Davita Allegheny Valley

“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: 32773 Based on review of manufacturers recommendations, observations, and staff (EMP) interviews, the agency failed to ensure dehumidifiers had annual preventative maintenance or documentation of cleaning for two (2) of two (2) dehumidifiers observed on the treatment floor. Findings include: Treatment floor observations on 7/21/25 at 9:27 a.m. revealed the following: A Hisense dehumidifier Model # DH7019K1G, Serial # KF8DSJG0529 was placed against the wall between dialysis stations six and seven, and had a light buildup of black and white material on all outside surfaces of the unit, the filter was not visible. This unit did not contain a sticker or other documentation of annual preventative maintenance. A second General Electric Dehumidifier Model # ADEL5OLZQ1, Serial # AT012866Q was behind the nurses station and had a heavy buildup of black and white material on all outside surfaces of the unit, the filter was observed to have a heavy buildup of grey material on the filter. This unit did not contain a sticker or other documentation of annual preventative maintenance. During an interview on 7/25/25, at 10:00 a.m. EMP1 The Biomedical Service Specialist confirmed the agency does not complete annual preventative maintenance for the two dehumidifiers. A review of the agency supplied manufacturers recommendations on 7/21/25, at 10:42 a.m. for the General Electric Dehumidifier Model # ADEL5OLZQ1, Serial # AT012866Q indicated the water bucket is to be cleaned every few weeks to prevent the growth of mold, mildew and bacteria. The air filter should be checked and cleaned at least every 250 hours operation or more often if necessary. A review of the agency supplied manufacturers recommendations on 7/21/25, at 10:46 a.m. for the Hisense dehumidifier Model # DH7019K1G, Serial # KF8DSJG0529 indicated the water bucket is to be cleaned every few weeks ... to avoid the growth of mold, mildew and bacteria. During an interview on 7/21/25 at 1:44 p.m. EMP2 the Administrator and EMP3 the Operations Director confirmed the above findings, and that the agency did not have a policy on or documentation of preventative maintenance or cleaning of the dehumidifiers.”

