West Houston Dialysis Center

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 30124 Based on medical record review and interview, the facility failed to ensure it is in compliance with applicable Federal, State and local laws and regulations in that all patients admitted to the facility were seen by a physician once every two weeks, citing of 3 of of 6 (Patient ID#s 3, 8, 9) (whose clinical records did not include documentation of evidence that they were seen by a physician every two weeks. (Texas State Regulations determine the minimum visit schedule is every 14 days). Findings: During medical record review in the facility on 02/18/2025 along with Regional Manager, staff ID #D it was noted the physician failed to document progress notes every 14 days as required. Records Reviewed: Patient ID #3 Records documented a physician progress notes for the following dates in the patient’s records by physician ID #E did not meet every 14-day requirement: 11/16/2024 to 12/07/2024 Patient ID #8 Records documented a physician progress notes for the following dates in the patient’s records by physician ID #F did not meet every 14-day requirement: 12/17/2024 to 01/14/2024 Patient ID #9 Records documented a physician progress notes for the following dates in the patient’s records by physician ID #F did not meet every 14-day requirement: 11/19/2024 to 01/17/2025 Interview in the conference room on 02/18/2025 at 15:30 PM staff #D confirmed there was no documentation of every 2-week physician as required. No additional information was received prior to exit of the survey.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 30124 Based on record review and interview the facility’s medical director failed to ensure that staff adhear to all policies and procedures in that hemodialysis prescriptions were verified by the registered nurse within the first hour of treatment in 4 of 6 records reviewed (Patient ID #s 3, 4, 5, 6). The facility has a current incenter hemodialysis census of 67 patients. Policy Reviewed: Review on February 18, 2025, of the facility’s current policy titled “Nursing Supervision and Delegation”; Reference number 45265; Published 11/06/2023. Purpose: The purpose of the policy is to provide guidance regarding nurse supervision and delegation of tasks to other licensed and unlicensed staff in the outpatient setting. Policy: The registered nurse must evaluate each patient preferably within an hour or according to state requirements to: “ Review patient treatment prescription and equipment parameters to verify correct setting, and if dialysis prescription is being followed. “ Confirm that the correct vascular access is being used, and that the access is visible. Observe patient’s response to treatment. “ Verify machine safety checks have been completed. Records Reviewed: Review of selected medical records on 02/18/2025 along with Staff ID #D of 4 of 6 current hemodialysis records revealed no documentation was found that the registered nurse verified the hemodialysis prescription within the first hour of treatmnt on each of the records reviewed for patient ID#s 3, 4, 5 and 6. Interview: Interview in the conference room on 02/18/2025 at 16:00 PM with the clinic manager, staff #D confirmed there was no documentation from the registered nurse that the hemodialysis prescription was verified.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 35561 Based on observation, interview, and review of the facility’s policy, it was determined the facility failed to ensure two of five Patient Care Technicians (Patient Care Technician (PCT)1 and PCT5) who were observed during care delivery, implemented proper infection control measures during initiation of dialysis. Failure to use recommended infection control practices increases the risk for cross contamination and has the potential to expose patients and staff to blood-borne pathogens. This deficient practice had the potential to affect 58 facility patients currently receiving treatment in the dialysis unit. Findings include: On 03/27/24 at 3:55 PM, PCT 5 was observed initiating hemodialysis for an unidentified patient with peripheral access at Station 17. PCT 5 was observed cleansing the cannulation sites with an alcohol pad in one quick swipe lasting no longer than two seconds. Before cannulation, PCT 5 assessed the flow of the access by placing his/her fingers over the access multiple times in the same areas that had been disinfected. After palpation, PCT 5 then proceeded to cannulate the access in an alternate location that had not been disinfected. On 03/27/24 at 4:20 PM, PCT 5 was observed initiating hemodialysis for an unidentified patient with peripheral access at Station 16. PCT 5 was observed cleansing the cannulation sites with an alcohol pad in one quick swipe lasting no longer than 3 seconds. Before cannulation, PCT 5 assessed the flow of the access by placing his/her fingers over the access multiple times in the same areas that had been disinfected. PCT 5 then proceeded to cannulate the access without further cleansing. On 03/29/24 at 11:15 AM, PCT 5 was observed initiating hemodialysis for an unidentified patient with peripheral access at Station 