Fkc Shaler

“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 (OBS), staff interviews (EMP), and a review of policies/procedures, the facility staff failed to perform proper hand hygiene during one (1) of two (2) observations of Post Dialysis AV fistula care. (OBS2) Findings include: A review of procedure titled Post Treatment Fistula Needle Removal revealed: “ Purpose ... To provide instruction for fistula and graft needle removal at the end of the dialysis treatment ...Procedure ...The person removing needles will perform hand hygiene and don clean gloves ... “ During a clinical care area observation (OBS2) conducted on 10/2/24 at approximately 10:00 am RN1 was witnessed providing of Post Dialysis Access Care for an AV Fistula for MR5. During OBS2 RN1 failed to change gloves and perform hand hygiene after discontinuing treatment, reinfusing the hemodialysis circuit, and disconnecting the bloodlines. RN1 maintained the same gloves while touching various single-patient care items at MR5 ’ s dialysis station and then maintained the same gloves to remove one of two needles from MR5 ’ s AV fistula site. The findings of OBS2 were reviewed with EMP1 (Director of Operations) on 10/2/24 at approximately 11:00 am.”

“ADDITIVES-LABEL SPIKED JUGS/LABEL SPECIFIC PT CFR(s): 494.40(a) 5.4.5 Additives: labeling spiked jugs/labeling if for specific pt (5.4.4.1 Concentrate jugs): If a chemical spike is added to an individual container to increase the concentration of an electrolyte, the label should show the added electrolyte, the date and time added, and the name of the person making the addition. Containers should be labeled to indicate the final concentration of the added electrolyte ...This information should also be recorded in a permanent record. Labels should be affixed to the containers when the mixing process begins. 6.4.2 Additives When additives are prescribed for a specific patient, the container holding the prescribed acid concentrate should be labeled with the name of the patient, the final concentration of the added electrolyte, the date on which the prescribed concentrate was made, and the name of the person who mixed the additive. This Standard is not met as evidenced by: 46886 Based on observations conducted during prescription reviews (PR), interviews with staff (EMP), and reviews of policy the facility failed to label acid concentrate containers to indicate electrolyte concentration for one (1) of four (4) PRs reviewed. (PR1) Findings included: A 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 ...2.5 gallon concentrate containers will be assigned and labeled with a permanent identification number to facilitate the tracking of containers ...Prior to Treatment ... Confirm the proper bath with the physician order. ..Confirm Proper Acid Concentrate Formula and HMIS/GHS labeling on the jug ... “ A review of agency policy titled Concentrate Labeling Requirements: “ policy for labeling requirements ...entering acid concentrate formulas in the hemodialysis machine ...Labeling strategies must allow for the positive identification of ...concentrate jugs ...concentrates entered into Hemodialysis Machines ...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 ... “ During a chairside hemodialysis prescription review (PR) conducted on 10/2/24 at approximately 10:35 am with RN2 for MR6 an unlabeled 2.5 gallon jug was connected to the hemodialysis machine. Surveyor was unable to determine the contents of the container. When questioned about the unlabeled container, RN2 pointed to an unmarked yellow tape on the handle of the jug as the method for identifying the unlabeled container ’ s contents. The surveyor reviewed the finding on the clinical floor at approximately 11:00 am on 10/2/24 with EMP1 (Director of Operations) by examining the container. EMP1 verified that the container was not appropriately labeled. The facility staff failed to label acid concentrate jugs as per facility policy, failed to positively identify the contents of PR1 ’ s acid concentrate jug, and failed to confirm the proper bath with the physician order for PR1. The finding was reviewed on 10/3/24 during an exit interview with EMP1 at approximately 2:45 pm.”

“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: 46886 Based on a review of personnel files (PF), and interviews with the Director of Operations (EMP1) the facility failed to maintain licensure requirements for one (1) of nine (9) PFs reviewed. (PF4) A review of PFs on 10/3/24 at approximately 11:00 am revealed: PF4: Date of Hire: 1/9/23. PF4 contained a Staff Registered Nurse Job Description signed 1/11/23 with a Job Code DF 160 and failed to contain documentation of RN licensure. During the review of personnel files, Director of Operations (EMP1) revealed that PF4 was hired on 1/9/23 as a Pre-Licensed RN (PLN). EMP1 provided a document titled FAQ ’ s for Operators: Pre-Licensed Nurses and Pre-Licensed Staff (PLN GUIDANCE) dated 6/30/22 which read: “ 6. What job codes are Pre-Licensed Nurses ...allocated to pre and post licensure ...Pre-Licensure: ...In-Center Pre-Licensed Nurse ...Job Profile: Nurse Resident 1 ...Pre License RN. Job code is JP _008519 ...In-Center Pre-Licensed Staff ...Job Profile Nurse Resident ...Pre License Staff ...JP_004412. The facility failed to follow company guidance by assigning a Pre-Licensed Nurse a Staff Registered Nurse Job Description and not maintaining documentation of nursing licensure. The finding was reviewed with EMP1 during an exit interview at approximately 2:45 pm.”

