Hospital Metropolitano Centro De Dialysis

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 20423 Based on observations made of the treatment area, and review of policies and procedures and interview with facility Charge Nurse (employee #8), it was determined that the facility failed to monitor the environment to ensure that it is sanitary to reduce possible transmission of infectious agents related to crash cart with expiration medication and multiuse medication opened without label available to use and no hemodialysis chair in the isolation room. Findings include: During the tour performed to the unit on 02/19/2025 from 8:00 AM through 1:30 PM the following was observed in the hemodialysis treatment area: 1. The medication area was reviewed on 02/19/2025 at 9:40 AM and was found a vial of Labetalol hydrochloride 100 milligram (mg) / 20 ml with an expiration date on 06/2026 opened without a label with the date and hour of when was open, available to use. 2. The unit crash cart was reviewed on 02/19/2024 at 11:00 AM and was identified that the medication review by the monthly pharmacy evaluation was not provided, the last one found in the medication crash cart log was from August 2024. The employee # 8 states that the pharmacy department has this evidence. However, it was not provided to the surveyor. During the review of the crash cart on 0920/2025 at 11:00 AM it was observed 3 syringes of Sodium Bicarbonate 8.4 % 50 milliequivalent (mEq)/50 milliliter (ml) with an expiration date January 1, 2025, 1 bag of Dextrose in water 5% 500 ml expired on Jan 2025 and a Suction Catheter French 16 opened, all this available for use. 3. On 02/20/2025 at 10:00 AM in the Isolation room located on the second floor of the hospital, the crash cart lacks monthly pharmacy medication review. 4. On 02/20/2025 at 10:00 AM the Isolation hemodialysis room located on the second floor was visited and lacks hemodialysis treatment chair. 47384 5. Approximately at 8:25 AM the bio medical waste room door was observed opened and with multiple used gallons of “Renal Pure” dialysate on the floor. 6. Eight (8) sharp containers (8 gals) were observed on the floor with an open rotating protection lid in the opened position and with blood on its outside. 7. On 15 of 15 dialysis machine water tubing were observed touching the ground, stations contain a metal hook where this tubing should be placed but are not used. 8. Blue pads with dark water stains were observed in the dirty sink area where equipment is laid out to dry. 9. Counter tops behind treatment stations #1, # 2, #3, #5, #6, #7 were observed with excessive dust. 10. Environmental maintenance employees dried the floor with a mop without bringing the bucket and wetting the floor as he walked through the unit. 11. Environmental maintenance employees were observed entering the unit with maintenance cart from other area. 12. Chlorine test strips were observed lying on the floor of the water treatment unit. Signs of dirt and water were also observed at the rear door of the unit. 17959 13. On 02/19/2025 at 8:00 AM the following was observed in the Waiting Room for dialysis patients and hemodialysis treatment area: Nursing staff, maintenance employees and other employees of the hemodialysis treatment unit were observed to leave the Hemodialysis treatment unit to the reception area and waiting room of patients with the white coat and then re-enter the unit with the same gown.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 47384 Based on observations made of the treatment area, and review of policies and procedures and interview with facility Institutional Program Director (employee #2) it was determined that the facility failed to observe that the building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. Findings include: 1. Acoustic tiles were observed missing in the maintenance equipment room, other acoustic tiles were observed with water damage in the room. 2. Column next to the dirty sink was observed with water damage to the gypsum board and peeling paint”

“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: 47384 Based on observations made of the treatment area, and review of policies and procedures and interview with facility Institutional Program Director (employee#2 ), it was determined that the facility failed to implement and maintain a program to ensure that all equipment are maintained and operated in accordance with the manufacturer’s recommendations. Findings include: 1. The scale was observed with the sandpaper like tape in poor condition. 2. No maintenance record was provided for two (2) Gambro AK 98 Dialysis machines installed in June 2024. Biomedical technician did not know specific preventive maintenance for this equipment. 