preparedness” dated “07/03/2023” stipulated: - “Community Based Drill ... Annually, each facility MUST participate in a community-based disaster drill.” - “Mock Table Top Drill ... facilities must select an even of high likelihood and conduct a table-top drill. It is recommended a different drill be completed annually.” - “Quarterly, all FKC patients must receive fire drill and emergency evacuation training.” - “The Governing Body at each facility will review the disaster policies annually.” During interview with the CM and ATL on 02/08/2024 at 1340, they confirmed that the emergency binder failed to contain the required documentation, and that the facility failed to conduct both quarterly fire drills and emergency education for staff and patients.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 37237 Based on interview and review of documentation, it was determined the facility failed to ensure that chlorine testing of water used to prepare dialysate was completed at least every 4 hours as required by this regulation, facility policy and AAMI recommendations. Findings: Facility daily chlorine logs documenting chlorine tests between 12/01/2023 through 02/07/2024 were reviewed. This review revealed the intervals between chlorine tests exceeded the required four-hour time limit on at least 2 occasions. Examples included: 12/31/2023 - chlorine tests were completed at 0916 and 1337, an interval of 4 hours and 21 minutes. 01/05/2024 - chlorine tests were completed at 0852 and 1155. No further tests were documented during the afternoon. Review of the facility policy titled, “Carbon Filtration Monitoring for Incenter central Water Systems Policy,” dated as 11/07/2022 stipulated in the section “Testing Locations and Frequency” that “Worker Carbon Filter” should be tested “Prior to initiation of the first patient treatment of the day and at a minimum of every four hours.” The findings were confirmed with the Biomed tech on 02/08/2024 at 1440. Should the carbon tanks become exhausted, chlorine breakthrough could occur potentially exposing patients to chloramine in the water used to prepare dialysate. Patient safety can only be ensured by monitoring the performance of the carbon adsorption bed at least every 4 hours. Exposure of patients to chloramine levels > 0.1 could potentially have an adverse effect on their health including but not limited to hemolysis and/or death.”

“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 that the facility failed to ensure that the building was constructed and maintained to ensure the safety of the patients, staff and the public. Findings: Observations of the facility treatment floor on 02/07/2024 at 0930 and 02/08/2024 at 1145 revealed: - An opened bottle of MesaLabs 7.0 pH conductivity solution was in use that expired on 01/25/2024. A second bottle with the same expiration date was available for use. - The sink in the lab area was labeled clean but lacked automatic on/off water control. The sink had wrist blade controls for the hot and cold water. The opened paper towel dispenser by the clean sink had a blood collection tube located inside. - A hand washing sink, used by patients to wash their hands and accesses, was not trimmed with fittings that were operable without use of the hands. - The automatic hand sanitizer units by the lab and by the biohazard room failed to operate. - The blood pressure cuffs located on the patient treatment chairs were dirty, covered with lint and debris. - The laminate/wood above the clean sink at the med prep area was worn down to a bare surface that could not be cleaned appropriately for infection control purposes. - The laminate on surfaces of the nurses’ stations had numerous areas with large chips missing. - There were four unfilled holes in the wall around the thermostat. - The fire extinguisher located by the lab area lacked initials that it was inspected during January. - The metal frames for the privacy screens that were in use in a patient area on the treatment floor had areas with layers of old tape wrapped around the frame. - Adhesive tape on the back of the backrest of a rolling chair. - Adhesive tape on the front of the backrest of another rolling chair. - Adhesive tape on the upright IV extension pole on the dialysis machine in the isolation room. - The wall base in the isolation room had gouges leaving a sheetrock surface that is unable to be cleaned appropriately for infection control purposes. During interview with the CM on 02/08/2024 at 1340, the above findings were confirmed.”

