Fkc Redstone Centerville

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 46886 Based on observations, reviews of policy, and patient interviews, the facility staff failed to follow infection control policy and require patients to perform hand hygiene during (2) of two (2) observations of Post Dialysis AV fistula care (OBS1&2) or AV fistula site cleansing during two (2) of three (3) observations of AV Fistula/Graft Initiation (OBS3&4). Findings include: A 5/9/25 review of Hand Hygiene policy revealed: “ All staff, patients, patient care givers ...must follow the same requirements for hand hygiene. ...Hands will be decontaminated using alcohol -based hand rub or by washing hands with antimicrobial soap and water immediately after removing gloves ...Hand Hygiene: Patients should perform hand hygiene if able, prior to and after each dialysis treatment. “ During 5/7/25 the following observations of Post Dialysis Arteriovenous Fistula Care were witnessed: OBS1: At hemodialysis station #8 at approximately 10:00 am patient (PT1) was witnessed applying pressure to their fistula site after needle removal with a gloved hand. After glove removal and assistance to the patient waiting area via wheelchair, PT1 was not requested to perform hand hygiene by EMP5. OBS2: At hemodialysis station #7 at approximately 2:15 pm patient (PT2) was witnessed applying pressure to their fistula site after needle removal with a gloved hand. After glove removal PT2 did not perform hand hygiene and exited the patient care area. A 5/9/25 review of Access Assessment and Cannulation policy revealed: “ Before each treatment, the internal access [Arteriovenous fistula or graft site] ... must be prepared properly for needle placement to prevent bacteria from entering the blood stream through the skin. ...Prior to treatment, ask patient to wash access area with soap and water, per hand hygiene procedure. Step 1 ... If the patient is unable to wash their own access, the staff or care partner should wear gloves to wash the patient ’ s access with soap and water. Step 9...[staff member performs after initial fistula site assessment and cleanse] Remove gloves and perform hand hygiene. Don new gloves. With new gloves ...perform the full cannulation procedure including skin disinfection... “ OBS3: On 5/7/25 at hemodialysis station # 7 at approximately 10:30 am EMP4 was observed performing a needle insertion on PT2 ’ s fistula site. A chairside cleansing of the insertion site was not performed prior to skin antisepsis. During an interview at approximately 11:00 am PT2 confirmed that they had not washed the fistula site at the sink upon arrival and that their site was not cleansed at the station with soap and water by staff. OBS4: On 5/9/25 at hemodialysis station #8 at approximately 10:30 am EMP5 was observed performing a needle insertion on PT2 ’ s fistula site. A single AV fistula site scrub was noted prior to needle insertion. EMP5 failed to follow policy and cleanse the AV fistula site with soap and water prior to skin antisepsis. The findings were reviewed during an exit conference on 5/12/25 at approximately 11:30 am with the clinic manager and director of operations.”

“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: 46886 Based on observations and a review of policies/procedures, the facility staff failed to perform hand hygiene per policy during one (1) OBS of a patient mechanical lift transfer. Findings include: A 5/9/25 review of the Hand Hygiene policy revealed: “ Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water ...after contact with other objects within the patient station or treatment space ... “ During a 5/9/25 observation (OBS) of the patient treatment area at approximately 10:00 am, EMP3 silenced the dialysis machine at Station 1, failed to remove their gloves or perform hand hygiene, then assisted with a wheelchair transfer at Station 3. The findings were reviewed with the Clinical Manager (EMP1) and Director of Operations (EMP2) during an exit interview on 5/9/25 at approximately 3:00 pm.”

“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: 46886 Based on observations (OBS), staff interviews (EMP), and a review of policies/procedures, the facility staff failed to perform proper surface disinfection during one (1) of two (2) observations of Dialysis Station Disinfection and Cleaning. (OBS1) Findings include: A review of Cleaning and Disinfecting the Dialysis Station procedure revealed: “ dialysis station must be cleaned and disinfected between dialysis patients. Definition: Dialysis Station [includes] machine ...and attachments ...after use, any non-disposable equipment and supplies brought into the station must be disinfected with 1:100 bleach or EPA registered disinfectant before being removed from the station ... “ During a 5/7/25 observation of hemodialysis station #7 at approximately 2:30 pm, EMP3 and EMP4 were witnessed performing a machine cleaning and disinfection. During observations the prime waste receptacle was not removed from the machine for surface disinfection. EMP4 was interviewed after completing station #7 ’ s disinfection, and they verified that the prime waste receptacle surface disinfection was not performed. The finding was reviewed during an exit conference on 5/12/25 at approximately 11:30 am with the clinic manager and director of operations.”