17. PCT 5 was observed cleansing the cannulation sites with an alcohol pad in one quick swipe lasting no longer than three seconds. Before cannulation, PCT 5 assessed the flow of the access by placing his/her fingers over the access multiple times in the same areas that had been disinfected. PCT 5 then proceeded to cannulate the access without further cleansing. When questioned, PCT 5 stated that the access sites should be cleaned for “several seconds” and then allowed to dry. When asked if the access sites should be cleaned at the same time, or separately, PCT 5 stated “it depends on where the access is.” On 03/29/24 at 11:30 AM, PCT 1 was observed initiating hemodialysis for an unidentified patient with peripheral access at Station 2. PCT 1 was observed cleansing the entire peripheral access with one alcohol pad for 15 seconds. PCT 1 then proceeded to cannulate the access without further cleansing. When asked how long the access sites should be disinfected, PCT 1 stated “30 seconds ... isn’t that what I did? During an interview on 03/29/24 at 3:20 PM, these findings were discussed with the Clinic Manager and the Senior Director of Operations, at which time the Senior Director of Operations responded, “These observations do not meet the requirements of our infection control policy.” Review of the agency policy titled “Access Assessment and Cannulation,” dated 07/05/22, indicated, “Disinfect cannulation site as follows: 70% isopropyl alcohol pad: using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow to dry before cannulating .... Perform skin antisepsis on one site at a time, allow to dry and then cannulate. Do not touch cannulation sites after skin disinfection.””

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 35561 Based on observation, interview, and review of the facility’s policy, the facility failed to ensure that cleaning and disinfection of equipment taken into the dialysis station was completed properly and according to the facility’s policy for five of seven post dialysis treatment station disinfections observed being completed by four of five Patient Care Technicians (Patient Care Technician (PCT)1, PCT2, PCT3 and PCT5). Failure to use recommended infection control practices increases the risk for cross contamination and has the potential to expose patients, staff, and others to blood-borne pathogens. This deficient practice had the potential to affect all 58 patients receiving treatment in the dialysis unit. Findings include: On 03/27/24 at 11:00 AM, PCT2 was observed disinfecting the treatment station 20 after an unidentified patient had left the area. During the disinfection procedure, PCT2 was observed completing a quick wipe with a cleaning rag used for disinfecting the stethoscope while it remained hanging from the IV (intravenous) pole on the dialysis machine. This stethoscope was not removed for thorough cleaning and remained in place to be used on the next scheduled patient at this station. When asked when the stethoscope had been placed on the machine, PCT2 stated “We keep them on the machines all the time.” On 03/27/24 at 3:00 PM AM, PCT5 was observed disinfecting the treatment station 17 after an unidentified patient had left the area. During the disinfection procedure, PCT5 failed to clean or remove the stethoscope from the dialysis machine. This stethoscope remained in place to be used on the next scheduled patient at this station. On 03/29/24 at 9:35 AM, PCT3 was observed disinfecting the treatment station 14 after an unidentified patient had left the area. During the disinfection procedure, PCT3 failed to clean or remove the stethoscope from the dialysis machine. This stethoscope remained in place to be used on the next scheduled patient at this station. On 03/29/24 at 10:50 AM, PCT1 was observed disinfecting the treatment station 2 after an unidentified patient had left the area. During the disinfection procedure, PCT1 failed to clean or remove the stethoscope from the dialysis machine. This stethoscope remained in place to be used on the next scheduled patient at this station. On 03/29/24 at 10:55 AM, PCT1 was observed disinfecting the treatment station 3 after an unidentified patient had left the area. During the disinfection procedure, PCT1 failed to clean or remove the stethoscope from the dialysis machine. This stethoscope remained in place to be used on the next scheduled patient at this station. During an interview on 03/29/24 at 11:30 PM, PCT1 was asked about why the stethoscopes were kept on each of the dialysis machines. PCT1 stated, “so we can listen to the patient’s access before we put the needles in.” When asked what the facility policy was on disinfecting the stethoscopes, PCT1 stated, “We are supposed to wipe them after each run.” Review of the facility’s policy titled “Cleaning and Disinfecting the Dialysis Station,” dated 09/05/23 indicated, “The dialysis station could become contaminated with blood and other body fluids during treatment. After use, any non-disposable equipment and supplies brought into the dialysis station (ex. Stethoscope), must be disinfected with 1:100 bleach of EPA [Environmental Protection Agency] registered disinfectant.””

