Dci Five Points

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 44820 Based on an escorted faciity tour, observations, review of facility Quality Assessment Performance Improvement (QAPI) Peer Review On-Site Corporate survey dated 5/28/24, and an interview with the clinic manager and chief technician; the facility failed to maintain the integrity of the reverse osmosis (RO) holding tank and the water treatment area for two (2) of two (2) observations(OBS) (OBS #1 & OBS#2) and the facility failed to ensure the storage room, treatment area, patients and staff were secured from unauthorized access. Findings included: An escorted facility tour conducted on 3/31/25 at approximately 10:15 a.m revealed the following: Surveyor was escorted by clinical nurse manager to the lower level of the facility via stairwell. Surveyor was escorted outside to the staff parking lot via an exit door at bottom of stairwell to continue tour. Upon completion of outside staff parking area and supply delivery area, surveyor proceeded back to same door that was exited. Surveyor noted a numerical code lock outside of exit door. Surveyor did not type in a code for re-entry. Surveyor was able to gain entry by turning knob of door and pulling open. Upon re-entry clinical nurse manager was able to open exit door from outside of facility without entering a code in the keypad. Biomed employee confirmed the “lock was not engaging”. The unsecured door gives access to storage area with supplies and acid/dialysate solution that are stored in large holding tanks. Individuals gaining entry through unlocked door also had immediate access to stairwell that leads to upper floor with treatment unit access to patients and staff allowing for unauthorized access. Interview with clinic manager and biomed technician confirmed above findings. Clinic manager states “We had an elevator repairman that was here I believe last Thursday and must have unlocked door then. It’s a habit to just enter my code and open the door. I did not check to see if the door locked or not.” OBS #1 completed by surveyor on 3/31/25 at approximately 10:25 AM revealed an active water leak from the RO holding tank. Floor directly under the tank had a puddle of water measuring approximately two feet in diameter. Clinic manager states “We know about it and have a ticket in to fix the drip. The drip is coming from the top pipe. If you look close you can see it drip. I believe when our corporate auditor was here they are the ones who brought it to the previous facility manager’s attention.” OBS#2 completed 3/31/25 at approximately 10:25 AM revealed an active water leak from a microfilter connection. Puddle of water under filter approximately 12 inches in diameter. Clinic manager states “I didn’t notice that before.” An interview conducted with the Chief Technician on 3/31/25 at approximately 12:10 PM confirmed the above findings. “Yeah, we knew about the RO holding tank leak back in May of 2024, I think, that’s when the internal audit was done. The other leak is new.””

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 44820 Based on review of policy, National Kidney Foundation (NKF) Guidelines, observation (OBS), and staff (EMP) interview, the facility failed to ensure two (2) of two (2) patients with an arteriovenous fistula (AVF) washed their access prior to disinfection and initiation of dialysis. (OBS#1 and OBS#2) Findings: Review of facility policy on 4/1/25, at approximately12:45 p.m. revealed: “Vascular Access Disinfectant Policy... Procedure NO:125... date issued: 2/12/2025... Policy... 2. Pateitns should was their hands and access with antibacterial soap and water prior to staff disinfection of access; if the patient is unable to complete this step, staff must complete this step at chairside...” “Procedure... Option 1 (preferred)... Chlorhexadine [antiseptic] is a 30 second contact time with a 1 minute dry time...” According to NKF Guidelines, “Tips for Everyday Care of Your AV Fistula or Graft Prevent Infection ... Wash your access site before every dialysis treatment. Your dialysis center has hand washing sinks and antimicrobial soap.” Retrieved from https://www.kidney.org/sites/default/files/11-50-0216_va.pdf OBS#1 on treatment floor on 4/1/25 at approximately 11:05 a.m. revealed patient walk to station 10 without first washing his/her access in facility sink. EMP10 wiped the patient’s AVF with a “Chloraprep Antiseptic Towelette”, inserted both needles, and initiated dialysis. Interview with EMP9 (dialysis technician) and EMP2 (registered nurse) after the observation confirmed the patient did not wash their access in the sink. OBS#2 on treatment floor on 4/1/25 at approximately 11:40 a.m. revealed patient walk to the dialysis station without first washing his/her access in the facility’s sink. EMP3 wiped the patient’s AVF with a “Chloraprep Antiseptic Towelette”, inserted both needles, and initiated dialysis. Interview with EMP3 (registered nurse) after the observation confirmed the patient did not wash their access in the sink.”