“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 that patients received appropriate and timely hemodialysis monitoring for 2 of 3 patients (Patients #s 1 and 2). Findings: 1. Review of Patient #1’s dialysis orders and treatment sheets dated 01/08/2024 through 02/05/2024 (4 hemodialysis treatments) reflected the following: * The treatment flowsheets reflected vital signs and access checks were missed: - On 01/29/2024, the PCT documented a VS and access check at 1004. The next VS and access check was documented 64 minutes later at 1108. - On 01/26/2024, the PCT documented a VS and access check at 0703. The next VS and access check was documented 41 minutes later at 0744. - On 01/19/2024, the PCT documented a VS and access check at 0800. The next VS and access check was documented 44 minutes later at 0844. A VS and access check was documented at 0935 and 63 minutes later at 1038. 2. Review of Patient #2’s dialysis orders and treatment sheets dated 01/08/2024 through 02/05/2024 (13 hemodialysis treatments) reflected the following: * The treatment flowsheets reflected vital signs and access checks were missed: - On 01/17/2024, the PCT documented a VS and access check at 1331. The next VS and access check was documented 65 minutes later at 1436. - On 01/22/2024, the PCT documented a VS and access check at 1433. The next VS and access check was documented 58 minutes later at 1531. - On 01/24/2024, the PCT documented a VS and access check at 1533. The next VS and access check was documented 78 minutes later at 1651. - On 01/26/2024, the PCT documented a VS and access check at 1504. The next VS and access check was documented 60 minutes later at 1604. * Review of the facility policy, “Patient Assessment and Monitoring,” dated “05/01/2023 Version: 4” stipulated in the section titled “During Treatment” that “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 [minutes] or more often as needed but not to exceed 45 minutes or per state regulation.” During an interview on 02/07/2024 at approximately 1600 with the ATL, DO and CM, the above findings were confirmed.”

“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: 37237 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 immunization history section of 23 patient medical records revealed 8 patient medical records that failed to reflect that the pneumococcal vaccination had been offered to those patients as recommended. Examples included: Three patients, with an age <65 years old had incomplete pneumococcal immunization documentation: * One patient received a dose of PPSV23 on 01/06/2015. No documentation as to subsequent pneumococcal vaccine given, offered or refused was noted. * One patient had documentation of an order for a dose of PCV13 on 01/26/2022. There was no documentation that the dose was administered. * One patient whose vaccine status was documented as “Vaccination Candidate” lacked documentation of any pneumococcal immunizations. Five patients with an age >65 years old had incomplete pneumococcal immunization documentation. *Two patients received a dose of the PPSV23. No documentation as to subsequent pneumococcal vaccine given, offered or refused was noted. *One patient received PPSV23 on 11/26/2006 and again on 01/13/2015. * One patient whose vaccine status was documented as “Vaccination Candidate” lacked documentation of any pneumococcal immunizations. * One patient received PCV13 on 02/21/2019. No documentation as to subsequent pneumococcal vaccine given, offered or refused was noted Review of the facility policy, “Pneumococcal Vaccine for Adults,” dated “02/05/2024” stipulated, “ Adults aged 19 and older diagnosed with chronic renal failure who have not previously been vaccinated or whose previous vaccination history is unknown, should receive: * One dose of Prevnar 20® (PCV20) OR * One dose of Vaxneuvance (Trademark) (PCV15) followed by one dose of Pneumovax® 23 (PPSV23) at least one year later. NOTE: Adults who have previously been vaccinated with Prevnar 13® (PCV13) and/or Pneumovax® 23 (PPSV23) should follow the CMAB algorithm for recommended vaccine schedule.” 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 02/07/2024 at 1610, the CM confirmed they were behind on pneumococcal immunizations.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 37237 Based on interview and review of documentation, it was determined the facility failed to ensure that 4 of 12 staff (Staff #s 3, 5, 10 and 11) had the qualifications and demonstrated competencies to meet the comprehensive care needs of the patients. Findings: The review of documentation included the “ESRD Survey Worksheet: Personnel Review” completed by the Facility Administrator on 02/08/2024 revealed: * Staff #3 - Identified as a PCT with a DOH of 07/03/2000, last completed “Emergency Preparedness Annual” training on 12/30/2022. * Staff #5 - Identified as a float PCT with a DOH of 08/01/2021, last completed the annual “Water Skills Validation” on 01/23/2023. * Staff #10 - Identified as a float RN with a DOH of 09/19/2022, last completed the annual “Competencies and Skills” trainings on 12/06/2022. * Staff #11 - Identified as a float RN with a DOH of 07/26/2023, lacked documentation that they received orientation to the facility. During interview with the CM on 02/08/2024 at 1340, they confirmed the above findings.”