3. No emergency disconnection kit was observed at treatment stations # 2 and #3.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 20423 Based on the observational tour, it was determined that the facility failed to ensure that patients receive treatment in a manner that allows staff to have full view of patient’s access sites for the first shift and second shift during on 02/19/2025 from 8:00 AM through 1:35 PM at patient’s stations #4 and, #6. This deficient practice affects 2 out of 24 patients observed receiving treatment. Findings include: 1. During observations of the hemodialysis treatment area on 02/19/2025 from 8:00 AM through 1:35 PM on the first and second shift the following was identified: a. Patient located on station #4 was observed with line connections located on the left forearm Graft Vascular Access covered with blankets while receiving treatment. During the patient interview she stated that it is cold, and she covered, and that personnel oriented related to not covered the vascular access. Rooms Temperature was 68 grade Fahrenheit. b. Patient located on station #6 was observed with her right forearm arteriovenous fistula vascular access and line connections covered with a blanket while receiving treatment. During the patient interview he stated that it cold in the unit and he covered, and that personnel oriented related to not covered the vascular access. Rooms Temperature was 69 grade Fahrenheit. 2. The facility failed to promote policies and procedures that establish that access sites are to be left uncovered to allow complete visibility by the nursing staff, during hemodialysis treatment.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 47384 Based on observations made of the treatment area, and review of policies and procedures and interview with facility Institutional Program Director (employee #2 ), it was determined that the facility failed to comply with provisions of the Life Safety Code. Findings include: 1. Fire alarm annunciator reported 16 troubles signals that were not restored to normal within 200 seconds. 2. No annual inspection and certification of fire doors was provided.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 17959 Based on policies, procedure reviewed, and five (5) records reviewed (RR) on 02/19/2025 through 02/20/2025, it was determined that the facility failed to ensure that the interdisciplinary group developed and implemented the plan of care for one (1) out of five (5) records review ( R.R #1). Findings include: 1. R.R #1 is a 61-year-old male admitted to the facility on 03/07/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/20/2025 at 9:30 AM, the hemodialysis treatment three a week for four thirty hours (4.5 hours), Dializaer Optiflux, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) of 1153 kilograms (kg). A. During the record review performed on 02/20/2025 at 9:30 AM, the patient received it three times a week, Tuesday, Thursday and Saturday, for 4.5 hours to achieve the extracorporeal removal of waste products. The record provides evidence that the Initial Plan of Care was performed on 03/07/2024 and the following was identified: 1. Lacks information related to physician patient name, anemia management, falls evaluation and dialysis prescription. 2. The Initial Plan of Care provides evidence that the patient has a Catheter, however, it did not indicate if the catheter was located on the right or left side. B. The record provides evidence that the next ’ Plan of Care ’ was performed on 06/30/2024 according of the policies and procedures and lacks the following information: Treatment Modality and the date of the last Plan of Care. C. The following areas of the plan of care was maintain in blank and it does not have the signature, the license number of the Nephrology and Nurse and lacks of date. The patient signed the plan of care, however, lacks date when signed the plan. 1. Dialysis Prescription 2. Problems identified in the comprehensive related to dialysis prescription. 3. Patient Education 4. Fluids Management and Blood Pressure 5. Problems identified in the comprehensive relate to weight gain and loss and blood pressure control. 6. Anemia Management 7. Problems identified in the comprehensive related to anemia management. 8. Fluids management and blood pressure 9. Problems identified in the comprehensive relate to weight gain and loss and blood pressure control. 10. Anemia Management 11. Vascular Access and patient education 12. Diabetes Management 13. Modality and patient education 14. Transplant and patient education 15. Falls Evaluation 16. Pain Evaluation 17.Mental health and Plan to achieve the specific goals D. Guide to the Management of Catheter Infections and the use of Antibiotics lacks date and Physician and Nurse signature.”

