Fkc Naranjito

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 47384 Based on document review it was determined that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials’ effort to maintain an integrated response during disaster or emergency situation. Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #3) and ATOM 35 (employee #2) on 07/10/2024 at 2:30 PM it was noted that the facility failed to include a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials as required under §494.62(a)(4) of the Emergency Preparedness.”

“Information on Occupancy/Needs CFR(s): §403.748(c)(7), §416.54(c)(7), §418.113(c)(7) §441.184(c)(7), §482.15(c)(7), §460.84(c)(7), §483.73(c)(7), §483.475(c)(7), §484.102(c)(6), §485.68(c)(5), §485.68(c)(5), §485.727(c)(5), §485.542(c)(7), §485.625(c)(7), §485.920(c)(7), §491.12(c)(5), §494.62(c)(7). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (7) [(5) or (6)] A means of providing information about the [facility’s] occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For ASCs at 416.54(c)]: (7) A means of providing information about the ASC’s needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. *[For Inpatient Hospice at §418.113(c):] (7) A means of providing information about the hospice’s inpatient occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee. This Standard is not met as evidenced by: 47384 Based document review it was determined that the facility failed to have a means of providing information about the facility’s needs and its ability to provide assistance to local and State emergency management agencies, local and state public health departments, the Incident Command Center, the Emergency Operations Center, or designee. Findings include: During the review of the facilities Emergency Preparedness Program with the Clinical Manager (employee #3) and ATOM 35 (employee #2) on 07/10/2024 at approximately 2:30 PM it was noted that the facility failed to have written procedures of providing information about the facility’s occupancy, needs, and its ability to provide assistance, to the authority having jurisdiction, the Incident Command Center, or designee.”

“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: 47384 Based on observational tour of the patient treatment area on 07/10/2024 from 9:00 AM through 4:00 PM, it was determined that the facility failed to ensure provide and monitor a sanitary environment to minimize the transmission of infectious agent. This deficient practice can affect all patients. Findings include: 1. On 07/10/2024 approximately at 10:45 AM it was observed that after disconnecting the patient at station number #20, a blood stain was present on the dialysis machine part where the gallons rest. The stain remained unclean for approximately 14 minutes. 2. On 07/10/2024 approximately at 11:00 AM white calsification like marks were observed on chair in treatment station #4.”

“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: 47384 Based on observations made of the water treatment area, during the first of 07/10/2024, it was determined that the facility failed to perform as required the chlorine, chloramine, or total chlorine test. Findings include: 1.At the time of the visual review of the chlorine test with ATOM 34 (employee #1), it was noticed that the nursing staff was not performing of the swish time required for the testing strip. 2. During the observation of the test, it was also observed that the staff makes contact of the strip with the color table, this can affect the integrity of the card and affect the reading.”

“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 observational tour of the patient treatment area during the first shift on 07/10/2024, it was determined that the facility failed to maintain the facility to ensure safety of the patients, the staff and the public. Findings include: 1. During observation of the unit with ATOM 35 (employee#2) it was noticed that throughout the unit the flooring was in bad condition. The junction area between flooring panels was observed unglued permitting dust and liquid accumulation and permitting the growth of bacteria. 2. Un identified green spot was found between stations #5 and #6.”

“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 observational tour of the treatment area and personnel interview on 07/10/2024, with ATOM 35 (employe #2), it was determined that the facility failed to maintain a program to ensure that all equipment is maintained and operated in accordance with the manufacturer’s recommendations. The deficient practice could affect all patients. Findings include: 1. Approximately at 9:40 AM dialysis machine #26 was observed with water leak from bottom back part of machine creating a puddle of water. 2. After reviewing five dialysis machine preventive maintenance (PM) it was noticed that the PM on some machines did not have registered the operational hours on the worked performed. 3. Approximately at 10:30 AM three treatment chairs (#5, #9, #22) were observed with broken Vinyl on seats. 4. Treatment chai on station #4 was observed with broken footrest.”

“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 observation and interviews made during the survey on 07/10/24 with ATOM 35(Employee #2), it was determined that the facility failed comply with provisions of the Life Safety Code (NFPA 101). Findings include: 1. Unprotected wall penetrations were observed between the hemodialysis unit, waiting area and water warehouse area. 2. During the evaluation of the evacuation plan it was noticed that the exit pathway to the outside of the building did not have illumination to safeguard patients and staff during an emergency.”