Davita Hanover Dialysis

“INVENTORY CONTROL CFR(s): 494.50(b)(1) 9.2 Inventory control Reprocessing supplies should be used on a first-in, first-out basis, and outdated supplies should be identified and discarded. This Standard is not met as evidenced by: 39848 Based on reviews of observations, facility policy, and an interview with the facility administrator, the facility failed to ensure proper inventory control for nine (9) of nine (9) observations (Observation # 1-# 9). Findings include: Review of Davita inc. Incenter Hemodialysis Policies and Procedures: Title: Medication Policy: “ Purpose: To provide guidance for medication management in the facility and to provide guidance for the safe and aseptic preparation of all medications; Policy: 1. The Facility Administrator/designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medications and performs monthly audit and inventory; 13. All open or unopened medication packages (i.e. vials, ampules, etc) are stored according to the manufacturer ’ s directions. Do not use any medication that has been stored improperly or has expired; 30. All medications in the facility are checked monthly for expiration dates; 32. Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations. “ Review of Davita inc. Incenter Hemodialysis Policies and Procedures: Title: “ Infection Control for dialysis facilities: “ Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment.; Policy: The Center for Disease Control (CDC) recommendations for preventing transmission of infections among chronic hemodialysis patients (dialysis precautions) will be followed when caring for all patients. Supplies: 8. Supplies will be stored in a manner that maintains their integrity. b. expiration date and package integrity will be verified prior to use. “ Review of Davita inc. policy Title: “ Facility Emergency Management Plan (ICHD, Home): “ Emergency Evacuation Kit: 1. Each facility will maintain an evacuation kit(s) with specified patient care supplies for use in case of an emergency evacuation. Facilities with home modalities may share kit if: a. easily accessible by both in-center and home modality teammates. 2. The contents of the evacuation kit(s) will include, at a minimum, enough supplies to provide care for a full shift of patients, including home patients, likely to be present in the facility at any given time. 7. Facility administrator (FA) or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly. “ Observations conducted in the facility ’ s Peritoneal Dialysis (PD) evacuation kit(s) on 5/13/25 between approximately 3:20 PM-4:00 PM revealed the following: Observation (OBS) # 1 revealed: Two vials of Heparin sodium injection thirty thousand (30,000) units per thirty (30) milliliters with expiration date of 8/1/2024. OBS # 2 revealed: Ten (10) Clear guard HD antimicrobial end caps with expiration of 4/6/24. OBS # 3 revealed: Five (5) BD vacutainer twenty-three (23) gauge by three-fourth (3/4) inch needle with expiration date of 4/30/24 OBS # 4 revealed: One (1) bottle of Alcair fifteen (15) disinfectant with expiration date of 5/2/25. OBS # 5 revealed: One (1) bottle of Exsept antimicrobial solution with expiration date of 3/8/24. OBS # 6 revealed: Nine (9) bags of 0.9 % normal saline one thousand (1,000) milliliters with expiration date of 4/24. OBS # 7 revealed: Two (2) bags of Baxter Dianeal low calcium with Dextrose 2.5 percent (%) milliequivalents per liter PD dialysis solution with expiration date 5/2024 and one (1) bag with expiration of 9/24. OBS # 8 revealed: Three (3) clear alcohol free hand sanitizer with expiration of 5/24 during treatment room observations on 5/13/25. Observations conducted in the facility ’ s water treatment room on 5/14/25 between approximately 1:15 PM and 1:45 PM revealed the following: OBS # 9 revealed: One (1) bottle of Purell Hand sanitizer with expiration date of 9/30/2023. An interview conducted with the Facility Administrator on 5/14/25 at approximately 3:30 PM confirmed the above findings.”

