Ncpdc Williamsport Dialysis Clinic

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 21832 Based on review of facility policy and procedures, and an interview with the facility unit manager and administrator the facility failed to ensure supplies were not outdated/expired. Findings Include: Cross Reference: 494.30 Sanitary Environment Tag V 0111 The facility failed to ensure supplies were not expired for thirteen of thirteen supplies observed. S#1-13. The cumulative effect of these systematic problems resulted in the facility’s inability to ensure a safe and sanitary environment and ensure that staff were competent in infection control practices.”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 21832 Based on review of facility policy and procedures, an observational tour of the facility, and an interview with the facility clinical manager; the facility failed to maintain the integrity of the walls and the floors within the dialysis treatment area and maintain a safe environment for patients Findings Include: Cross Reference: 42CFR 494.60 Pe-Safe/functional/comfortable environment Tag 401 the facility failed to maintain a sanitary a safe treatment environment for two (2) of three (3) observations (OBS #1 & #3). 42CFR 494.60(a) Pe-Building-Construct/maintain for safety Tag 402 the facility failed to maintain the integrity of the dialysis unit area for two (2) of three (3) observations. OBS #1-#3). The cumulative effect of these systematic problems resulted in the facility’s inability to ensure a safe and sanitary environment.”

“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: 21832 Based on an observations, review of policies and procedures, facility documentation, and staff interview staff clinic failed to maintain a safe and sanitary environment for two (2) of three (3) observations; failed to ensure supplies were not expired for thirteen of thirteen supplies observed. S#1-13. Findings include: OBS #1 completed 7/28/25 at approximately 10:30 AM revealed: Drywall to the left of pod B back boards blistering and peeling Drywall behind station #5, #21 & # 22 peeling Pod A under dirty sink, 2 areas of white liquid on floor Brown dry splattered liquid found under clean sink area. OBS #3 completed 7/31/25 at approximately 9:00 AM revealed The front outside door leading into the clinic had a piece of metal bent on the bottom right of the door causing a sharp protruding area Review of Policy on 7/31/25 at 9:00 AM Rotation of Stock states, “In order to provide quality of care, a facility must maintain adequate stock to sustain them through daily operations and in emergent events...It is important to verify that stock is being rotated as it is delivered so that expiration dates if applicable are not being reached and that stock on the shelves is used prior to that which has just arrived....In the stock room...expiration dates will be checked on all stock, both incoming and existing...In the treatment room Expiration dates are checked on all stock stored in the treatment room.” Review of documentation on 7/31/25 at 9:00 AM revealed the following: A construction estimate from Bryer Tech Construction Services dated 5/29/25 noted to be valid for 30 days states,”I propose to provide the materials and labor to complete the following. Patch and paint the treatment area and waiting rooms inside the Williamsport clinic. Floor protection will be used and minor holes will me patched as needed. The walls will then be painted along with the center island area to complete the project.” Interview conducted with Staff #2 on 7/28/25 at approximately 1:00 PM revealed the residual chlorine testing strips were used on Mondays to test the dialysis machines for residual chlorine from having been disinfected the evening prior. Observations of supplies during a flash tour of the clinic on 7/28/25 between approximately 10:40 AM and 1:30 PM revealed S#1 -6 (six) BD eclipse 3ml 25G x 5/8 injection needle with luer lock syringes expired 6/30/25. located in Supply cart Pod B across from station 18. S#2- 1 Safety fistula needle 17G expired 9/30/24. S#3- 12 (twelve) BD eclipse 3ml 25G x 5/8 injection needle with luer lock syringes expired 6/30/25 located in Tall Brown supply Cabinet by Pod A. S#4- 6 (six) BD eclipse 3ml 25G x 5/8 injection needle with luer lock syringes expired 6/30/25 located in Supply Cart Pod B across from station 21. S#5- 1(one) bottle of Residual Chlorine Testing strips expired 3/31/25 located in Supply Cart Pod A: Across from station 5. S#6- 2 (two) BD eclipse 3ml 25G x 5/8 injection needle with luer lock syringes expired 6/30/25 located in Supply Cart outside of isolation room. S#7- 1 (one) bottle rubbing alcohol 70% USP expired 5/25. S#8- (1) bottle of Pure Bright Bleach best by date 7/15/25 located in Isolation Room. S#9- 1 (one) bottle betasept surgical scrub expired 4/25. S#10- 1(one) bottle of Residual Chlorine Testing strips expired 3/31/25. S#11-4 (four) BD eclipse 3ml 25G x 5/8 injection needle with luer lock syringes expired 6/30/25 located in Isolation Room. S#12- 1 (one) bottle of hardness tester #7 expired 2/25 located in Isolation Room: . S#13-1(one) bottle of Residual Chlorine Testing strips expired 6/30/25. An interview conducted with the Clinic Unit Manager on 7/31/25 at approximately 11:30 AM and interview with the