“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: 17959 Based on policies, procedure reviewed, and five (5) records reviewed (RR) on 02/19/2025 through 02/20/2025, it was determined that the facility failed to ensure monitor and document the patients’ blood pressure (B/P) and document nurse action when patients present hypotension and/or hypertension during dialysis treatment for 1 out of 5 records reviewed (R.R #1). Findings include: 1. R.R #1 is a 61-year-old male admitted to the facility on 03/07/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/20/2025 at 9:30 AM, the hemodialysis treatment three a week for four thirty hours (4.5 hours), Dializaer Optiflux, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) of 1153 kilograms (kg). a. On 02/14/2025 at 8:50 AM, it was revealed that the Blood Pressure (BP) was 150/92mg/Hg, the patient maintains stable blood pressure during the hemodialysis treatment. However, the treatment ended at 1:31 PM and the BP was 167/108mg/Hg per two times however, no evidence of manual blood pressure and the patient leaves to his house. The nurse failed to take the manual B/P before the patient went to his house.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 17959 Based on policies, procedure reviewed, and five (5) records reviewed (RR) on 02/19/2025 through 02/20/2025, it was determined that the facility failed to ensure that the physician, nurse and other personnel are providing ESRD care monthly as evidenced by a monthly progress note for 1 out of 5 records reviewed ( R.R #1) Findings include: 1. R.R #1 is a 61-year-old male admitted to the facility on 03/07/2024 with a diagnostic End Stage Renal Disease. During the record review performed on 02/20/2025 at 9:30 AM, the hemodialysis treatment three a week for four thirty hours (4.5 hours), Dializaer Optiflux, Blood Flow Rate (BFR) of 400, Dialysis Flow Rate (DFR) of 800 and Patient Dry Weight (EDW) of 1153 kilograms (kg). A. During the record review performed on 02/20/2025 at 9:30 AM, the patient received three times a week, Tuesday, Thursday and Saturday for 4.5 hours to achieve the extracorporeal removal of waste products. B. No evidence of monthly progress notes of physicians during months of March, May, June, July and November of 2024 and January of 2025. C. No evidence of monthly progress notes of Social Worker during months of April, May, June, July, August, September, October, November and December of 2024 and January of 2025. D. No evidence of initial assessment and monthly progress notes of Nutritionist during months of April, May, June, July, August, September, October, November and December of 2024.”

“PQ-SELF/HOME TRG RN-12 MO RN+3 MO MODALITY CFR(s): 494.140(b)(2) (2) Self-care and home dialysis training nurse. The nurse responsible for self-care and/or home care training must- (i) Be a registered nurse; and (ii) Have at least 12 months experience in providing nursing care and an additional 3 months of experience in the specific modality for which the nurse will provide self-care training. This Standard is not met as evidenced by: 17959 Based on interview with the facility staff Charge Nurse (employee #2) on 02/19/2025 at 8:00 AM, it was determined that the facility failed to have a Nurse Manager responsible for Nursing Services in the Hemodialysis Treatment Unit. Findings include: 1. On interview with the Charge Nurse (employee #2) on 02/19/2025 at 8:00 AM in the dialysis unit she stated: The facility Hemodialysis Unit lacks Nurse Manager at this moment because she resigns. I cover all the functions of supervisor, charge nurse and covers in treatment hemodialysis unit. The Hospital Nurse Director visits the hemodialysis unit occasionally. At this moment the unit has fifty patients receiving hemodialysis from Monday to Saturday from 5:50 AM in the morning to 8:00 PM. At this moment the unit has seven register nurses to cover all the days and hours and one register nurse in orientation a week ago. 2. On interview with the hemodialysis unit CEO Administrative Director she stated: “At this time the hemodialysis unit did not have Nurse Manager however we are in the process of getting a nurse to prepare for this position.’’ 3. The surveyors requested the Charge Nurse, the CEO and the Director of Human resources of the date the Nurse Manager resign, and the information was never provided nor shown to the surveyor. The facility has no charge nurse since some time ago (not determine) and had failed to provide information during the survey as requested to ensure requirements were met. ( Refer to 42 CFR 489.53)”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 02/21/2024 from 9:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to develop procedures to track the location of on-duty staff and sheltered patients in the dialysis facility’s care during and an emergency. Findings include: During the review of the facilities Emergency Preparedness Program on 02/21/2024 it was noted that the EP failed to have written procedures to document the specific name and location of the receiving facility or other location.”

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 02/21/2024 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements, it was determined that the facility failed to provide means to shelter in place for patients, staff and volunteers who remain in the facility. Findings include: During the review of the facilities Emergency Preparedness Program on 02/21/2024 at 8:00 AM through 4:00 PM it was noted that the EP failed to have written process for activation and designation of a shelter in place area in the unit during and after an emergency.”

