Fkc Hazleton

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 19122 Based on a review of facility policy, observational tour and interview with the Clinic Manager (Employee #6), the facility failed to ensure hemodialysis supplies were stored in accordance with facility policy for one (1) of two (2) observations. (Observation #2) Findings include: On January 22, 2026 at approximately 11:13 AM, review of facility policy 47543, titled “Storage of Supplies”, revealed the following: Background...Proper storage conditions are necessary to provide a safe-environment and to ensure supplies are not...contaminated... Environmental Storage Conditions...All supplies must be stored in a clean...environment. Observation #2: During environmental tour conducted on January 21, 2026 between the approximate times of 10:20 AM and 12:30 PM, observation of the hemodialysis treatment area revealed an open box, which was labeled as 14/15 g (gauge-access needle sizes), had been placed on the hemodialysis treatment floor near the biohazard container. The box which contained pre-made hemodialysis access kits, including unopened access needle packets, remained on the hemodialysis treatment area floor until approximately 12:00 noon on 01/21/2026 when the box was then transferred to a countertop in the treatment area. During interview conducted on January 23, 2026 at approximately 3:05 PM, the Clinic Manager confirmed the above referenced box containing the pre-made hemodialysis access kits/unopened access needles packets was not stored in accordance with facility policy on 01/21/2026.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 19122 Based on a review of facility policy and documentation, observational tour and interview with the biomedical technician (Employee #5) and the Clinic Manager (Employee #6), the facility failed to ensure twelve (12) of twelve (12) hemodialysis station wall boxes (water/dialysis concentrate delivery port and waste disposal drain) were maintained in accordance with facility policy. (Stations 1 through 12) Findings include: On January 22, 2026 at approximately 11:08 AM, review of facility policy 48564, titled “Cleaning and Disinfection General Policy for Inpatient Services”, revealed the following: Definitions...Dialysis Wall Box...A box designed to connect a central distribution system to a hemodialysis machine that is located in the wall behind a machine. Cleaning of Wall Boxes...Special attention should be given to removing build-up and/or splatter and spray of concentrate solution. On January 21, 2026 at approximately 12:55 PM, review of the biomedical/technical log titled “QAI-Repair Orders for a Date Range” revealed the following: 05/23/2025: Smell from wall ports (boxes) at stations 6 through 9 09/15/2025: Horrible smell and baby flies coming from the drains in the wall boxes at stations 6 through 9. During environmental tour conducted on January 20, 2026 at approximately 10:30 AM, observation of the hemodialysis treatment area revealed a white and/or tan crystallized residue was present at the base/drain area of the wall boxes located at hemodialysis stations 1 through 12. During interview conducted on January 21, 2026 at approximately 1:47 PM, the biomedical technician confirmed a crystallized residue was present on the wall boxes in the hemodialysis treatment area. During interview conducted on January 23, 2026 at approximately 3:05 PM, the Clinic Manager confirmed the wall boxes at hemodialysis stations 1 through 12 had not been maintained in accordance with facility policy.”

“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: 19122 Based on a review of facility policy and medical records and interview with the Clinic Manager (Employee #6), the facility failed to ensure four (4) of four (4) active patients were notified in writing of the time and date of Plan of Care (POC) reviews conducted in 2025. (Patients #1, #2, #3 and #4) Findings include: On January 23, 2026 at approximately 2:40 PM, review of facility policy 45283, titled “Comprehensive Interdisciplinary Assessment and Plan of Care”, revealed the following under “Patient Participation in Plan of Care”: Notify the patient in writing of the time and date of the Plan of Care review. Patient #1: On January 22, 2026 at approximately 11:03 AM, review of the medical record revealed the admission date was 10/30/2025 and that the initial POC review was conducted on 11/19/2025 as documented on the POC. There was no documentation in the medical record which provided evidence the facility had provided the patient with written notification of the time and date of the POC review scheduled for and conducted on 11/19/2025. Patient #2: On January 22, 2026 at approximately 1:17 PM, review of the medical record revealed the first date of chronic hemodialysis at the facility was 10/24/2024 and that the 3 month (90 day) POC review was conducted on 02/27/2025 as documented on the POC. There was no documentation in the medical record which provided evidence the facility had provided the patient with written notification of the time and date of the POC review scheduled for and conducted on 02/27/2025. Patient #3: On January 23, 2026 at approximately 10:29 AM, review of the medical record revealed the admission date was 04/27/2024 and that an annual POC review was conducted on 06/19/2025 as documented on the POC. There was no documentation in the medical record which provided evidence the facility had provided the patient with written notification of the time and date of the POC review scheduled for and conducted on 06/19/2025. Patient #4: On January 23, 2026 at approximately 11:15 AM, review of the medical record revealed the admission date was 05/27/2023 and that an annual POC review was conducted on 07/26/2025 as documented on the POC. There was no documentation in the medical record which provided evidence the facility had provided the patient with written notification of the time and date of the POC review scheduled for and conducted on 07/26/2025. During interview conducted on January 23, 2026 at approximately 3:05 PM, the Clinic Manager confirmed written notification of the time and date of the POC reviews was not provided to the above identified patients for the aforementioned POC reviews conducted in 2025,”