“PE-PT CARE ENVIRONMENT-SUFFICIENT SPACE CFR(s): 494.60(c)(1) The space for treating each patient must be sufficient to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. This Standard is not met as evidenced by: 39848 Based on observations and an interview with the facility administrator, it was determined the facility failed to ensure adequate space between clean sinks, sharps containers and dialysis chairs to prevent cross-contamination for three (3) observations (Observation #1- # 3). Findings include: Review of Davita inc. Incenter Hemodialysis Policies and Procedures: Title: “ Infection Control for dialysis facilities: “ Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment.; Policy: The Center for Disease Control (CDC) recommendations for preventing transmission of infections among chronic hemodialysis patients (dialysis precautions) will be followed when caring for all patients. Facility hygiene: 19. Sinks should be easily accessible and readily available in the treatment room. Review of Davita inc. Incenter Hemodialysis (ICHD), Peritoneal Dialysis (PD), Home Hemodialysis (HHD), Davita Skilled Nursing Facility Dialysis (DSD) Clinic Administration: Title: “ Physical Environment: 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 ....a safe, functional, and comfortable environment. 5. The space for treating each patient will be sufficient to provide needed care and services, prevent cross contamination ... “ Observation #1: On 5/12/2025 at approximately 10:45 AM patient wheelchair was blocking biohazard bin by station # 14. Observation #2: On 5/12/2025 at approximately 10:55 AM patient wheelchair was blocking clean sink in treatment pod area # 2. Observation #3: On 5/12/2025 at approximately 10:55 AM garbage can was blocking clean sink in treatment pod area # 2. An interview conducted with the Facility Administrator on 5/14/25 at approximately 3:30 PM confirmed the above findings.”

“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: 39848 Based on review of policy, medical records (MR), and an interview with the facility administrator; the facility failed to ensure that the patient prescriptions were being implemented as ordered by the physician for one (1) out of seven (7) patient prescriptions reviewed (MR # 3). Findings include: A review was conducted of facility policy on May 14, 2025, at approximately 2:50 PM Policy:1-03-08 “ Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment Policy section #2 “ states: “The nursing assessment will be performed and documented by a licensed nurse ...., (a)(ii) Verification that machine safety checks have been completed and documented... (a)(iii) Verification of prescription including machine parameters”. Section #3 states “Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment”. “Prescription components include but are not necessarily limited to: (b) “Treatment time” (f) Blood flow rate (BFR) (g) Dialysate flow rate (DFR)”. ‘Intradialytic Data Collection/Assessment’: section # 9 states “ Intradialytic treatment monitoring and data collection which may be performed by the patient care technician (PCT) or licensed nurse includes: a. Vital signs and treatment monitoring: iii. Non-nocturnal treatments are completed at least every thirty (30) minutes. b. At a minimum, obtain and document the following: i. blood pressure iii. Blood and dialysate flows. Section # 10 states “ if the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate), the reason will be documented and the licensed nurse informed. section #12 states “The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status”. Section # 13 states “ All findings, interventions and patient response will be documented in the patients’ medical record”. Dialysis Regulatory and Ancillary Policies and Procedures: Policy: 3-02-03: Davita Inc.: Title: “PHYSICIAN ORDERS FOR PATIENT CARE” reviewed on 9/14/23 at approximately 2:50 PM revealed: “Purpose: To verify that orders are properly documented, transcribed, verified and implemented in a timely manner for patient care in Davita facilities and meet all Davita, federal and applicable state regulations.”; Policy: General: A physician, in accordance with Davita medical staff bylaws, federal and state regulations, provides orders for patient care activities in one of the following ways: hand writes or electronically enters orders in the patient medical record. Gives verbal or telephone orders.; Orders must be received prior to the delivery of any treatment or service ordered.; non-licensed teammates may only transcribe written physician orders into a computerized system if signed in advance by the licensed physician. A Registered Nurse verifies the order entered in the computer against the written order in the chart before implementation.; All orders must be entered into the electronic medical record. All orders entered into the electronic medical record must be signed and dated by the ordering physician on any unsigned orders report or through eSignature within thirty (30) days.” On May 13, 2025 between approximately 2:00 PM and 3:10 PM, review of patient orders and dialysis treatment flow sheets revealed: MR # 3: Physician orders dated: 3/15/24 “Blood Flow Rate (BFR) 300” and “ Dialysate flow rate (DFR) 500 “ . Treatment flow sheet dated: 5/5/25 showed DFR: 600. No documentation explaining the DFR difference from the prescribed DFR. No documentation showing the physician was notified. Treatment flow sheet dated: 5/10/25 showed BFR:200. No documentation explaining the BFR difference from the prescribed BFR. No documentation showing the physician was notified. An interview conducted with the Facility Administrator on 5/14/25 at approximately 3:30 PM confirmed the above findings.”