Davita Nashville Home Training Dialysis Pd

“IC-HBV-TEST PTS/STAFF POST LAST DOSE CFR(s): 494.30(a)(1)(i) Hepatitis B Screening: Patients and Staff Test all vaccines [patients and staff] for anti-HBs 1-2 months after last primary vaccine dose. -- If anti-HBs is <10 mIU/mL, consider patient or staff member susceptible, revaccinate with an additional three doses, and retest for anti-HBs. -- If anti-HBs are =10 mIU/mL, consider immune, and retest patients annually. -- Give booster dose of vaccine to patients if anti-HBs declines to <10 mIU/mL and continue to retest patients annually. This Standard is not met as evidenced by: 46831 Based on policy review, employee file review, and interview, the facility failed to initiate a screen for the Hepatitis B surface antigen (HBsAg) and Hepatitis B surface antibody (Anti-HBs) for 1 of 9 (RN #1) sampled staff. The findings included: Review of the facility policy “Teammate Hepatitis B Monitoring and Follow-Up Guidance” revised 4/2024, revealed, “ ...New teammates who are not able to provide documentation of hepatitis B surface antibodies of 10 mIU/ml or greater from any time in the past, regardless of documentation indication completion of the hepatitis B vaccine series, will be screened for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) within 10 days and offered the vaccination as indicated by their results ...” Review of the employee file for RN #1 on 6/16/2025, revealed no HBsAb test had been initiated within 10 days of starting employment at the facility. During an interview on 6/16/2025 at 2:00 PM, the FA stated, “ ...This occurred during the cyber breach ...I thought she [RN #1] had been tested, but it somehow got lost in the midst of all this ...” When asked if the RN should have been tested, the FA stated, “Yes.””

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 46831 Based on facility policy, observation, and interview, the facility failed to ensure medications and supplies were discarded before their expiration date for 1 of 2 (PD Room 1) PD rooms and 1 of 1 medication rooms on 1 of 2 observation days. The findings included: 1. Review of the facility policy “Medication Policy” revised 11/2023, revealed, “...Do not use any medication that has been stored improperly or has expired ...Medications containing a preservative must be discarded 28 days after opening or accessed...Medications are ordered and replaced prior to expiration...” 2. Observation in the medication room on 06/16/2025 at 9:44 AM, revealed two (2) blood culture kits (two bottles used to collect blood to detect bloodstream infections) with expiration date of 5/9/2025. Observation in the PD treatment room 1 on 06/16/2025 at 9:57 AM, revealed one (1) tube of Gentamicin Sulfate Cream 0.1% (a cream used to treat skin infections caused by certain bacteria) dated 10/23/2024. 3. During an interview on 6/16/2025 at 9:50 AM, the FA stated, “These [Blood culture kits] should not be here. They are expired.” The FA stated the Gentamicin cream was good for 28 days and should have been discarded.””

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas must meet one of the following: *Contain 1 hour rated enclosure when non-sprinklered *Sprinkler protected with smoke resistive separation *Severe Hazard locations contain sprinkler protection and 1 hour separation with 3/4 hour rated self-closing doors 20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7 This Standard is not met as evidenced by: 36006 Based on observations, the facility failed to protect 1 hazardous area. The findings included: Observation on 06/16/2025 at 10:30 AM, revealed the storage room door held open with a box. NFPA 101, 21.3.2.1 (2012 Edition) NFPA 101, 21.2.2.4 (2012 Edition) The Biomedical Technical was present when these findings were identified, and the Administrator acknowledged these findings during the exit conference on 06/16/2025.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 21.7.1.4 through 21.7.1.7 This Standard is not met as evidenced by: 36006 Based on document review, the facility failed to conduct 2 fire drills. The findings included: Document review on 06/16/2025 at 11:04 AM, revealed the facility failed to provide documentation of fire drills conducted during 1st and 3rd quarters of 2024. NFPA 101, 21.7.1.6 (2012 Edition) The Administrator was present when these findings were identified and the Administrator acknowledged these findings during the exit conference on 06/16/2025.”

“Maintenance, Inspection & Testing - Doors CFR(s): This Standard is not met as evidenced by: 36006 Based on document review, the facility failed to inspect the fire doors. The findings included: Document review on 06/16/2025 at 10:01 AM, revealed the facility failed to provide documentation of a fire door inspection conducted during 2024. Last documented inspection was dated 11/23/2023. NFPA 101, 21.7.6 (2012 Edition) NFPA 101, 4.6.12 (2012 Edition) NFPA 101, 5.2.1 (2010 Edition) The Biomedical Technician was present when these findings were identified and the Administrator acknowledged these findings during the exit conference on 06/16/2025.”