Davita Willow Lakes Dialysis

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 47219 Based on review of medical records (MRs), agency policy review, and interview with facility administrator, agency failed to maintain documentation of completed emergency preparedness (EP) fire safety quarterly patient education in three (3) out of eight (8) medical records reviewed (MR #6-8). Findings include: Review conducted on December 6, 2023, at approximately 9:00 AM to 3:00 PM, of medical records revealed: MR#6 soc 11/17/22, no documentation of EP Fire Safety Preparedness training for 2023 quarters 1 and 3. MR#7 soc 7/29/20, no documentation of annual emergency training for 2021; no documentation of EP Fire Safety Preparedness training for 2021 quarter 1, 2022 quarters 1 and 3, and 2023 quarters 1 and 3. MR#8 soc 7/27/22, no documentation of EP Fire Safety Preparedness training for 2023 quarters 1 and 3. Review conducted on December 7, 2023, at approximately 1:00 PM, of agency policy “4-07-01 Facility Emergency Management Plan (ICD, HOME) pages 25-28 of 38, b. Patients: ... ii. Quarterly 1. Fire Safety Preparedness. ... v. Document training on applicable forms.” Interview conducted on December 7, 2023, at approximately 1:30 PM, with facility administrator confirmed above findings.”

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 47219 Based on a review of Centers for Disease Control (CDC) guidelines, agency personnel files (PFs) and policy, and interview with agency administrator, it was determined the agency failed to ensure direct care workers, prior to patient contact, that the individual had been screened for and was free from active mycobacterium tuberculosis (TB) for two (2) of three (3) PFs reviewed (PF1, PF3). Findings Included: Review conducted on December 4, 2023, at approximately 1 PM, of personnel files (PFs) revealed: PF#1 date of hire (doh) 12/27/22, #1 tuberculin skin test (TST) negative test result; #2 TST never completed. PF#3 doh 3/22/23, no TSTs performed. Review conducted on December 4, 2023, at approximately 1:30 PM, of CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 revealed: “...Baseline testing for M. Tuberculosis infection is recommended for all newly hired health care workers [HCWs]...If TST [tuberculin skin testing] is used for baseline testing, two-step testing is recommended for HCWs whose initial TST results are negative...If the first-step TST result is negative, the second-step TST should be administered 1--3 weeks after the first TST result was read...A second TST is not needed if the HCW has a documented TST result from any time during the previous 12 months. If a newly employed HCW has had a documented negative TST result within the previous 12 months, a single TST can be administered in the new setting...This additional TST represents the second stage of the two-step testing... .” *Baseline (preplacement) screening and testing, in addition to the IGRA (interferon-gamma release assay) or TST, shall include a symptom screen questionnaire and an individual TB risk assessment. Serial screening and testing not routinely recommended. Annual TB education is recommended. (CDC/MMWR/May 17, 2019/Vol. 68/No. 19). Review conducted on December 4, 2023, at approximately 1:35 PM, of agency policy 4-06-05 Tuberculosis Monitoring and Follow-up revealed: “Baseline new hire requirements for all new teammates ... will complete the following: 3c. Testing options (any one of the following): If exemption criteria for TST is not met, the following testing options are available: Baseline TST using a two step Purified Protein Derivative (PPD) Mantoux test (a *second TST repeated one to three weeks after the first if the initial test is negative). Test results will be recorded on the Teammate Health Monitoring Record.” Interview conducted on December 4, 2023, at approximately 1:45 PM, with agency administrator revealed confirmation of the above findings. Administrator immediately contacted PF#3 and performed TST #1 on 12/4/23. PF#3 #1 TST result was read on 12/6/23 Negative. TST #2 will be performed in 2-3 weeks.”