Davita St Luke’s Whitehall Dialysis

“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: 36372 Based on review of facility policy, observations, and an interview with the Facility Administrator, the facility failed to ensure the staff followed infection control protocols, included but not limited to, preventing intravascular catheter-related infections, for one (1) of one (1) ‘Initiation of Dialysis with Central Venous Catheter’ observations (Observation #1) and for two (2) of two (2) ‘Central Venous Catheter (CVC) Exit Site Care’ observations (Observations #1, Observation #2). Findings include: A review was conducted of facility policy on July 1, 2025 at approximately 2:30 p.m. Policy:1-04-02B ‘Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure’ ‘Procedure’ (1) “....Put on PPE and provide a mask to the patient. Teammate and patient will wear masks covering the nose and mouth during this procedure.” Observations conducted in patient treatment area on June 30, 2025 between approximately 8:30 a.m. - 11:30 a.m. revealed the following: Observation #1: During observation #1 of ‘Central Venous Catheter (CVC) Exit Site Care’ and ‘Initiation of Dialysis with Central Venous Catheter’ on 06/30/2025 at approximately 11:00 a.m. of patient #6, station #10; Employee #5 failed to ensure the patients face mask was covering the patients nose throughout the procedure. Observation #2: During observation #2 of ‘Central Venous Catheter (CVC) Exit Site Care’ on 06/30/2025 at approximately 11:30 a.m. of patient #3, station #2; Employee #6 failed to ensure the patient wore a face mask covering their nose and mouth throughout the procedure. An interview conducted with the facility Administrator on July 1, 2025 at approximately 2:45 p.m. and on July 2, 2025 at approximately 8:45 a.m. confirmed the above findings.”

“SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL CFR(s): 494.40(a) 5.2.4 Softeners: auto regen/timers/salt/salt level Prior to exhaustion, softeners should be restored; that is, new exchangeable sodium ions are placed on the resin by a process known as “regeneration,” which involves exposure of the resin bed to a saturated sodium chloride solution. 5.2.4 Softeners Refer to RD62:2001, 4.3.10 Automatically regenerated water softeners: Automatically regenerated water softeners shall be fitted with a mechanism to prevent water containing the high concentrations of sodium chloride used during regeneration from entering the product water line during regeneration. The face of the timers used to control the regeneration cycle should be visible to the user. 6.2.4 Softeners Timers should be checked at the beginning of each day and should be interlocked with the RO system so that the RO is stopped when a softener regeneration cycle is initiated. The softener brine tank should be monitored daily to ensure that a saturated salt solution exists in the brine tank. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head. This Standard is not met as evidenced by: 36372 Based on a request of facility policy, observations, and an interview with the facility Administrator, the facility failed to ensure salt pellets filled at least half of the brine tank in the water treatment room, for one (1) of one (1) observations (Observation #1). Findings include: Facility policy related to the water room brine tank was requested on July 1, 2025 at approximately 2:30 p.m. Per the Administrator, there is no specific policy. No specific policy provided. The facility Daily Water Treatment Log was provided for review. ‘Monitored Process or Component’, section #10, ‘Salt Level in Brine?’ ‘Acceptable Limit(s)’ “Tank at least half full, above the water (Y/N/NA)”. Observations conducted in patient treatment/water treatment areas on June 30, 2025 between approximately 8:30 a.m. - 11:30 a.m. revealed the following: Observation #1: During obervations of the water treatment area on 06/30/25 at approximately 8:34 a.m., the brine tank was observed to be approximately 1/4 full of salt. An interview conducted with the facility Administrator on July 1, 2025 at approximately 2:45 p.m. and on July 2, 2025 at approximately 8:45 a.m. confirmed the above findings.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 36372 Based on review of facility policy, medical records, and an interview with the facility Administrator, the facility failed to ensure an initial comprehensive assessment was conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions, for three (3) of three (3) patient medical records (MRs) reviewed. (MR#2, MR#3, MR#5). Findings: A review was conducted of facility policy on July 1, 2025 at approximately 2:30 p.m. Policy 1-14-01 ‘New Patient’ ‘Assessment’ states “Within 30 days of admission to facility ....” ‘Plan of Care’ states “Within 30 days of admission to facility (or within 13 treatments) for new patients ......” A review of medical records was completed on July 1, 2025 at approximately 2:30 p.m. Patients admission date is listed below. MR#2, Date of admission 2/29/24: Patients initial interdisciplinary comprehensive assessment was conducted on 4/24/24. Fifty-four (54) days after admission. MR#3, Date of admission 10/07/24: Patients initial interdisciplinary comprehensive assessment was conducted on 11/20/24. Forty-five (45) days after admission. MR#5, Date of admission 6/27/24: Patients initial interdisciplinary comprehensive assessment was conducted on 7/31/24. Thirty-four (34) days after admission. An interview conducted with the facility Administrator on July 1, 2025 at approximately 2:45 p.m. and on July 2, 2025 at approximately 8:45 a.m. confirmed the above findings.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 36372 Based on a review of facility policy, water treatment equipment records, and an interview with the facility Administrator, the facility failed to ensure facility forms were completed per policy/procedure,for one (1) of one (1) water treatment equipment records reviewed. (Record #1). Findings: A review was conducted of facility policy on July 1, 2025 at approximately 2:30 p.m. ‘Procedure: 1-20-05C’ ‘Granuflo Concentrate Dissolution Unit II (99 gallon) Mixing Procedure’ includes ‘Materials required:’ “....’Granuflo 99 Gallon Batch Production Record’....” (Note: The facility utilizes a (132) Gallon drum. No other facility policy/procedure provided.) A review of water treatment equipment records was completed on July 1, 2025 at approximately 11:00 a.m. Record #1: ‘Granuflo (132) Gallon Batch Production Records’ were reviewed and included the following omissions: 08/04/23: Ca++ and K+ sections blank with no entries. 08/21/23: Ca++ and K+ sections blank with no entries. 09/06/23: Ca++ and K+ sections blank with no entries. 11/08/23: Ca++ and K+ sections blank with no entries. ‘Dissolution Tank Serial Number’ blank with no entry. 11/22/23: Ca++ and K+ sections blank with no entries. ‘Dissolution Tank Serial Number’ blank with no entry. “09/09” (No complete date): ‘Licensed Nurse Signature’ blank with no entry. 10/05/24: Ca++ and K+ sections blank with no entries. 12/02/24: ‘Licensed Nurse Signature’ blank with no entry. 05/12/25: ‘Dissolution Tank Serial Number’ blank with no entry. 05/23/25: ‘Dissolution Tank Serial Number’ blank with no entry. An interview conducted with the facility Administrator on July 1, 2025 at approximately 2:45 p.m. and on July 2, 2025 at approximately 8:45 a.m. confirmed the above findings.”