biomedical technician on 7/31/25 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: 21832 Based on an observations, Policies and procedures, facility documentation, and staff interview the facility failed to maintain a sanitary a safe treatment environment for two (2) of three (3) observations (OBS #1 & #3). Findings include: OBS #1 completed 7/28/25 through between 10:40 AM and 1:30 PM revealed Drywall to the left of pod B back boards blistering and peeling Drywall behind station #5, #21 & # 22 peeling Pod A under dirty sink, 2 areas of white liquid on floor Brown dry splattered liquid found under clean sink area OBS #3 completed 7/31/25 at approximately 9:00 AM revealed The front outside door leading into the clinic had a piece of metal bent on the bottom right of the door causing a sharp protruding area Review of Policy on 7/31/25 at 9:00 AM Rotation of Stock states, “In order to provide quality of care, a facility must maintain adequate stock to sustain them through daily operations and in emergent events...It is important to verify that stock is being rotated as it is delivered so that expiration dates if applicable are not being reached and that stock on the shelves is used prior to that which has just arrived....In the stock room...expiration dates will be checked on all stock, both incoming and existing...In the treatment room Expiration dates are checked on all stock stored in the treatment room.” Review of documentation on 7/31/25 at 9:00 AM revealed the following: A construction estimate from Bryer Tech Construction Services dated 5/29/25 noted to be valid for 30 days states,”I propose to provide the materials and labor to complete the following. Patch and paint the treatment area and waiting rooms inside the Williamsport clinic. Floor protection will be used and minor holes will me patched as needed. The walls will then be painted along with the center island area to complete the project.” An interview conducted with the Clinic Unit Manager on 7/31/25 at approximately 11:30 AM and interview with the biomedical technician on 7/31/25 confirmed the above findings”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 21832 Based on an observations, facility documentation, and staff interview the facility failed to maintain the integrity of the dialysis unit area for two (2) of three (3) observations. OBS #1-#3). Findings include: OBS #1 completed 7/28/25 through between 10:40 AM and 1:30 PM revealed Drywall to the left of pod B back boards blistering and peeling Drywall behind station #5, #21 & # 22 peeling Pod A under dirty sink, 2 areas of white liquid on floor Brown dry splattered liquid found under clean sink area OBS #3 completed 7/31/25 at approximately 9:00 AM revealed The front outside door leading into the clinic had a piece of metal bent on the bottom right of the door causing a sharp protruding area Review of documentation on 7/31/25 at 9:00 AM revealed the following: A construction estimate from Bryer Tech Construction Services dated 5/29/25 noted to be valid for 30 days states, I propose to provide the materials and labor to complete the following. Patch and paint the treatment aarea and waiting rooms inside the Williamsport clinic. Floor protection will be used and minor holes will me patched as needed. The walls will then be painte along with the center island area to complete the project.” An interview conducted with the Clinic Unit Manager on 7/31/25 at approximately 11:30 AM and interview with the biomedical technician on 7/31/25 confirmed the above findings and that no work had been completed per the above estimate.”

“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: 21832 Based on review of policy, medical records (MR), and an interview with the facility clinic manager; the facility failed to ensure that the patient prescriptions were being implemented as ordered by the physician for three (3) out of seven (7) patient prescriptions reviewed (MR # 1, #5 and #6). Findings include: A review was conducted of facility policy Routine Standard Care on 7/30/25 at 4:00 PM which states, “The following information is observed and recorded during the dialysis treatment: 1. Machine Settings will be verified for accuracy by a second staff member (PCT, LPN or RN) within the first 30 minutes of treatment onset and documented in the progress notes. The staff member is verifying the correct dialysate, treatment length, blood pressure limit alarms, heparin infusion rate and stop time, programmable sodium parameters if ordered, UFR rate, target loss, dialysate flow rate, temperature and blood flow rate.” Review of medical records on 7/30/25 from approximately 9:15 AM through 3:30 PM revealed the following: MR#1: The physician ordered Blood flow rate (BRF) was 425 Treatment flow sheet dated: 7/22/25 showed BFR: 400. No documentation explaining the BFR difference or documentation showing the physician was notified. MR#5: The physician ordered Blood flow rate (BRF) was 400 Treatment flow sheet dated: 7/23/25 showed BFR: 350. Documentation noted BFR at 350 due to “machine issues.” There was no documentation of what the machine issues were, that the patient was put on a different machine or that the physician was notified. Treatment flow sheet dated: 7/28/25 showed BFR: 350w. No documentation explaining the BFR difference or documentation showing the physician was notified. MR#6: The physician ordered Blood flow rate (BFR) was 425 Treatment flow sheet dated: 7/19/25 showed BFR: 350. No documentation explaining the BFR difference or documentation showing the physician was notified. An interview conducted with nurse manager on 7/30/25 at approximately 3:30 PM confirmed the above findings.