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 35561 Based on record review and interview, the facility failed to monitor the implementation of infection control policies and activities within the dialysis unit. The failure to observe staffs adherence to infection control policies has the potential to allow the spread of infections among the 58 patients who were currently receiving dialysis services. Findings include: Review of the facility’s infection control monitoring and staff infection control audits for the last 12 months were reviewed. The documentation provided failed to reveal any infection control observations or monitoring for the months of 4/23, 5/23, 6/23, 7/23, 8/23, 9/23, 10/23, 11/23 or 12/23. Review of the “Clinic Audit Checklists” provided by the Clinical Manager dated “01-Jan-24 to 28-Mar-24”, reflected scores at 100% for one or two observations per month. The 100% scores did not document what type of practices were observed or the checklists used to determine these scores. Interview on 03/28/24 at 3:05PM with the Clinic Manager was asked to provide the worksheets which were used for the direct observations, the Clinic Manager stated that he/she was unable to provide the worksheets. When asked for documentation of observations documented before January 2024, the Clinic Manager stated, “I did not document.” During an interview on 3/28/24 at 3:40 PM, the Senior Director of Operations confirmed these findings and stated, “we are unable to retrieve any documentation of direct observations of infection control practice.” A policy reflecting the facility’s process for infection control audits, direct observation of infection control practices or infection control monitoring was requested on 03/28/24 of the Senior Director of Operations, however, was not provided. The policy was requested again on 3/29/24 at 1:00 PM at which time the Senior Director of Operations stated that there was no infection control monitoring policy available to review.”

“IC-STAFF REPORT IC ISSUES CFR(s): 494.30(b)(3) [The facility must-] (3) Require all clinical staff to report infection control issues to the dialysis facility ’ s medical director (see § 494.150 of this part) and the quality improvement committee. This Standard is not met as evidenced by: 18750 Based on record review, interview, document review and facility policy review, the facility failed to ensure patient infections were reported to the quality assurance performance improvement program (QAPI) for two of six patients (Patient (P) 11 and P14) reviewed for infections. This deficient practice had the potential to affect 58 patients who may develop an infection that is not get reported and discussed in QAPI. Findings include: Review of the facility’s policy titled, “Infection Control Overview,” dated 05/02/22 revealed, “Purpose: The purpose of this policy is to provide an overview of the bloodborne pathogen control requirements that each facility shall meet. . . Policy General. . .The facility will monitor the effectiveness of the infection control program through the Quality Assessment and Performance Improvement Program. . .” Review of the facility’s policy titled “Quality Assessment and Performance Improvement Program, dated 05/02/22 revealed “Policy. . . Quality improvement is everyone’s responsibility’ and encompasses BOTH the QAPI committee and all facility and program staff. . .” 1. Review of P11’s “Nursing Progress Notes,” provided by the facility revealed an admission date of 07/03/23 with diagnoses of atrial- fibrillation, end stage renal disease (ESRD), chronic obstructive pulmonary disease (COPD), and urinary tract infection. Review of hospital discharge provided by the facility, revealed on 08/10/23, P11 was admitted into the hospital with sepsis secondary to infected dialysis catheter with Staphylococcus epidermidis. P11 returned to the facility for dialysis with orders dated 08/21/23 provided by the facility for Vancomycin 750 milligrams (mg) intravenous during dialysis three times a week for 12 weeks. Review of the “August 2023 National Healthcare Safety Network (NHSN) Event Information report” revealed P11 was started on Vancomycin for an infection. Review of the “Infection Control log” presented by the facility revealed P11 was listed on the “Infection Control Log” with an infection of the central venous catheter (CVC). During an interview on 03/28/24 at 11:30 AM, the Clinical Manager was asked about infections for the last 12 months. The Clinical Manager said the last infection they had was in July of 2023. There were no other infections. She was asked about the NHSN report and P11 having an infection in August of 2023. The Clinical Manager stated, “The infection was found at the hospital. We do not count it because it was not here.” The Clinical Manager was asked if the infection was reviewed in QAPI. The Clinical Manager stated, “No.” 2. Review of P14’s, “End Stage Renal Disease Medical Evidence Report. . .” provided by the facility revealed P14 was admitted to the facility on 11/12/18 with diagnoses of hypertension, diabetes, and congestive heart failure. Review of the “Nurses Progress Notes” provided by the facility revealed on 01/17/24 the Charge Nurse noted an order for vancomycin one gram per medical doctor. Review of P14’s “Physician Orders,” provided by the facility revealed on 01/19/24, Vancomycin 1000 mg intravenous during dialysis three times a week times three times for an infection of P14’s leg. Review of the “January 2024 NHSN Event Information reports” revealed P14 was started on Vancomycin for an infection at the site of the fracture. Review of the “Infection Control log” presented by the facility revealed no infections for January 2024. During an interview on 03/28/24 at 11:30 AM, the Clinical Manager was asked about the NHSN report and P14 having an infection in January 2024. The Clinical Manager stated, “I was not aware of the infection.” The Clinical Manager was asked if it was reviewed during the QAPI. The Clinical Manager stated, “No.” During an interview on 03/29/24 at 8:25 AM, the Charge Nurse was asked about P14’s infection. The Charge Nurse stated, “The patient had a fracture and developed an infection at the fracture site. The patient was started on Vancomycin.” The Charge Nurse was asked if P14’s infection was placed on the infection log. The Charge Nurse looked at the log and stated, “I forgot.” On 03/28/24 at 12:11 PM, the Director of Operations was asked if an infection of one of the patients should have been reported in QAPI. The Director of Operations stated, “Yes. All infections should be reviewed in QAPI.””

