Davita Westtown Dialysis

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 34009 Based on observations, policy and procedure review, and an interview with the ESRD administrator, it was determined the ESRD failed to ensure the Patient Care Technician (PCT #1) to change gloves and perform hand hygiene during for Central Venous Catheter (CVC) exit site care for one (1) of two (2) central venous catheter exit site care observations observed. ( Observation #1). Findings include: Review of policy Central Venous Catheter (CVC) Care Procedure on September 19 at approximately 11:00 am states “ 4. remove old dressing and discard...7. remove gloves and discard. Perform hand hygiene per procedure and re-glove...8...clean exit site...10. Remove gloves and discard, perform hand hygiene per procedure and re-glove.....” Observation #1, on 9/17/2024 at approximately 11:00 AM, PCT #1 was observed at Station #17, removing the old CVC dressing, without changing gloves and performing hand hygiene after performing the task, then cleansing CVC exit site, again without changing gloves and performing hand hygiene after performing the task, and placing a new dressing on the CVC exit site. An interview with the facility administrator on 9/19/2024 at approximately12:00 pm confirmed the above findings.”

“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: 34009 Based on observation and interview with Registered Nurse #1, it was determined the clinic failed to ensure documentation of preventative maintenance for ancillary equipment for 2023 for eleven (11) out of eleven (11) pieces of Ancillary Equipment used in the dialysis den located within Skilled Nursing facility (SNF#1) (Ancillary Equipment #1-Ancillary Equipment #11). Findings include: Observations were conducted at the following skilled nursing facility (SNF) dialysis treatment den on 9/18/2024: SNF #1, Skilled Nursing & Rehab Pottstown, 724 N Charlotte St, Pottstown, PA 19464 Ancillary Equipment Observations of Dialysis Den #1 were conducted on 9/18/2024 from 11:00 AM-11:30 AM, revealing the following: Ancillary Equipment #1, a Laboratory Centrifuge, contained a sticker reading “ Maintenance Due October 2023”. Ancillary Equipment #2, a Scale, contained a sticker reading “ Maintenance Due October 2023”. Ancillary Equipment #3, a Hoyer Lift, contained a sticker reading “ Maintenance Due October 2023”. Ancillary Equipment #4, a Automated External Defibrillator, contained a sticker reading “ Maintenance Due October 2023”. Ancillary Equipment #5, a Suction Machine, contained a sticker reading “ Maintenance Due October 2023”. Ancillary Equipment #6, a Medication Fridge, contained a sticker reading “ Maintenance Due October 2023”. Ancillary Equipment #7, a Biohazard Waste Fridge, contained a sticker reading “ Maintenance Due October 2023”. Ancillary Equipment #8-Ancillary Equipment #11, Oxygen Concentrators, all contained a sticker reading “ Maintenance Due October 2023”. There was no available documentation present in the Dialysis Den to show Ancillary Equipment #1-Ancillary Equipment #11 received preventative maintenance for 2023. An interview on 9/18/2024 with Registered Nurse #1 at approximately 12:00 PM confirmed the above findings.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 37972 Based on review of facility policies, clinical records (CR), and interview with facility staff, the facility failed to assess and manage patient’s blood pressure needs according to facility policy for four (4) of six (6) in-center hemodialysis CR reviewed (CR #1, 6, 7, and 9). Findings Included: Review of facility policy #1-03-08 titled “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” on September 17, 2024, at approximately 3:30 P.M. stated, “Intradialytic Data Collection/Assessment... 11. Abnormal findings or findings outside any patient specific physician ordered parameters will be reported to the licensed nurse immediately... The licensed nurse will use his/her clinical judgement based on individual patient needs to be determined if any clinical interventions are necessary...” “Abnormal Findings: Blood Pressure- Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg. Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg.” Review of CR conducted on September 16, 2024, from approximately 11:15 A.M. to 3:00 P.M. and September 17, 2024, from approximately 9:00 A.M. to 3:00 P.M. revealed the following: CR #1, admission date July 16, 2024. The hemodialysis flow sheet dated September 3, 2024, contained documentation of a blood pressure reading of 161/11 at 12:32 P.M., 160/102 at 1:02 P.M., and 183/150 at 2:32 P.M. The hemodialysis flow sheet dated September 10, 2024, contained documentation of a blood pressure reading of 158/101 at 11:24 A.M. The hemodialysis flow sheet dated September 12, 2024, contained documentation of a blood pressure reading of 178/122 at 2:01 P.M. There was no documentation that the Registered Nurse (RN) was notified of the elevated blood pressure readings. CR #6, admission date December 7, 2021. The hemodialysis flow sheet dated September 10, 2024, contained documentation of a blood pressure reading of 156/105 at 10:22 A.M., 192/171 at 10:21 