Guadalupe Kidney Disease Cl

“CFC-PERSONNEL QUALIFICATIONS CFR(s): 494.140 This Condition is not met as evidenced by: 34839 Based on employee file review and staff interviews, the facility failed to maintain current documentation to demonstrate personnel met the basic requirements of their assigned roles. Specifically, 3 of 3 facility float pool staff (Personnel #12, #13, and #14) did not have documented evidence that they had the competencies and the skills required to perform hemodialysis, initiate and/or terminate hemodialysis treatments of patients with CVCs (central venous catheter), water checks, and dialysis machine training. Refer to tag V681 for specific evidence. Based on record review and interview, the facility failed to maintain current documentation to demonstrate personnel met the basic requirements of their assigned roles, in that the 5 of 5 staff (Personnel #1, #2, #3, #4 and #5) did not have documented evidence that they had the competencies and the skills required to perform hemodialysis, and initiate and/or terminate hemodialysis treatments of patients with CVCs (central venous catheter), water checks, and dialysis machine training. Findings included: ~The facility failed to ensure that the staff demonstrated the competencies and skill necessary to serve collectively the comprehensive needs of the patients, citing 5 of 5 staff (Personnel #1, #2, #3, #4 and #5) who did not have documented evidence that they demonstrated competencies and skill required to perform hemodialysis, and initiate and/or terminate hemodialysis treatments of patients with CVCs (central venous catheter), water checks and dialysis machine training. Cross refer to V tag 681. Based on record review and interview, the facility failed to maintain current documentation to demonstrate personnel met the basic requirements of their assigned roles, in that the 5 of 5 staff (Personnel #1, #2, #3, #4 and #5) did not have documented evidence that they had the competencies and the skills required to perform hemodialysis, and initiate and/or terminate hemodialysis treatments of patients with CVCs (central venous catheter), water checks, and dialysis machine training. Findings included: ~The facility failed to ensure that the staff demonstrated the competencies and skill necessary to serve collectively the comprehensive needs of the patients, citing 5 of 5 staff (Personnel #1, #2, #3, #4 and #5) who did not have documented evidence that they demonstrated competencies and skill required to perform hemodialysis, and initiate and/or terminate hemodialysis treatments of patients with CVCs (central venous catheter), water checks and dialysis machine training. Cross refer to V tag 681.”

“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: 34839 Based on observation, policy and procedure review and staff interview, the facility staff failed to ensure a clean and sanitary environment was monitored and maintained to minimize the transmission of infectious agents in the patient lobby, in-center treatment area, supply room; and in accordance with the facility’s policy titled, “General Cleanliness and Infection Control Guidelines”. This deficient practice had the likelihood to result in the transmission of infectious agents within the unit and between patients, staff members, and members of the public. Findings included: During a tour of the facility on 4/15/24 the following infection control issues were observed: In-Center Treatment Area Observations conducted on 4/15/2024 from 1029 to 1128 revealed: 4 out of 4 patient treatment chairs observed with heavy amount of white dry splatter and dust on the chair frame and white dry splatter on the back of the chairs. The Director of Operations stated on 4/15/24 at 11:02, “We’re going to have a huddle. We’re going to rewipe all the chairs.” Exposed wood and paint peeling and cracked on the chase boxes and walls throughout the treatment area. Director of Operations directed staff to correct findings during observations. Review of the facility’s policy titled, General Cleanliness and Infection Control Guidelines, Published 02/07/2022 indicated, in part: All areas must be kept clean and organized, including but not limited to the treatment area, water/supply room, and offices. Walkways must be kept clear of debris and free of clutter. Facilities must adhere to any state-specific regulations that pertain to facility cleaning and disinfection. Eating, drinking, applying cosmetics or lip balm, and handling contact of lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets, or on countertops or bench tops where blood or other potentially infectious materials are present . Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff. Such cleaning should be done regularly using a schedule developed by the facility. Supplies or patient’s belongings should not be kept or stored behind the machine at the patient station . All containers for storage or disposal of needles/sharps shall be replaced on a regularly scheduled basis or when no more than 2/3 to 3/4 full. The Centers for Disease Control (CDC) defines a “sanitary environment” as an environment that meets the “Standard Precautions” for an inpatient hospital setting plus the more stringent precautions which are recommended for Hemodialysis units because of the increased potential for contamination with blood and pathogenic microorganisms.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 34839 Based on staff file review and staff interview, the facility failed to ensure that staff met personnel qualifications and demonstrated competencies before providing dialysis treatment. The dialysis facility staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. The findings included: Review of staff files on 4/15/24 at 12:30 p.m. in the facility conference room revealed 3 of 3 facility float pool (Personnel #12, #13, and #14) files reviewed lacked evidence of staff annual skills check off prior to providing patient care in the facility. 3 of 3 facility float pool staff files (Personnel #12, #13, and #14) reviewed did not contain current in center hemodialysis competency skills checklists and competency skills for the patient care equipment used in the facility. Surveyors asked the Director of Operations if staff files are complete. Director of Operations stated on 04/16/24 1041 “This is what I have access to. Yes, this is all I have access to.” Surveyors asked if staff #13 does water checks. “She’s doing my water, yes. Without a color blindness, yes.” Confirmed with Director of Operations facility uses dialysis machines T Machines with Bibag. 3 out of 3 facility float pool staff members(Personnel #12, #13, and #14) that have worked at the facility did not train on these machines. Regarding the dialysis machines that facility staff are checked off as able to demonstrate skills, the Director of Operations stated on 4/16/24 at 1220 “It depends where they’re getting them done. It depends what clinic they’re getting skills checked off.” Surveyors presented current annual skills checklist of a staff member and asked the Director of operations if the 3 facility float pool (Personnel #12, #13, and #14) have that certificate. On 4/16/24 the Director of Operations stated at 1220, “A certificate like that? No.” Surveyors confirmed with biomedical staff member, Staff #6 that staff had specific training for dialysis machines using Bibag, stated on 4/16/24 at 1304 “Yes, LMS (Learning Managment System) Bibag.” Confirmed with Clinical Services Specialist on 4/16/24 around 1300 that 3 out of 3 facility float pool staff members (Personnel #12, #13, and #14) home dialysis facilities did not have same dialysis machines as facility surveyed.”