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 18750 Based on record review, interview, and review of the facility’s policy, it was determined the facility failed to maintain, and evaluate an effective, data-driven, quality assessment and performance improvement (QAPI) program with infection prevention and control. Failure to maintain an accurate Infection Control Surveillance program that included all patients’ infections had the potential to allow infection control concerns to be unidentified and would not assist the facility to improve health outcomes and the prevention and reduction of infections. This had the potential to affect the 58 patients who were currently receiving dialysis services. Findings include: Review of the facility’s policy titled, “Quality Assessment and Performance Improvement Program,” with a publish date of 05/02/22 revealed, “Purpose: This policy outlines the purpose, structure, and required activities of the facility Quality Assessment and Performance Improvement (QAPI) Program. . .QAPI committee Responsibilities. . . Clinical Manager (CM) Charge Nurse II. . . Measuring, analyzing, and tracking quality indicators or other aspects of the performance that the facility adopts or develops that reflect processes of care and facility operations. . . QAPI Meeting Objectives: The QAPI Committee will monitor data/information; prioritize area for improvement; determine root causes; develop, implement, evaluate, and revise action plans that result in sustainable improvements in patients care. Elements to be reviewed will include. . . Infection Surveillance. . .” Review of the “National Healthcare Safety Network (NHSN) Event Information report” for August 2023 revealed Patient (P)11 was started on Vancomycin for an infection. Review of the January 2024 “NHSN Event Information reports” revealed P14 was started on Vancomycin for an infection. During review of the “Infection Prevention and Control Log” for the past 12 months, March 2023 through February 2024, indicated Patient (P)1 had an infection of the central venous catheter (CVC) and was to receive Vancomycin 750 milligrams (mg) three times a week for 12 weeks. P14 did not appear on the log for January 2024. During an interview on 03/28/24 at 11:30 AM, the Clinical Manager was asked about infections for the last 12 months. The Clinical Manager said the last infection they had was July 2023. There were no other infections. During an interview on 03/29/24 at 8:25 AM, the Charge Nurse was asked about the infection tracking and trending. The Charge Nurse stated that the Infection Control log was used to keep track of patients’ infections. The Charge Nurse was asked about P11’s infection in the CVC. The Charge Nurse stated that P11’s infection was found when P11 was in the hospital. When P11 returned to the facility. there was an order to start the patient on Vancomycin. The Charge nurse was asked about P14 not being added to the Infection Control log after starting Vancomycin. The Charge Nurse stated, “I forgot.” The Charge Nurse was asked if this information went to the QAPI meeting. The Charge Nurse stated this information should be provided during the QAPI meeting and documents presented. During review of the QAPI program meeting minutes, there were no infections indicated for the months of August 2023 or January 2024. During an interview on 03/28/24 at 12:11 PM, the Director of Operations was asked if an infection of one of the patients should have been reported in QAPI. The Director of Operations stated, “Yes. All infections should be reviewed in QAPI.” During an interview on 03/29/24 at 1:20 PM, Area Team Lead and Senior Director of Operations confirmed all suspected and confirmed infections should be reviewed in QAPI for tracking and trending.”