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 21832 Based on review of policy/procedure, medical records (MR) and staff interview the clinic failed to conduct a monthly reassessment of the patient to revise the plan of care for one (1) of one (1) record reviewed for an unstable patient (MR #1). Findings include: Review of policy Comprehensive Individualized Patient Assessment (CIPA) reviewed on 7/30/25 at 4:00 PM states, “Each patient at this facility will have a Comprehensive Individualized Patient Assessment (CIPA) to ensure that he/she receives the appropriate modality of care and the appropriate care within that modality...The CIPA will also be done monthly if an established patient triggers an indicator that they are unstable.” Review of medical records on 7/30/25 from approximately 9:15 AM through 3:30 PM revealed the following: MR#1, start of care: 10/3/23. A CIPA was conducted on 2/20/25 noting the patient was unstable. There was no documentation that monthly CIPAs had been conducted or the patients stability status. An interview conducted with nurse manager on 7/30/25 at approximately 3:30 PM confirmed the above findings”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 21832 Based on a review of facility policy/procedure, review of medical records, and staff interview, the facility failed to ensure that the standardized mental and physical assessment tool (KDQOL-36) was administered by the time of the first reassessment (i.e., within 4 months of initiating treatment), for one (1) of seven (7) patient medical records reviewed (MR#2). Findings: A review was conducted of facility policy Initial Psychosocial Evaluation on 7/30/25 at 4:00 PM which states, “The initial psychosocial evaluation is completed within the first 30 days of the patient’s initial dialysis treatment.” Review of medical records on 7/30/25 from approximately 9:15 AM through 3:30 PM revealed the following: MR#2: Date of admission 1/21/25: Documentation provided of the initial KDQOL-36 being administered late on 7/7/25. No exemption/no patient refusal to completing the KDQOL-36 was documented in the medical record. An interview conducted with nurse manager on 7/30/25 at approximately 3:30 PM 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: 21832 Based on a review of Facility Policies, Medical Record reviews (MR) and staff interview it was determined the medical director failed to ensure the policy for blood pressure assessment was followed for four (4) of seven (7) MR reviewed (MR#1, MR#3, MR#4 & MR#5) and management of the role of the licensed practical nurse for six (6) of seven (7) MR reviewed (MR#1, MR#2, MR#3, MR#4, MR#5, MR#7) Findings include: A review of facility policy Routine Standard Care on 7/30/25 at 4:00 PM states, “ The following information is observed and recorded during the dialysis treatment...recorded eevery thirty minutes or more frequently, if necessary...f, Blood Pressure and pulse.” A review of facility policy Role of the Licensed Practical Nurse (LPN) on 7/30/25 at 4:10 PM states, “The LPN may additionally provide the following services in coordination with the Registered Nurse (RN) in the facility: 1) Assess patients prior to treatment initiation.” Review of medical records on 7/30/25 from approximately 9:15 AM through 3:30 PM revealed the following: MR#1: Admit date 10/3/23: Treatment flow sheet dated 7/22/25 showed there was no blood pressure or pulse assessment from from 1:30 PM until 2:30 PM Treatment flow sheet dated 7/15/25 showed the LPN did the initial patient assessment. There was no documentation of coordination with the RN. MR#2: Admit date 1/21/25: Treatment flow sheets dated 7/25 & 7/28/25 showed the LPN did the initial patient assessment. There was no documentation of coordination with the RN. MR#3: Admit date 1/23/14: Treatment flow sheet dated 7/22/25 showed there was no blood pressure or pulse assessment from from 12:30 PM until 1:26 PM Treatment flow sheet dated 7/16 & 7/26/25 showed the LPN did the initial patient assessment. There was no documentation of coordination with the RN. MR#4: Admit date 8/11/22: Treatment flow sheet dated 7/19/25 showed there was no blood pressure or pulse assessment from from 7:30 AM until 8:30 A M Treatment flow sheet dated 7/17 & 7/22/25 showed the LPN did the initial patient assessment. There was no documentation of coordination with the RN. MR#5: Admit date 1/16/25: Treatment flow sheet dated 7/25/25 showed there was no blood pressure or pulse assessment from from 2:00 PM until 3:01 PM Treatment flow sheet dated 7/18/25 showed the LPN did the initial patient assessment. There was no documentation of coordination with the RN. MR#7: Admit date 5/21/24: Treatment flow sheet dated 7/1/25 showed the LPN did the initial patient assessment. There was no documentation of coordination with the RN. An interview conducted with nurse manager on 7/30/25 at approximately 3:30 PM confirmed the above findings.”