Fkc Harrisburg

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 39848 Based on review of policy/procedures, observations (OBS.) and an interview with the facility administrator, the facility failed to ensure staff performed handwashing/hand hygiene and wore gloves in two (2) out of fourteen (14) observations. (OBS # 1- # 2) Findings include: Review of Fresenius Kidney Care Clinical services hand hygiene on 9/11/25 at approximately 3:00 PM revealed: “ Purpose: The purpose of this policy is to prevent transmission of pathogenic microorganisms to patients and staff through cross contamination.; Responsibility: All staff, patients, patient care givers ....and any other indirect patient care staff must follow the same requirements for hand hygiene.; Policy: Hand hygiene includes either washing hands with soap and water or using a waterless alcohol-based antiseptic hand rub ... ; Hands will be decontaminated using alcohol-based hand rub or by washing hands with soap and water when: Before and after direct contact with patients, Before performing any invasive procedure such as vascular access cannulation.., immediately after removing gloves, after contact with inanimate objects near the patient, when moving from a contaminated body site to a clean body site of the same patient, after contact with other objects within the patient station or treatment space ... “ Floor observations conducted on 9/9/25 between 10:30 AM-1:00 PM and 9/10/25 between 1:35 PM-3:30 PM revealed: Observation #1: 9/9/25 between 12:30 PM-12:50 PM: EMP # 1 was observed discontinuing treatment for patient at station # 17 and did not perform glove change or hand hygiene after disconnecting patient ‘s blood lines and touching patient ’ s blanket to place in patient ’ s belongings bag. Observation #2: 9/10/25 between 1:40 PM-1:45 PM: EMP # 2 was observed discontinuing treatment for patient at station # 19 and did not perform glove change or hand hygiene after touching dialysis machine then touched patient ’ s belongings then touched dialysis machine again then touched patient ’ s belongings again. An interview conducted with the facility administrator and facility director of operations on 9/11/25 at approximately 3:30 PM 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: 39848 Based on reviews of observations, facility policy, and an interview with the facility administrator, the facility failed to ensure proper inventory control for one (1) of one (1) observation (Observation # 1). Findings include: Review of Fresenius Kidney Care Clinical services emergency medications, equipment and supplies on 9/12/25 at approximately 11:05 AM revealed: Purpose: “ The purpose of this policy is to provide guidelines for staff when determining and maintaining emergency equipment and supplies. Responsibility: Licensed nurse; Definitions: Emergency evacuation box: an emergency evacuation box contains supplies primarily needed to emergently remove needles, cap catheters, and provide saline as needed for every licensed station once the patient is in a secure location. Policy: Emergency evacuation box: An emergency evacuation box must: be checked monthly or after use for contents, expiration dates and cleanliness. An itemized log must be kept indicating the contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date. “ Observations conducted of the facility ’ s evacuation kit on 9/11/25 between approximately 3:00 PM-3:20 PM revealed the following: Observation (OBS) # 1 revealed: Ten (10) B Braun Intravenous (IV) administration sets with universal spike with expiration date of 6/30/2025. An interview conducted with the facility administrator and facility director of operations on 9/11/25 at approximately 3:30 PM confirmed the above findings.”