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[For OPOs at §486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 02/21/2024 from 8:00 AM through 4:00 AM, to evaluate emergency preparedness requirements, it was determined that the facility failed to have policies and procedures describing the system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains the availability of records. Findings include: During the review of the facilities Emergency Preparedness Program on 02/21/2024 it was noted that the EP failed to have written process for preserving patient information as required under §494.62(b)(4). When asked it was stated that medical documentation was a Nursing Department responsability and was not included on the EP.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 47384 Based upon an Emergency Preparedness Program (EPP) survey performed on 02/21/2024 at 8:00 AM through 4:00 PM, to evaluate emergency preparedness requirements for recertification, it was determined that the facility failed to develop and maintain policies and procedures related with the role of the facility under a waiver declared by the Secretary in accordance with section 1135 of the Act in the provision of care and treatment. Finding includes: During the review of the facilities Emergency Preparedness Program on 02/21/2024 it was noted that the EP failed to include policies and procedures which outline the facility’s role in the provision of care and treatment under section 1135 waivers during a declared public health emergency.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 15884 Based on an ESRD Core survey and observations made of the treatment area, and review of policies and procedures and interview with facility Social Worker (employee#12) it was determined that the facility failed to monitor the environment to ensure that it is sanitary to reduce possible transmission of infectious agents related to patients carrying bags with belongings inside hemodialysis stations and locating theses bags on nearby surfaces were hemodialysis procedures are performed. This deficient practice was observed on 5 out of 14 (random sample observations performed patients receiving treatment on the first shift on 02/21/2024 ( Station #1,Station #2,Station #3 and Station #4 ) and 1 out of 4 cases observed beginning treatment on 02/21/2024 (station #6) and 9 out of 14 receiving teatment during the second shift at stations #4, #5, #6, #7, #8, #9, #10, #12 and #13. Findings include: Review on 02/21/2024 at 10:30 AM of the facility’s directive and rules established to be followed by patients last review in January 2022. Directive clearly stated in the rules that it is not permitted get inside the hemodialysis treatment area bags or carry-on luggage. The directive clearly stated that there is a designated area to store those items. 1. The following was observed on the hemodialysis treatment area, during the first shift and second shift while patients are receiving hemodialysis treatment during the first shift on 02/21/2024 from 8:45 AM through 11:15 AM and during the second shift on 02/21/2024 from 11:20 am till 1:00 PM: a. Patient’s located on station #1, #2, and #3 were observed to maintain a plastic shopping bag with belongings hanging on the right-side table located in the hemodialysis chair. Those plastic shopping bags had a size of approximately 13 x 13 inches. 17959 2. The following was observed on the hemodialysis treatment area, during the first shift and second shift while patients are receiving hemodialysis treatment during the first shift on 02/21/2024 from 8:55 AM through 11:55 AM and during the second shift on 02/21/2024 from 11:55 AM till 1:00 PM: a. Patient’s located on station #4, #5, #6, #7, #8, #9, #10, #12 and #13 were observed that maintain a large suitcase with belongings directly on the floor, other suitcases were observed on both side of the hemodialysis treatment chair and the small suitcase and shopping bags were observed on the top of the small hang rest localized at both side of the treatment chairs. b. On 02/21/2024 at 9:00 AM during review the medication emergency cart located on the main entrance of the hemodialysis treatment was observed with rust on both side of the security lock handless. Dust was observed on the interior and exterior of the emergency cart. Four Cloraprep with expiration date in March of 2023 were identified on the interior of the emergency suitcase. c. On 02/21/2024 at 9:05 AM during observation performed on the hemodialysis treatment unit was observed that the security lock red and green of the hemodialysis treatment machines located on stations #1, #2, #3, #4, #5, #6, #7, #8, #10, #12 and #13 have a broken security lock. d. On 02/21/2024 at 9:15 AM during performed visual observation on the hemodialysis treatment unit the black plastic cover of the patient treatment chair’s footrest was observed broken and with dust. e. On 02/21/2024 at 9:20 AM the plastic cart used to maintain the materials used during connection and disconnection process located in front of station #10 to #13 was observed with dust and deteriorated plastic material. f. On 02/21/2024 at 9:10”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 15884 Based on an unannounced recertification ESRD CORE survey review of policies, credential file and observations during patient disconnections procedures and interview with Quality Institutional Director (employee #2), it was determined that the facility failed to demonstrate that follows infection control precautions to prevent transmission of infections among hemodialysis patient’s evidenced by lack of appropriate procedures performed by housekeeping personnel while performed cleaning and waste disposal at the unit. This deficient practice had the potential to affect 14 out of 14 patients receiving services at the facility during the first shift. Findings include: Housekeeping personnel (employee # 10) was observed on 02/21/2024 at 11:15 AM While performing biohazard and regular garbage disposal and mopping the floor inside the hemodialysis unit and the end of the first shift. While (employee # 10) perform housekeeping procedures the following was observed: 1. Housekeeping personnel (employee # 10) carry regular waste plastic bags to be used to change regular waste container waste on her gown front pockets. 