“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: 32773 Based on a review of facility policy, clinical records (CR) and staff (EMP) interview, it was determined that the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician for three (3) of six (6) in center hemodialysis patient clinical records reviewed (CR1, CR4, CR6). Findings included: Review of facility policy “Prescribed Treatment Time Not Met” on 7/21/25, at 1:03 p.m. Indicated it’s purpose is to provide requirements for teammates to follow when a patent’s treatment time is terminated early or extended. 1. The Registered Nurse (RN) will verify that patient signs the Early Termination of Treatment Against Medical Advice (AMA) form any time the patent requests to terminate their treatment earlier than the prescribed run time. 3. If a patients treatment is shortened/early terminated, the RN will document the event in the patient’s electronic health record. Documentation will include as appropriate: the amount of time by which the treatment was shortened, a description of why the treatment was shortened, whether the patient’s nephrologist was notified, a description of the followup medical orders by the attending nephrologist, if any. 5. Additionally if the patient’s dialysis treatment is terminated 30 or more minutes to the ordered treatment length, the reason must be documented in the patients electronic health record at the time the treatment was terminated while reconciling the treatment times. Review of Clinical Records (CR) on 7/21/25 at 12:25 p.m. Treatment Detail Reports (documentation of ordered treatment time and duration administered) from 7/7/25 (Monday) through 7/12/25 (Saturday) revealed the following: CR1, admitted on 4/24/19, review of the Treatment Detail Report dated 7/12/25, indicated the prescribed treatment duration time ordered by the physician was 210 minutes, review of the treatment duration revealed it was 182 minutes (28 minutes short). There was no documentation that staff notified the physician of the changes in the dialysis prescription, or a description of why the treatment was shortened and did not contain a signed AMA document. CR4, admitted on 2/2/21, review of the Treatment Detail Report dated 7/8/25, indicated the prescribed treatment duration time ordered by the physician was 210 minutes, review of the treatment duration revealed it was 196 minutes (14 minutes short). There was no documentation that staff notified the physician of the changes in the dialysis prescription, or a description of why the treatment was shortened and did not contain a signed AMA document. CR6, admitted on 3/26/24, review of the Treatment Detail Report dated 7/7/25, indicated the prescribed treatment duration time ordered by the physician was 195 minutes, review of the treatment duration revealed it was 165 minutes (30 minutes short). There was no documentation that staff notified the physician of the changes in the dialysis prescription, or a description of why the treatment was shortened. During an interview on 7/21/25 at 1:44 p.m. EMP2 the Administrator and EMP3 the Operations Director confirmed the above findings.”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 42178 Based on review of facility schedule, medical records (MR), and employee interviews, the facility failed to ensure an adequate number of qualified personnel available to meets the needs of patients for seven (7) of twenty-two (22) MR reviewed (MR5, 8, 9, 11, 15, 19, & 20). Findings included: Review of facility schedule dated 9/1/24-9/28/24, on 10/1/24 at approximately 10:00am with facility administrator revealed dialysis treatments cancelled 9/14/24 due to inadequate staffing. A review of medical records on 10/1/24 at approximately 11:00am revealed: MR5, start of service (SOS) 12/23/20. Per late entry note dated 9/18/24, “due to staffing issues” facility administrator called patient 9/13/24. No return call documented. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24. MR8, SOS 2/24/20. Per late entry note dated 9/18/24, “due to staffing issues” facility administrator called patient 9/13/24 to offer to reschedule to another unit either 9/13/24 or 9/14/24. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24. MR9, SOS 4/30/24. Per late entry note dated 9/18/24, “due to staffing issues” facility administrator called patient 9/13/24 to offer to reschedule to another unit either 9/13/24 or 9/14/24. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24. MR11, SOS 6/25/24. Per late entry note dated 9/18/24, “due to staffing issues” facility administrator called patient 9/13/24 to offer to reschedule to another unit either 9/13/24 or 9/14/24. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24. MR15, SOS 8/10/24. Per late entry note dated 9/18/24, “due to staffing issues” facility administrator called patient 9/13/24. No return call documented. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24. MR19, SOS 7/15/24. Per late entry note dated 9/18/24, “due to staffing issues” facility administrator called patient 9/13/24 to offer to offer treatment at a different location. Patient refused due to transportation. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24. MR20, SOS 10/4/17. Per late entry note dated 9/18/24, “due to staffing issues” facility administrator called patient 9/13/24 to offer to reschedule to another unit either 9/13/24 or 9/14/24. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24. An interview conducted with Facility Administrator, Manager of Clinical Services, and Facility Administrators from 2 additional locations on 10/1/24 at approximately 2:00pm confirmed the above findings.”

“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: 38039 Based on observation and interview with staff, the facility failed to provide a sanitary environment to minimize the transmission of infectious agents within the facility for three (3) of seven (7) observations. (Observation #2, Observation #4, Observation #7). Findings include: Review of facility policy completed on 5/1/24 at approximately 3:30 p.m. revealed: Policy: 1-05-01 with last revision date of April 2023. TITLE: Infection Control for Dialysis Facilities. PURPOSE: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment... POLICY: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients.... PPE (i.e., gown, gloves, eye protection, face shield). 5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas. PPE is to be: a. Removed prior to leaving the treatment area...c. PPE is not to be worn in non-treatment areas...6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-physicians and visitors when in the treatment area... Observations of dialysis treatment and care completed on 5/1/24 between approximately 9:00 a.m. and 12:00 p.m. revealed the following: Observation #2 on 5/1/24 at approximately 9:05 a.m. Registered Nurse (RN) was observed in the medication area drawing up parenteral medications with mask and gown on. Observation #4 on 5/1/24 at approximatley 9:25 a.m. PCT#1 was observed removing the used tubing from the dialysis machine and transporting the tubing across the clinical floor to dispose of it in a biohazard waste container. Observation #7 on 5/1/24 at approximately 11:00 a.m. transport attendant observed to be standing at Station #8 while Station #7 patient being put on treatment. PCT#2 was actively cleaning the Central Venous Catheter (CVC) site of the patient in Station #7. Surveyor observed transport attendant without mask or gown on. Interview with facility administrator (FA) at approximatley 11:05 a.m. regarding this observation, “Yes, he should have a gown and mask on.” Reviewed findings (observation #4) on 5/1/24 at approximately 11:10 a.m. with FA.”I’d have to look at the policy.” Interview with FA (observation #2) on 5/1/24 at approximately 11:15 confirmed “when in the medication room, should have gowns off.””