Davita Cheltenham Dialysis

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 40929 Based on a review of the facility Medical Records (MR), facility policy, and an interview with the facility administrator, the facility did not conduct fire safety drills according to facility policy for three (3) of seven (7) MRs. MR# 2, 4, & 5. Findings include: A review of facility policy occurred on 7/23/25 at approximately 9:45 AM and revealed the following: Policy titled, “Facility Emergency Management Plan 4-07-01” stated, “Training and Education...Patients...Quaterly...Fire safety prepardness and Emergency take-off procedures...” A review of Medical Records was conducted on 7/22/25 at approximately 9:30 AM and 7/23/25 at approximately 10:00 AM and revealed the following: MR#2 admission date 10/5/21 did not have a fire safety drill conducted for any quarters in 2024. MR#4 admission date 12/13/16 did not have a fire safety drill conducted for any quarters in 2024. MR#5 admission date 5/18/22 did not have a fire safety drill conducted for any quarters in 2024. An interview with the facility administrator conducted on 7/23/25 at approximately 3:00 PM confirmed the above findings. Facility Administrator stated fire safety drills were not completed in all of 2024 for the incenter hemodialysis patients.”

“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: 40929 Based on observation of the clinical area, facility policy and an interview with the facility administrator, the facility did not ensure infection control procedure regarding glove removal and handwashing for one (1) of three (3) observations of “cleaning and disinfection of the dialysis station.” (OBS# 3) Findings include: A review of facility policy occurred on 7/23/25 at approximately 9:45 AM and revealed the following: Policy titled, “Infection Control for Dialysis Facilites 1-05-01” stated, “Hand hygeine. All teammates, physicians and non-physician will perform hand hygiene...before touching clean areas such as supplies, supply cart and chairside keyboard/mouse...Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station, this will include patients and visitors assisting with procedures...Gloves should be changed when...going from a “dirty” area or task to a “clean” area or task...” Observations conducted in the patient treatment area on 7/21/25 between 9:45 AM and 12:30 PM and on 7/22/25 between 11:15 AM and 11:45 revealed the following: OBS #3. Station # 11, PCT # 4. PCT #4 removed old bloodlines after patient vacated the station and placed in the appropriate trash receptacle. PCT #4 then reached into clean bleach solution/wipes without first cleaning hands/applying new gloves and proceeded to clean the dialysis station. An interview with the facility adminstrator conducted on 7/23/25, at approximately 2:00 PM confirmed the above findings.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 40929 Based on a review of facility policy/procedure, treatment area observations, and an interview with the facility administrator, the facility failed to ensure that clinical staff maintain aseptic technique for the care of vascular accesses, including intravascular catheters, for one (1) of two (2) ‘Discontinuation of Dialysis with Central Venous Catheter’ observations. (Observation #1) Findings: A review of facility policy occurred on 7/23/25 at approximately 9:45 AM and revealed the following: Policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure 1-04-02B” stated, “Upon Completion of Dialysis...Procedure...Teammate and patient will wear masks covering the nose and mouth during this procedure...” Observations conducted in the patient treatment area on 7/21/25 between 9:45 AM and 12:30 PM and on 7/22/25 between 11:15 AM and 11:45 revealed the following: Discontinuation of Dialysis with Central Venous Catheter Observation #1 :On 7/21/25 at approximately 10:30 a.m. while observing ‘Discontinuation of Dialysis with Central Venous Catheter’ observation #1 of 2, station #11 RN #1 failed to ensure face mask on themselves was above nose throughout the procedure. An interview with the facility administrator on 7/23/25 at approximately 2:00 p.m. 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: 40929 Based on review of facility policies/procedure, medical records (MR), hemodialysis (HD) treatment records, and interviews with the facility administrator (FA), the facility failed to follow its policy for monitoring vital signs, reporting and/or documenting abnormal findings during HD, for three (3) of seven (7) MR reviewed: MR#1, 3, & 5 Findings include: A review of facility policy occurred on 7/23/25 at approximately 9:45 AM and revealed the following: Policy titled” Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment (Policy: 1-03-08)” stated “Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes ... measurement of BP (blood pressure), Heart or pulse rate;” “Intradialytic Data Collection/Assessment: the licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation .... Vital signs and treatment monitoring - for non-nocturnal treatments is completed at least every thirty (30) minutes ....Abnormal findings will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The licensed nurse notifies the physician (or non physician practitioner if applicable) as needed of changes in patient status...Abnormal Findings - any weight loss from last post weight .... Blood Pressure -Intradialytic: Systolic greater than 180 mm Hg or less than 90 mm Hg; Diastolic greater than or equal to 100 mmHg; Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minutes or greater than 100 beats per minutes and/or an irregular heart beat.” During observation of the treatment floor on 7/21/25 at approximatley 10:00 AM observed documentation that stated the following hanging throughout the treatment floor, “Do not initiate treatment BP 80/50- RN to call MD...Heart rate 50 and below- RN to call MD” This document was also given to to surveyor by facility administrator on 7/23/25 at approximately 10:00AM. A review of medical records took place on 7/22/25 and 7/23/25 from approximately 9:45AM-3:00PM and revealed the following: MR #1. Start of Care at facility: 5/21/25 HD (hemodialysis) Treatment on 7/9/25 was initiated at 11:21 AM by the PCT (patient care technician) and revealed the following: 11:21 AM the PCT documented a BP (blood pressure) of 205/83. 2:02 PM the PCT documented a BP of 202/71, Heart Rate of 47. Rechecked at 2:03 PM by PCT and BP was 183/75 Heart Rate remained at 47. 2:47 PM PCT documented Heart Rate of 46. There was no documentation of an RN notification during the treatment on 7/9/25 of the above findings. MR #3. Start of Care at facility: 6/17/25. HD Treatment on 7/16/25 was initiated at 11:46 AM by the PCT and revealed the following: 2:32 PM the PCT documented a BP of 80/49. There was no documentation of an RN notification during the treatment on 7/16/25 of the above findings. MR#5. Start of Care at facility: 5/18/22. HD Treatment on 7/17/25 was initiated at 11:31 AM by the PCT and revealed the following: 2:03 PM the PCT documented a BP of 97/48. There was no documentation of an RN notification during the treatment on 7/17/25 of the above findings. HD Treatment on 7/19/25 was intiated at 11:05 AM by the PCT and revealed the following: 1:32 PM the PCT documented a BP of 77/46 1:33 PM the PCT documented a BP of 95/47 There was no documentation of an RN notification during the treatment on 7/19/25 of the above findings. An interview conducted with Facility Administrator on 7/23/25 at approximatley 2:00PM confirmed the above findings.”