“MIXING SYSTEMS-LABELING CFR(s): 494.40(a) 5.4.4.1 Mixing systems: labeling Labeling strategies should permit positive identification by anyone using the contents of mixing tanks, bulk storage/dispensing tanks, and small containers intended for use with a single hemodialysis machine. Mixing tanks: Prior to batch preparation, a label should be affixed to the mixing tank that includes the date of preparation and the chemical composition or formulation of the concentrate being prepared. This labeling should remain on the mixing tank until the tank has been emptied. Bulk storage/dispensing tanks: These tanks should be permanently labeled to identify the chemical composition or formulation of their contents. Concentrate jugs: At a minimum, concentrate jugs should be labeled with sufficient information to differentiate the contents from other concentrate formulations used at the facility. This Standard is not met as evidenced by: 46886 Based on equipment observations conducted during the facility flash tour, interviews with staff, and policy reviews, facility staff failed to label acid containers (CN) to indicate electrolyte concentration for one (1) of two (2) CNs viewed. (CN1) Findings include: A 5/12/25 review of agency policy titled Acid Concentrate Storage and Handling revealed: “ The purpose of this policy is to provide instruction for acid concentrate storage and handling . ...Term ...Reusable Concentrate Containers ...Definition ...Secondary Acid Concentrate Containers ...labels must be clearly visible, be in good condition and readable. ...Label all acid containers as outlined in the Concentrate Labeling Requirements policy” A review of agency policy titled Concentrate Labeling Requirements: “ policy for labeling requirements ...concentrate storage. ... Policy: Permanent Labeling: Concentrate Jugs ...acid concentrate jugs must be labeled to identify their contents...secondary containers into which acid concentrate has been transferred ... must be labeled with the product name, and the appropriate hazard warnings (HMIS) label ... acid concentrate jug labels must identify the chemical constituents “ During the 5/7/25 facility flash tour at approximately 9:00 am two reusable concentrate containers (CN1 and CN2) were observed on a transport cart in the patient care area. CN1 contained liquid and was labeled with a length of tape marked with a “ 3 “ . CN2 contained liquid and was labeled with a length of tape marked with “ 2K2.5Ca “ . During an interview with EMP4 it was determined CN1 and CN2 contained acid concentrate to be used for patient treatments. During an interview with EMP1 (clinic manager) at approximately 10:00 am it was determined the acid containers were not labeled per facility policy. The finding was reviewed again during an exit interview on 5/12/25 at approximately 11:30 am with the clinic manager and director of operations.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 46886 Based on equipment observations conducted during the facility flash tour and interviews with staff, the facility failed to ensure patient lifts (EQU) were inspected and maintained for one (1) of two (2) EQUs reviewed. (EQU2) Findings include: During the 5/7/25 facility flash tour at approximately 9:00 am two mechanical patient lifts (EQU) were observed. EQU2 ’ s asset tag was labeled ISS Solutions #050130274 and read: “ due for inspection 2/2025. “ The finding was reviewed with the clinic manager (EMP1) at approximately 10:00 am. EQU2 was then observed near the water room away from the patient care area at approximately 11:30 am. The finding was reviewed during an exit conference on 5/12/25 at approximately 11:30 am with the clinic manager and director of operations.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 46886 Based on observations, interviews with staff (EMP), medical record (MR) reviews, and policy reviews, the facility staff failed to monitor and ensure provision of a patient ’ s ordered dialysis prescription for one (1) of four (4) MRs reviewed (MR3) and one (1) of ten (10) dialysis Machine Prescription Observations (OBS4). Findings include: A review of Patient Assessment and Monitoring on 5/9/25 revealed: “ Purpose: ...to provide guidance to FKC direct patient care staff on assessment and monitoring patients ...Data Collection ... Machine Parameters and Extracorporeal Circuit ...Check dialysate flow rate (DFR) setting is correct, and the prescribed flow is being delivered ...If heparin pump is used, ensure heparin is infusing at prescribed rate. “ During a machine prescription verification (OBS4) conducted on 5/7/25 at hemodialysis station #4 at approximately 1:15 pm with the clinical manager (EMP1), the intradialytic IV heparin infusion was running at 1 milliter [1000 units] per hour. A concurrent review of the Treatment Setup Detail sheet with EMP1 revealed an intradialytic IV heparin infusion prescription as follows: “ Heparin Sodium 1,000 Units/mL Systemic Infusion 500 units IVP per hour ... “ A treatment sheet review conducted on 5/9/25 between approximately 2:00 pm - 3:00 pm revealed: MR4: Admission date: 6/14/24. MR4 ’ s Treatment Sheets dated 4/23/25, 4/25/25 and 5/2/25 noted dialysis prescriptions with an ordered Dialysate Flow Rate (DFR) of 800 mL/min. Treatment Data on 4/23 recorded DFRs of 500 mL/min between 10:00 am - 11:00 am. Treatment Data on 4/25 recorded DFRs of 500 mL/min from 10:13 am to the end of the treatment at 11:35 am. Treatment Data on 5/2 recorded DFRs of 500 mL/min from 11:01 am to the end of the treatment at 12:00 pm. The facility staff failed to follow policy and verify accurate dialysis machine prescriptions for MR4 and during OBS4. The findings were reviewed during an exit conference on 5/12/25 at approximately 11:30 am with the clinic manager (EMP1) and director of operations (EMP2).”