2. Housekeeping personnel (employee # 10) carry biohazard waste plastic bags to be used to change biohazard waste container waste on her gown front pockets. 3. When housekeeping personnel (employee # 10) change biohazard and regular waste plastic bags before putting the new bag to the container, she was observed shaking the bags to open them. This practice promotes that particles found on surfaces and floor spread on the environment. 4. While housekeeping personnel (employee # 10) proceed to mop the area where hemodialysis stations # 5, #6,# 7 and # 8 are located she did not bring with her the mop bucket with her. She was observed carrying the mop to”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 15884 Based on an unannounced recertification ESRD CORE review of water and dialysate procedures and interview with the facility staff on 02/22/2024 from 8:30 AM till 1:30 PM, it was determine that facility failed to have in place a mechanism to ensure that color perception tests are apply to employees from which the ability to discern color is an essential job function. Findings include: 1. A mechanism to ensure that facility apply color vision screening tests on employees responsible for reading colormetric tests were not performed accordingly with the following findings: a. Facility had not established policies and procedures to assure that the ability to discern color is tested in employees responsible for reading colormetrics test. During interview performed on 02/22/2024 at 10:00 Nursing Director (employee #1) stated that facility did not have policies and procedures to assure that color perception test/color vision screening is applied to employees who are responsible to read colormetrics test. b. Facility failed to ensure that staff assigned with the responsibility of reading colormetrics test are capable of distinguishing between different shades of pink and other colors or a digital meter must be used. 2. Based on an unannounced recertification ESRD CORE review of water and dialysate procedures and interview with the facility staff on 02/22/2024 from 8:40 AM till 9:30 PM, it was determined that facility failed to have perform an accurate Chlorine testing procedure. a. During a Chlorine testing observation it was found that only one employee performed the test, this employee left the test strip on top of a plastic shelf for another employee to check. Policies state that two employees should be present at the moment of the test.”

“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: 47384 Based on an unannounced recertification CORE survey and observational tour of the patient treatment area with the Institutional Program Director (employee #2) during the first shift, on 02/21/2024 from 8:30 AM till 1:00 PM, it was determined that the facility failed to ensure that medical surgical equipment and items needed to performed an emergency disconnection from hemodialysis machine circuits were not available for 4 out of 15 hemodialysis stations where patients are receiving treatment on the first shift ( Station # 1,# 2,# 7 and # 13). Findings include: 1.Four hemodialysis treatment stations did not have attached to the chair the disconnection kit. 2. Facility failed to maintain emergency disconnection kit on every chair where a patient is receiving hemodialysis treatment.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 47384 Based on an unannounced recertification CORE survey and observational tour of the patient treatment area with the Institutional Program Director (employee #2) during the first shift, on 02/21/2024 from 8:30 AM till 1:00 PM, it was determined that the facility failed to maintain the facility free from defects or hazards to ensure safety and functionality. This deficient practice had the potential to affect 48 out of 48 patients receiving services at the facility. Findings include: 1. A broken gypsum board was observed at the bottom of the wall column next to the scale. 2. The scale was observed with peeling paint and torn sandpaper. 3. The wall near the scale was observed with black marks referring to friction with the stretchers. 4. Broken Formica was observed on the clean sink counter in front of station #6. 5. Acoustic tiles with moisture damage are observed in front of station #6, between station #8 and the hallway, in front of station #11 and in the warehouse. 6. Signs of condensation were observed on the air conditioning outlet grill in front of station #8. 7. The counter of the “dirty sink” was observed with rust stains on the security screws and lock area. The base of the counter was observed with signs of fungus due to humidity.”

“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: 47384 Based on an unannounced recertification ESRD CORE review of preventive maintenance (PM) records and procedures on 02/22/2024 from 8:30 AM till 4:30 PM, it was determined that facility failed to maintain a program to ensure that all equipment are maintained and operated in accordance with the manufacturer’s recommendations. Findings include: During review of PM documentation on 3 of 5 dialysis machines audited were missing recorded operating hours on the annual PM form.”