A.M. and 131/103 at 1:31 P.M. There was no documentation that the RN was notified of the elevated blood pressure readings. CR #7, admission date November 18, 2023. The hemodialysis flow sheet dated September 3, 2024, contained documentation of a blood pressure reading of 178/157 at 6:46 A.M., 176/104 at 7:02 A.M., 166/101 at 8:02 A.M., and 174/100 at 10:32 A.M. The hemodialysis flow sheet dated September 5, 2024, contained documentation of a blood pressure reading of 172/103 at 7:32 A.M. The hemodialysis flow sheet dated September 10, 2024, contained documentation of a blood pressure reading of 178/102 at 6:44 A.M., 169/102 at 7:01 A.M., and 175/131 at 9:31 A.M. There was no documentation that the RN was notified of the elevated blood pressure readings. CR #9, admission date July 1, 2024. The hemodialysis flow sheet dated September 4, 2024, contained documentation of a blood pressure reading of 183/110 at 7:18 A.M., 183/116 at 7:31 A.M., 176/109 at 8:01 A.M., and 175/103 at 8:31 A.M. The hemodialysis flow sheet dated September 9, 2024, contained documentation of a blood pressure reading of 178/111 at 6:20 A.M., 183/113 at 6:21 A.M., and 189/110 at 6:51 A.M. The hemodialysis flow sheet dated September 11, 2024, contained documentation of a blood pressure reading of 175/109 at 6:36 A.M., 182/108 at 6:41 A.M., 175/108 at 7:01 A.M., 171/105 at 7:31 A.M. and 160/107 at 8:03 A.M. The hemodialysis flow sheet dated September 13, 2024, contained documentation of a blood pressure reading of 179/103 at 6:55 A.M., 217/121 at 7:01 A.M., 185/115 at 7:02 A.M., 181/112 at 7:31 A.M., 171/106 at 8:01 A.M., 165/105 at 8:31 A.M., 186/107 at 9:01 A.M., 154/102 at 10:01 A.M., 171/107 at 10:31 A.M., and 152/101 at 11:14 A.M. There was no documentation that the RN was notified of the elevated blood pressure readings. An interview with the Facility Administrator on September 17, 2024, at approximately 3:45 P.M. 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: 43085 Based on observations, review of facility policies, communication documentation, and interviews with staff and patient, it was determined that the facility failed to provide a safe, functional, and comfortable treatment environment for patients and staff. Findings Include: Reviewed DaVita ’ s physical environment policy on 8/20/2024 at 9:45AM. Policy: 8-04-01 titled, “ Physical Environment “ states, “ Purpose: To provide guidance on the physical environment of dialysis facility and treatment area. Policy: 1. The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment. 2. The building in which dialysis services are furnished will be constructed and maintained for the safety of the patients, the teammates and the public ...6. The dialysis facility will take reasonable steps to: Maintain a comfortable temperature within the facility ...10 ...Supplies are stored as to minimize deterioration, contamination or breakage ... “ Observations of the dialysis den located in a skilled nursing facility was conducted on 8/9/24 at approximately 9:40 AM/ The following was observed: This surveyor immediately felt the warmth of the room, and about 15 minutes after being in the room, this surveyor began to sweat and feel uncomfortable. Interviews with staff and patient #1 on 8/9/2024 between 10:12AM and 1:00PM, confirmed that the temperature in the den has been very hot for several months, and that conditions have not improved. The RN reported that the temperature in the den has been hot “ all summer “ , and that two (2) staff members were constantly complaining about the heat and were “ visibly “ exhibiting signs of diaphoresis. The RN stated that they (dialysis den staff) asked the SNF to install a thermostat in the dialysis den to keep track of the rising temperatures, but a thermostat “ was never installed “ . Therefore, the Regional Operations Manager (ROM) provided portable thermometers to be placed throughout the dialysis den (1 on the wall in the medication area, the nurse ’ s station, storage room, and on 1 of the steel storage racks where the dialysate jugs are kept). The RN stated that on Friday (8/2/2024), the portable thermometer in the dialysis den read 92 degrees Fahrenheit, and on Monday (8/5/2024) it read 90 degrees Fahrenheit. During an interview with the Regional Operations Manager (ROM) on 8/9/2024 at 1:06 PM the Regional Operations Manager (ROM) for the dialysis provider was asked if there was a standard temperature that must be maintained in the dialysis den. The ROM stated, “We like to keep the dialysis den at around 75 - 78 degrees Fahrenheit to ensure it is comfortable and our supplies, machines, and ROs (portable water machines) are working to the best of their abilities. “ The ROM also stated, “ For the supplies, we maintain based on what the supplies requirements are, mainly the acid. The acid has storage requirements on the label which we ensure to maintain. “ Label requirements were not reviewed. The ROM stated that it has been “ extremely difficult “ getting updates about repairs for the air conditioning (AC) from the skilled nursing facility. Interview with the Regional Operations Director on 8/9/2024 at 1:10PM confirmed the above findings.”