“PE-PT CARE ENVIRONMENT-SUFFICIENT SPACE CFR(s): 494.60(c)(1) The space for treating each patient must be sufficient to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. This Standard is not met as evidenced by: 39848 Based on observations and an interview with the facility administrator, it was determined the facility failed to ensure adequate space between clean sinks, dirty sinks, dialysis chairs, wheelchairs and hoyer lift to prevent cross-contamination for four (4) observations (Observation #1- # 4). Findings include: Review of Fresenius Kidney care clinical services general cleanliness and infection control guidelines on 9/12/25 at 1:30 PM revealed: Purpose: “ The purpose of this policy is to provide guidance for ...staff on preventing the spread of infectious disease and maintaining a clean, safe, and aesthetically pleasant environment for patients, staff and visitors. Policy: All areas must be kept clean and organized, including but not limited to treatment areas, water/supply rooms, offices and restrooms. Walkways must be kept clear of debris and free of clutter. Facilities must adhere to any state-specific regulations that pertain to facility cleaning and disinfection. Clean supplies may not be kept under dirty sinks. “ Observation # 1: On 9/9/2025 at approximately 10:20 AM dialysis chair was blocking clean sink by patient scale. Observation # 2: On 9/9/2025 at approximately 10:30 AM hoyer lift was blocking dirty sink in the middle of the treatment room floor. Observation # 3: On 9/10/2025 at approximately 1:35 PM patient ’ s wheelchair was blocking clean sink by patient scale. Observation # 4: On 9/11/2025 at approximately 3:00 PM hoyer lift was blocking dirty sink in the middle of the treatment room floor. An interview conducted with the facility administrator and facility director of operations on 9/11/25 at approximately 3:30 PM confirmed the above findings.”

“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: 39848 Based on review of policy, medical records (MR), and an interview with the facility administrator; the facility failed to ensure that the patient prescriptions were being implemented as ordered by the physician for five (5) out of seven (7) patient prescriptions reviewed (MR # 3- # 7). Findings include: Review of Fresenius Kidney Care Clinical services patient assessment and monitoring on 9/11/25 at approximately 3:00 PM revealed: “ Purpose: The purpose of this policy is to provide guidance to Fresenius kidney care (FKC) direct patient care staff on assessment and monitoring patients before, during and after treatment.; Definitions: Date Collection: Gathering of objective and subjective information related to the patient’s health status as it corresponds to the ordered renal replacement.; During treatment: Document machine parameters and safety checks every thirty (30) minutes or more often as needed but not to exceed forty-five (45) minutes or per state regulations.. “ ; “ Follow the steps below for monitoring patient and machine parameters during treatment: Machine parameters and extracorporeal circuit: 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. Check dialysate flow setting is correct, and the prescribed flow is being delivered. “ Review of Fresenius Kidney Care Clinical services patient monitoring and safety checks during hemodialysis treatment on 9/11/25 at approximately 3:00 PM revealed: “ Purpose: The purpose of this document is to provide guidance for patient monitoring and safety check guidelines during the hemodialysis treatments; Policy: patient monitoring and safety check guidelines: safety check-machine checks: monitor and document machine checks every thirty (30) minutes or more frequently as needed but not to exceed forty-five (45) minutes or per state regulations in the Fresenius kidney care treatment record ... “ Review of patient orders and dialysis treatment flow sheets on 9/11/25 between approximately 10:05 AM and 1:30 PM and 2:15 PM and 2:45 PM, review of patient orders and dialysis treatment flow sheets revealed: MR # 3: Physician orders dated: 6/10/25; “Blood Flow Rate (BFR) 350. “ Treatment flow sheet dated: 8/30/25 showed BFR: 400. No documentation explaining the BFR difference from the prescribed BFR. No documentation showing the physician was notified. Treatment flow sheet dated: 9/2/25 showed BFR: 400. No documentation explaining the BFR difference from the prescribed BFR. No documentation showing the physician was notified. Treatment flow sheet dated: 9/4/25 showed BFR: 400. No documentation explaining the BFR difference from the prescribed BFR. No documentation showing the physician was notified. MR # 4: Physician orders dated: 9/10/25; “Blood Flow