Dialysis Center of Tiverton

“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: 41720 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to be maintained to provide dialysis patients, staff, and the public with a comfortable treatment environment, relative to garbage and other debris on the grounds of the facility. Findings are as follows: Review of a community reported complaint received at the Rhode Island Department of Health on 2/1/2024, alleges in part, “...the exterior of the building is not well maintained. The paint and facade are deteriorating, and on the west side of the building the paved area is breaking away and often times there is standing water in that area. Pine trees on the west side are not being trimmed at their base and therefore debris is being trapped in the lower branches...” Surveyor observation on 2/7/2024 at 8:25 AM of the exterior of the building revealed four visibly dirty surgical masks, discarded examination gloves, and other paper debris strewn about on the ground and in the shrubbery along the walkway leading to the facility. Further observations revealed additional discarded materials such as surgical masks on the ground and intertwined within the lower branches of a pine tree in the front of the building. During an additional surveyor observation on 2/7/2024 at 10:15 AM in the presence of the Facility Technical Manager (FTM), he acknowledged the above observations and indicated that he was aware that outside of the building has not been maintained but is unaware for how long. Additionally, he indicated that he is responsible for maintaining the building and the grounds. During a surveyor interview on 2/7/2024 at 12:00 PM with the Regional Technical Manager, he indicated that his expectation would be that all staff would monitor the outside of the building to ensure that the area is free of garbage and debris.”

“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: 41720 Based on surveyor observation, record review and staff interview, it has been determined that that facility failed to ensure that the acid bicarbonate distribution system was properly maintained (bicarbonate is added to the dialysis fluid during hemodialysis to replenish the buffers in the body and neutralize acid accumulation between dialysis treatments), for 1 of 1 bicarbonate storage tank observed. Findings are as follows: Review of the facility’s monthly maintenance documentation of the Acid/Bicarbonate Distribution System, states in part, “...The expectation is that systems will have little to no build up of precipitate [matter that forms on the exterior of the systems due to seepage of the contents]. External surfaces should be sprayed with vinegar and wipe down precipitate...” Surveyor observation on 2/7/2024 at 10:01 AM of the bicarbonate storage tank in the presence of the Facility Technical Manager (FTM), revealed a buildup of thick white, hardened crystallized matter approximately two inches wide, surrounding the entirety of the area where the drainage tubing and spigot of the tank connect. Further observation revealed multiple pieces of this white hard crystallized matter on the floor underneath the tubing and the spigot’s connection. During a surveyor interview immediately following the above-mentioned observation, the FTM indicated that the white hard crystallized matter is a build up of acid. Additionally, he revealed that he was aware of the built-up of acid precipitate and indicated it has been like that since he began working at the facility in early January of this year. During a surveyor interview on 2/7/2024 at 12:00 PM with the Regional Technical Manager, he indicated that his expectation would be that the acid/bicarbonate distribution system would be properly maintained.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 41720 Based on record review and staff interview, it has been determined that the facility failed to ensure that their grievance process was implemented and included a description of how the patient will be informed of the steps taken to resolve their grievance for 1 of 1 grievance reviewed. Findings are as follows: Review of the facility policy titled, “Grievance Process: Patients”, states in part, “...The Center Manager will keep a log of all patient complaints that are addressed and resolved without progressing to a formal grievance. The log should include the patient name, complaint, and date/details of complaint resolution. The Center Manager shall keep a log of all grievances that notes the date the grievance was initiated and the ongoing status of the grievance...” During a surveyor interview on 2/7/2024 at 11:25 AM with Patient ID #1, s/he indicated that s/he had discussed concerns s/he had regarding the lack of maintenance of the facility and the grounds with staff previously. Additionally, s/he indicated that s/he has not received any follow-up regarding the status of his/her grievance. Review of a document titled, “Complaint and Grievance Tracking Form”, revealed in part, that Resident ID #1 filed a grievance relative to “...messy parking lot; trash, lawns not well maintained...” in September of 2023. Further review revealed the resolution documented was, “...will speak with FTM to speak with lawn services/maintenance...” During a surveyor interview on 2/7/2024 at 12:52 PM with the Clinical Manager, she was unable to provide evidence of a resolution to the complaint that Patient ID #1 submitted in September of 2023. Additionally, she acknowledged that the outside of the building has not been maintained and that all staff are responsible for ensuring that garbage and debris are not littered about on the property grounds. Cross Reference V-401”