Davita Pocono Dialysis Center

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 36372 Based on a review of facility policy, review of patient clinical records, and an interview with facility Administrator, the facility failed to ensure patients were provided with quarterly emergency training for four (4) of five (5) in-center patient medical records reviewed (MR#1, MR#2, MR#4, MR#5). Findings: A review was conducted of facility policy on December 12, 2025 at approximately 1:00 p.m. Policy: ‘Facility Emergency Management Plan’ ‘Emergency Drills’ ..... (3) Fire Safety Drills (b) Required on a QUARTERLY basis. ....” A review of patient medical records was completed on December 12, 2025 at approximately 1:00 p.m. Patients admission date is listed below: MR#1 Date of admission 08/03/12: No quarterly emergency training documentation provided for the 1st, 2nd, nor 3rd quarter of 2025. MR#2 Date of admission 02/03/20: No quarterly emergency training documentation provided for the 1st nor 3rd quarter of 2025. MR#4 Date of admission 11/08/22: No quarterly emergency training documentation provided for the 1st nor 2nd quarter of 2025. MR#5 Date of admission 07/04/20: No quarterly emergency training documentation provided for the 1st nor 3rd quarter of 2025. An interview with the facility Administrator on December 12, 2025 at approximately 1:45 p.m. confirmed the above findings.”

“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: 36372 Based on a review of facility policy, observations, and an interview with the facility Administrator, the facility failed to ensure the staff followed infection control protocols, included but not limited to, performing hand hygiene/donning clean gloves, for three (3) of three (3) ‘Access of AV Fistula or Graft for Initiation of Dialysis’ observations (Observations #1- #3) and failed to ensure the staff followed infection control protocols, included but not limited to, performing hand hygiene/donning clean gloves, for one (1) of two (2) ‘Central Venous Catheter Exit Site Care’ observations (Observations #2). Findings include: A review was conducted of facility policy on December 12, 2025 at approximately 1:00 p.m. Policy #1-04-01E ‘AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose’ ‘Procedure’ (1) states “Have patient wash access site with appropriate antibacterial soap, if able. If patient is unable to wash access site, patient care teammate will clean access extremity with skin cleansing agent.” (2) Perform hand hygiene. Put on PPE.” ...... (11) “While maintaining aseptic technique, cleanse the site by applying skin antiseptic ....” Observations conducted in the patient treatment area on December 12, 2025 between approximately 9:00 a.m. and 1:15 p.m. revealed the following: Observation #1: During observation #1 of ‘Access of AV Fistula or Graft for Initiation of Dialysis’ on 12/10/25 at approximately 11:00 a.m., of patient #37 at station #7, Employee #2 washed skin over access site and did not remove gloves/perform hand hygiene before applying antiseptic over cannulation site. Observation #2: During observation #2 of ‘Access of AV Fistula or Graft for Initiation of Dialysis’ on 12/10/25 at approximately 11:15 a.m., of patient #35 at station #9, Employee #4 washed skin over access site and did not remove gloves/perform hand hygiene before applying antiseptic over cannulation site. Observation #3: During observation #3 of ‘Access of AV Fistula or Graft for Initiation of Dialysis’ on 12/10/25 at approximately 11:25 a.m., of patient #32 at station #15, Employee #6 washed skin over access site and did not remove gloves/perform hand hygiene before applying antiseptic over cannulation site. Policy #1-04-02B ‘Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure’ ‘Procedure’ (4) “Remove old dressing and discard.” ... (7) Remove gloves and discard. perform hand hygiene per procedure and re-glove.” Observation #2: During observation #2 of ‘Central Venous Catheter Exit Site Care’ on 12/10/25 at approximately 12:00 p.m., of patient #18 at station #11, Employee #4 removed old dressing/discarded and did not remove gloves/perform hand hygiene before cleansing area around CVC exit site with antiseptic. An interview with the facility Administrator on December 12, 2025 at approximately 1:45 p.m. confirmed the above findings.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 36372 Based on a review of facility policy/procedure, clinical records, and an interview with facility Administrator, it was determined the facility failed to ensure medications were administered as ordered for one (1) of five (5) patient medical records (MR) reviewed (MR#1) and failed to ensure a licensed nurse verified each chlorine test for one (1) of one (1) chlorine testing logs reviewed (Log #1). Findings include: A review was conducted of facility policy on December 12, 2025 at approximately 1:00 p.m. Policy: 1-06-01 ‘Medication Policy’ ‘Policy’ (9) states “Medications are administered as prescribed.” A review of patient medical records was completed on December 12, 2025 at approximately 1:00 p.m. Patients admission date is listed below: MR#1 Date of admission 08/03/12: ‘Active Heparin Orders’ include ‘Heparin Pork, 600 units/hour, intravenous infusion, every dialysis treatment. Stop time for hourly dose before end of treatment: “60 minutes”. Patient treatment flow sheet dated 11/29/25 reviewed. (Treatment time 3 hours, 34 minutes.)Entry by Employee 2, ‘Medications Administered’ ‘Heparin Pork’ ‘600 units/hour, intravenous: Infusion’. ‘Given:’ “1,900 Units.” (The total treatment hourly dose order was for 1500 units. 1900 units were administered.) Patient treatment flow sheet dated 12/04/25 reviewed. (Treatment time 3 hours, 49 minutes.)Entry by Employee 1, ‘Medications Administered’ ‘Heparin Pork’ ‘600 units/hour, intravenous: Infusion’. ‘Given:’ “1,900 Units.” (The total treatment hourly dose order was for 1650 units. 1900 units were administered.) Patient treatment flow sheet dated 12/05/25 reviewed. (Treatment time 3 hours, 0 minutes.)Entry by Employee 5, ‘Medications Administered’ ‘Heparin Pork’ ‘600 units/hour, intravenous: Infusion’. ‘Given:’ “1,900 Units.” (The total treatment hourly dose order was for 1200 units. 1900 units were administered.) Patient treatment flow sheet dated 12/08/25 reviewed. (Treatment time 3 hours, 32 minutes.)Entry by Employee 5, ‘Medications Administered’ ‘Heparin Pork’ ‘600 units/hour, intravenous: Infusion’. ‘Given:’ “1,900 Units.” (The total treatment hourly dose order was for 1500 units. 1900 units were administered.) Policy: 1-18-02 ‘Daily Water Treatment System Total Chlorine Monitoring’ ‘Policy’ ....(11) “.... Record results on the “Routine Total Chlorine Testing” log which contains .... and signature of licensed nurse verifying that each test on the daily log is complete and results appropriate. ...... “ A review of the facility ‘Routine Total Chlorine Testing Log’ was completed on December 11, 2025 at approximately 10:30 a.m. Log #1: Log entries were reviewed from 01/01/25 - 12/01/25. 01/17/25: The chlorine test conducted by a personal care technician at 2:00 p.m. was not verified by a licensed nurse. 01/24/25: The chlorine test conducted by a personal care technician at 2:00 p.m. was not verified by a licensed nurse. 03/28/25: The chlorine test conducted by a personal care technician at 2:00 p.m. was not verified by a licensed nurse. 05/09/25: The chlorine test conducted by a personal care technician at 2:00 p.m. was not verified by a licensed nurse. An interview with the facility Administrator on December 12, 2025 at approximately 1:45 p.m. confirmed the above findings.”