“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: 40929 Based on a review of facility policy/procedure, observations, and an interview with the facility administrator, the facility failed to ensure that the staff performed proper aseptic technique while initiating treatment for one (1) of two (2) ‘Access of AV Fistula or Graft for Initiation of Dialysis’ observations (Observation #2). Findings include: A review of facility policy occurred on 7/23/25 at approximately 9:45 AM and revealed the following: Policy titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose 1-04-01E” stated, “procedure...Do not palpate insertion site once area has been prepped. Rationale. Once the access site has been prepped, touching it will contaminate the site and possible allow for the introduction of bacteria during cannulation...” Observations conducted in the patient treatment area on 7/21/25 between 9:45 AM and 12:30 PM and on 7/22/25 between 11:15 AM and 11:45 revealed the following: Observation #2: On 7/21/25 at approximately 11:55 a.m., station #5, PCT #5 began to initiate dialysis treatment. PCT #5 cleansed insertion site then palpated site with gloved hands. PCT #5 then inserted needle without re-cleansing site. An interview with the facility administrator on 7/23/25 at approximately 2:00 PM. confirmed the above findings.”

“QAPI-COVERS SCOPE SERV/EFFECTIVE/IDT INVOL CFR(s): 494.110 The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility’s organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS. This Standard is not met as evidenced by: 40929 Based on a review of the facility’s quality assurance and performance improvement (QAPI) program and an interview with the facility administrator and nurse manager, the facility meetings did not include all members of the facility’s interdisciplinary team for five (5) of five (5) QAPI meeting minutes/data reviewed. Findings include: A review of facility policy occurred on 7/23/25 at approximately 12:30 PM and revealed the following: Policy titled, “Continuous Quality Improvement Program” stated, “Each dialysis facility will have a continuous quality improvement (CQI) committee comprised of at least the following individuals from the interdisciplinary team: Facility Medical Director, Facility Administrator/Designee, Registered Nurse, Biomed Technician, Registered Dietitian, Social Worker...Facility Health Meetings (FHM) are conducted Monthly....” A review of the QAPI meeting minutes/data/documentation and QAPI meeting sign in sheets was reviewed on 7/23/25 at approximately 11:00 AM. On the following QAPI dates the following individuals are marked as “Did not attend” or there is nothing written next to their name: February 2025 Meeting: No Peritoneal Dialysis RN March 2025 Meeting: No Incenter Hemodialysis RN, Peritoneal Dialysis RN, MSW or Dietitian April 2025 Meeting: No Incenter Hemodialysis RN or Dietitian May 2025 Meeting: No Incenter Hemodialysis RN or Dietitian June 2025 Meeting: No Peritoneal Dialysis RN or Dietitian An interview with the facility administrator on 7/23/25 at 3:00 PM confirmed the above findings.”