“PQ-PCT CERTIFIED CFR(s): 494.140(e)(4) Patient care dialysis technicians must- (4) Be certified under a State certification program or a national commercially available certification program, as follows- (i) For newly employed patient care technicians, within 18 months of being hired as a dialysis patient care technician; or (ii) For patient care technicians employed on October 14, 2008, within 18 months after such date. This Standard is not met as evidenced by: 46886 Based on a review of personnel files (PF) and an interview with EMP1, Director of Operations, the facility failed to ensure that patient care technicians (PCT) were certified for hemodialysis within 18 months of being hired for one (1) of nine (9) PFs reviewed. (PF4) Findings included: During a review of personnel (PF) files on 10/3/24 at approximately 11:00 am, Director of Operations (EMP1) revealed that PF4 was hired on 1/9/23 as a Pre-Licensed RN (PLN). EMP1 provided a document titled FAQ ’ s for Operators: Pre-Licensed Nurses and Pre-Licensed Staff (PLN GUIDANCE) dated 6/30/22 which read: “ 9. ...Upon a PLN ...failing the initial attempt at the NCLEX (RN licensure exam) the manager should immediately demote to PCT. “ It was revealed by EMP1 that PF4 initially attempted the NCLEX on “3/14/23” and did not pass. The PLN GUIDANCE document also reads: “ [after failing to pass initially] PLN..retake[s] the NCLEX one time, within 90 days of failing the original exam. ...If the 2nd NCLEX exam is failed, then: Demote to PCT permanently ... “ It was revealed by EMP1 that PF4 did not pass the second NCLEX attempt on “6/25/24.” PF4 failed to contain a signed PCT job description or documentation of the date that PF4 was demoted to PCT status. EMP1 stated they were unsure of when PF4 was supposed to be designated as a PCT or when PF4 should have been certified for hemodialysis. As of 10/3/24 PF4 failed to obtain certification for hemodialysis within 18 months of 3/14/23, the PLN GUIDANCE ’ s demotion to PCT status date. The finding was discussed with EMP1 on 10/3/24 at approximately 2:45pm.”

“MD RESP-STAFF ED, TRAINING & PERFORM CFR(s): 494.150(b) Medical director responsibilities include, but are not limited to, the following: (b) Staff education, training, and performance. This Standard is not met as evidenced by: 46886 Based on a review of personnel files (PF), interviews with the Director of Operations (EMP1) and a review of company guidance the facilities medical director failed to ensure staff training was completed for one (1) of nine (9) PFs reviewed. (PF4) Findings included: During a review of personnel (PF) files on 10/3/24 at approximately 11:00 am, Director of Operations (EMP1) revealed that PF4 was hired on 1/9/23 as a Pre-Licensed RN (PLN). EMP1 provided a document titled FAQ ’ s for Operators: Pre-Licensed Nurses and Pre-Licensed Staff (PLN GUIDANCE) dated 6/30/22 which read: “ 9. ...Upon a PLN ...failing the initial attempt at the NCLEX (RN licensure exam) the manager should immediately demote to PCT. “ It was revealed by EMP1 that PF4 initially attempted the NCLEX on “3/14/23” and did not pass. The PLN GUIDANCE document also reads: “ [after failing to pass initially] PLN..retake[s] the NCLEX one time, within 90 days of failing the original exam. ...If the 2nd NCLEX exam is failed, then: Demote to PCT permanently ... “ It was revealed by EMP1 that PF4 did not pass the second NCLEX attempt on “6/25/24.” PF4 failed to contain a signed PCT job description or documentation of the date that PF4 was demoted to PCT status. EMP1 stated they were unsure of when PF4 was supposed to be designated as a PCT or when PF4 should have been certified for hemodialysis. As of 10/3/24 PF4 failed to obtain certification for hemodialysis within 18 months of 3/14/23, the PLN GUIDANCE ’ s demotion to PCT status date. The finding was discussed with EMP1 on 10/3/24 at approximately 2:45pm.”