Rate (BFR) 500. “ Treatment flow sheet dated: 9/8/25 showed BFR ordered: 500. BFR during treatment 350-400. No documentation explaining the BFR difference from the prescribed BFR. No documentation showing the physician was notified. MR # 5: Physician orders dated: 9/1/25; “Blood Flow Rate (BFR) 450. “ Treatment flow sheet dated: 9/1/25 showed BFR 400 during treatment from 5:49 AM-6:32 AM for forty-three (43) minutes before BFR set to prescribed rate. No documentation explaining the BFR difference from the prescribed BFR. No documentation showing the physician was notified. MR # 6: Physician orders dated: 8/29/25; “Dialysate Flow Rate (DFR) 600. “ Treatment flow sheet dated: 8/29/25 showed DFR 800. No documentation explaining the DFR difference from the prescribed DFR. No documentation showing the physician was notified. Treatment flow sheet dated: 9/1/25 showed DFR 800. No documentation explaining the DFR difference from the prescribed DFR. No documentation showing the physician was notified. MR # 7: Physician orders dated: 9/2/25; “Blood Flow Rate (BFR) 450. “ Treatment flow sheet dated: 8/30/25 showed BFR: 500. No documentation explaining the BFR difference from the prescribed BFR. No documentation showing the physician was notified. Treatment flow sheet dated: 9/4/25 showed BFR: 500. No documentation explaining the BFR difference from the prescribed BFR. No documentation showing the physician was notified. Treatment flow sheet dated: 9/6/25 showed BFR: 400. No documentation explaining the BFR difference from the prescribed BFR. No documentation showing the physician was notified. Treatment flow sheet dated: 9/9/25 showed BFR: 475-500. No documentation explaining the BFR difference from the prescribed BFR. No documentation showing the physician was notified. An interview conducted with the facility administrator and facility director of operations on 9/11/25 at approximately 3:30 PM confirmed the above findings.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 39848 Based on review of medical records (MR), policies, procedures and interview with facility administrator, it was determined that the facility failed to adequately monitor blood pressures during treatment in one (1) of seven (7) medical records (MR) reviewed (MR # 2). Findings include: Review of Fresenius Kidney Care Clinical services patient assessment and monitoring on 9/11/25 at approximately 3:00 PM revealed: “ Purpose: The purpose of this policy is to provide guidance to Fresenius kidney care (FKC) direct patient care staff on assessment and monitoring patients before, during and after treatment.; Definitions: Date Collection: Gathering of objective and subjective information related to the patient’s health status as it corresponds to the ordered renal replacement; Data collection: direct care staff may collect data such as weight, blood pressure (BP), pulse .....Pre-treatment: Blood pressure: record blood pressure; During nursing rounds, the Registered Nurse (RN) will review the data collected ...Document findings and interventions in the medical record. During treatment: Obtain blood pressure and pulse rate every thirty (30) minutes or more as needed but not to exceed forty-five (45) minutes or per state regulations. “ Review of Fresenius Kidney Care Clinical services patient monitoring and safety checks during hemodialysis treatment on 9/11/25 at approximately 3:00 PM revealed: “ Purpose: The purpose of this document is to provide guidance for patient monitoring and safety check guidelines during the hemodialysis treatments; Policy: patient monitoring includes: Blood pressure, pulse, respirations. “ Review of patient orders and dialysis treatment flow sheets on 9/11/25 between approximately 10:05 AM and 1:30 PM and 2:15 PM and 2:45 PM, review of patient orders and dialysis treatment flow sheets revealed: MR # 2 review revealed: 1. Treatment flow sheet on 8/30/25 revealed treatment was started at 8:54 AM and first documented blood pressure was at 9:06 AM which was twelve (12) minutes after treatment was started. 2. Treatment flow sheet on 9/4/25 revealed two (2) episodes during this treatment of blood pressure not being taken adequately. Between 9:08 AM to 10:00 AM which is fifty-two (52) minutes between blood pressure checks. Blood pressure 136/69 was taken at 9:08 AM and then taken again at 10:00 AM and was 158/71. Between 11:32 AM to 12:31 PM which is fifty-nine (59) minutes between blood pressure checks. Blood pressure 178/81 was taken at 11:31 AM and then taken again at 12:31 PM and was 186/102. An interview conducted with the facility administrator and facility director of operations on 9/11/25 at approximately 3:30 PM confirmed the above findings.”