“PE-COMFORTABLE TEMPERATURE CFR(s): 494.60(c)(2) The dialysis facility must: (i) Maintain a comfortable temperature within the facility; and (ii) Make reasonable accommodations for the patients who are not comfortable at this temperature. This Standard is not met as evidenced by: 43085 Based on observations, review of facility policies, communication documentation, and interviews with staff and patient, it was determined that the facility failed to provide a safe, functional, and comfortable treatment environment for patients and staff. Findings Include: Reviewed DaVita ’ s physical environment policy on 8/20/2024 at 9:45AM. Policy: 8-04-01 titled, “ Physical Environment “ states, “ Purpose: To provide guidance on the physical environment of dialysis facility and treatment area. Policy: 1. The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment. 2. The building in which dialysis services are furnished will be constructed and maintained for the safety of the patients, the teammates and the public ...6. The dialysis facility will take reasonable steps to: Maintain a comfortable temperature within the facility ...10 ...Supplies are stored as to minimize deterioration, contamination or breakage ... “ Observations of the dialysis den located in a skilled nursing facility was conducted on 8/9/24 at approximately 9:40 AM/ The following was observed: This surveyor immediately felt the warmth of the room, and about 15 minutes after being in the room, this surveyor began to sweat and feel uncomfortable. Interviews with staff and patient #1 on 8/9/2024 between 10:12AM and 1:00PM, confirmed that the temperature in the den has been very hot for several months, and that conditions have not improved. The RN reported that the temperature in the den has been hot “ all summer “ , and that two (2) staff members were constantly complaining about the heat and were “ visibly “ exhibiting signs of diaphoresis. The RN stated that they (dialysis den staff) asked the SNF to install a thermostat in the dialysis den to keep track of the rising temperatures, but a thermostat “ was never installed “ . Therefore, the Regional Operations Manager (ROM) provided portable thermometers to be placed throughout the dialysis den (1 on the wall in the medication area, the nurse ’ s station, storage room, and on 1 of the steel storage racks where the dialysate jugs are kept). The RN stated that on Friday (8/2/2024), the portable thermometer in the dialysis den read 92 degrees Fahrenheit, and on Monday (8/5/2024) it read 90 degrees Fahrenheit. During an interview with the Regional Operations Manager (ROM) on 8/9/2024 at 1:06 PM the Regional Operations Manager (ROM) for the dialysis provider was asked if there was a standard temperature that must be maintained in the dialysis den. The ROM stated, “We like to keep the dialysis den at around 75 - 78 degrees Fahrenheit to ensure it is comfortable and our supplies, machines, and ROs (portable water machines) are working to the best of their abilities. “ The ROM also stated, “ For the supplies, we maintain based on what the supplies requirements are, mainly the acid. The acid has storage requirements on the label which we ensure to maintain. “ Label requirements were not reviewed. The ROM stated that it has been “ extremely difficult “ getting updates about repairs for the air conditioning (AC) from the skilled nursing facility. Interview with the Regional Operations Director on 8/9/2024 at 1:10PM confirmed the above findings.”