Usrc Greenville

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(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:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 41743 Based on record review and interview, the dialysis facility failed to provide an updated staff contact list. The finding includes: Review of facility’s Emergency Preparedness Plan (EPP) on 11/15/2023 at 12:00 PM revealed there was no documentation for some staff members’ contact information. On 11/15/2023 at 12:39 PM, Registered Nurse (RN) #5 reported “Not all names ...doesn’t work here anymore” and verified the finding.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 41743 Based on record review and interview, the dialysis facility failed to perform test exercises to test their emergency plan for the past 2 years. The finding includes: Review of facility’s Emergency Preparedness Plan (EPP) on 11/15/2023 at 12:00 PM revealed there was no documentation of emergency drills performed or natural disaster drills recorded for the past 2 years. On 11/15/2023 at 12:39 PM, Registered Nurse (RN) #5 reported “No drills done, only in-services” and verified the finding.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 41743 Based on observation, interviews, and review of the facility policies, entitled, “Infection Control” and “Precautions for All Patients”, “Intradialytic Monitoring of Patient”, the facility failed to ensure staff changed wet external transducer protectors in a timely manner and 1 of 1 Patient Certified Technician (PCT) #3. The finding includes: Observations on 11/15/2023 at 10:37 AM in dialysis station 24 at dialysis machine 22 revealed an external transducer protector wet with red fluid. Registered Nurse (RN) #3 was observed in the dialysis station at 10:40 AM, but failed to change the wetted external transducer protector. The end of treatment was 11:05 AM, and observations showed PCT #3 performed rinse back and ended the patient’s dialysis treatment. At 11:37 AM, PCT #3 removed all dialysis tubing from the dialysis machine, but failed to observe the machine side of the wetted external transducer protector. When the surveyor observed the machine side of the wetted external transducer protector, it was dry and clear. When PCT #3 was interviewed at 11:40 AM on 11/15/2023, PCT #3 reported “Was at the end of treatment if we see red in the windows, we alert Biomed and take it out of use.” When asked if the machine side of the external transducer protector does not show wetness, PCT #3 gave the same answer. On 11/15/2023 at 1:40 PM, the Facility Administrator reported “If the back is not wet, it does not need to come off of the floor.” Facility policy, entitled, “Infection Control and Precautions for All Patients”, revealed, “If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination”. Policy entitled “Intradialytic Monitoring of Patient” reveals, “If transducer filter becomes wet, replace immediately. Inspect the side of the protector that faces the machine. If fluid is visible, biomed technician will be notified and machine taken out of service after dialysis treatment is completed.””

“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: 22313 Based on observations, record reviews, and interview, the facility failed to ensure that accepted principles for Infection Control practices are in place to prevent potential cross contamination in the renal setting for 4 of 4 Registered Nurses. (Registered Nurse (RN)#1, RN#2, RN#3 and RN#4) The findings are: Observations on 11/15/2023 from 0900 AM - 1:00 PM revealed staff failed to sanitize the stethoscopes used to assess patients between patients. Registered Nurse (RN)#1, RN#2, RN#3 and RN#4 placed the stethoscope around their necks after using it to auscultate patients, and then returned the stethoscope around their necks without sanitizing it between patient use or neck-wear. .” The findings were verified with the Facility Administrator in an interview on 11/15/23 at 2:00 PM.”

“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: 41743 Based on observation, interviews, and the facility policy, entitled, “Guidelines for Administration of Medication”, the facility failed to ensure expired and/or unlabeled medications are removed and that staff follow best practices for administering medications. The findings include: Observations on 11/13/2023 from 9:04 AM to 10:30 AM revealed: Korsuva 32 vials expired 10/2023. Observations on 11/13/2023 from 9:04 AM to 10:30 AM revealed 9 syringes 25 gauge 5/8 expired 07/31/2023, glucose test strip bottle expired 10/25/2023, 1 green top lab tube expired 08/31/2021, and lying on top of dialysis machine #17, 3 used needles with covers left unattended, and Alcohol pad, soiled gloves, papers, and used test strips noted strewn on the floor. Observations in Pod 1 and 2 on 11/14/2023 from 10:10 AM to 12:10 PM revealed medication carts unlocked, open multi-dose vial labeled Heparin had no label for the date when opened and was left unattended on top of the medication cart. Observations in Pod 3 showed 8 pre-filled syringes labeled Heparin without the preparer’s initials or time prepared and left unattended on the counter top. Registered Nurse (RN) #4 was observed preparing medications and failed to sanitize the septum of the multi-dose vial prior to inserting the needle. Observations on 11/15/2023 from 10:00 AM to 11:42 AM revealed an unlocked medication cart in Pod 2 that contained 11 pre-filled syringes labeled Heparin without the preparer ’ s initials or time prepared and open multi-dose vials of Heparin with no date when opened. In Pod 3, observations revealed 3 pre-filled syringes labeled Heparin that was left unattended on the counter top. Water standing on the floor under dirty and clean sinks in Pod 2. Water standing on floor under dirty sink in Pod 3. On 11/15/2023 at 1:30 PM, the Facility Administrator reported he/she has “Been doing in-services.” Facility policy, entitled, “Guidelines for Administration of Medication”, revealed, “Medication(s) will be secured in a locked cabinet except for the emergency medication supply ...Open only one vial of any specific multi-dose medication at a time. Date and initials vials when opened as a point of reference for staff utilizing the medications ...Label pre-drawn medications with the patient ’ s name, medication name, dose, date, time and preparer ’ s initials ...Ensure all supplies, medications and testing strips are checked at least monthly for expiration. Ensure expired items are discarded appropriately ...”.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 22313 Based on record review, policy entitled “Prescription/Orders” and interview, the dialysis facility failed to follow physician instructions regarding high Blood Pressures (BP) at end of treatments for 4 of 10 patient charts. (Patient #2, #3, #5 and #9). The finding includes: Chart review for Patient #2 on 11/14/2023 at 9:00 AM revealed: Post treatment sitting BP on 11/04/2023 of 190/108 and on 10/14/2023 of 188/90. There was no documentation that the physician was notified per standing orders. On 11/14/2023 at 1:55 PM, the Facility Administrator reported staff have been trained to report the findings and verified the findings. Chart review for Patient #3 on 11/14/2023 at 9:40 AM revealed: Post treatment sitting BP on 11/09/2023 of 189/108 and on 10/31/2023 of 206/122. There was no documentation that the physician was notified per standing orders. On 11/14/2023 at 1:40 PM, the Facility Administrator reported staff have been trained to report and verified the findings. Chart review for Patient #5 on 11/14/2023 at 1:05 PM revealed: Post treatment sitting BP on 11/04/2023 of 197/72. There was no documentation that the physician was notified per standing orders. On 11/14/2023 at 2:18 PM, the Facility Administrator reported staff have been trained to report and verified the findings. Chart review for Patient #9 on 11/13/2023 at 3:00 PM revealed: Post treatment sitting BP on 10/31/2023 of 208/100. There was no documentation that the physician was notified per standing orders. On 11/14/2023 at 2:40 PM, the Facility Administrator reported staff have been trained to report and verified the findings. Facility policy/orders, entitled, “Prescription/Order”, revealed, “Hypertension ...Notify MD(Medical Doctor) if post sitting systolic BP> (greater than)180 mmHg (millimeters/Mercury)”.”