Davita Marymont Dialysis Center

“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: 26190 Based on document review, interview and policy review the facility staff failed to conduct Emergency Preparedness (EP) exercises to test the emergency management plan annually by holding a full scale exercise that was community based or a table top exercise on yearly basis for the past two years. This failure had the probability to negatively impact all 84 patients currently dialyzing at the facility. Findings include: Review of the facility’s “Emergency Management Plan” binder indicated a “Training/Inservice Documentation Form” dated 08/2006 stated, “ 2 Type of Training Inservice: Emergency Preparedness.” The form included the names and signatures of 10 Facility Administrators that were dated on 05/24/24 and 05/26/24. This form was the only documented participation in an emergency preparedness training for the facility for the past two years. During an interview on 11/01/24 at 9:55 AM with the Facility Administrator, confirmed he did not have any written information regarding what was covered in the training during May of 2024. The Facility Administrator said this training was considered an EP community based exercise/training. The Facility Administrator stated that he/she did not relay the EP information that was covered at the training to the facility staff. During an interview on 11/01/24 at 10:05 AM with the Manager Clinical Services (MCS), stated the training in May of 2024 was provided by the Southwest Texas Regional Advisory Council. During the exit conference on 11/01/24 at 2:15 PM the MCS stated they should have documentation of an emergency preparedness exercise/training for 2023. An EP exercise/training was not provided prior to the surveyors’ exiting the building at 2:30 PM. Review of the facility’s policy titled, “Facility Emergency Management Plan” revised 04/24 stated, “ ...Policy Goal The Governing Body shall establish and maintain a facility specific Emergency Management Program ...designed to manage the consequences of emergencies and disasters that may disrupt the facility’s ability to provide patient care ...Emergency Drills 1. The FA (Facility Administrator) of designee, will maintain the emergency preparedness training and testing based on the facility EMP (Emergency Management Plan) 2. EMP training exercises: ...d. Testing exercises must be based on the facility’s identified hazards, to include natural or manmade disasters. e. Frequency: i. The facility will conduct and/or participate in one (1) exercise to test the facility EMP at least ANNUALLY, conducted on OPPOSITE years (one year full-scale exercise, next year facility based/exercise of choice): 1. Full-scale exercise that is community-based: ...b. Defined as an operations-based exercise that typically involves multiple agencies, jurisdictions, and disciplines ...c. Participation with any of the following: i. Emergency management agency, ii. Local, state, and/or federal emergency response agencies iii. Healthcare coalition 2. Individual facility-based exercise: a. Tabletop exercise that includes a group discussion led by the FA b. Scenario situation must be based on hazards relevant to facility c. Designed to challenge facility EMP d. Actions taken will be simulated and not disrupt patient treatments e. Facility may choose to participate instead in a full scale community based exercise ...””

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 27438 Based on observations, interview, and policy review, the facility failed to ensure staff wear personal protective equipment (PPE-used to prevent potential exposure) appropriately during initiation of dialysis treatment for two of three survey days. Failure to ensure proper use of disposable gowns provided a mode of cross contamination with the potential spread of infection which could negatively impact patients receiving dialysis treatments in this facility. Findings include: 1. Observations of the hemodialysis treatment area on 10/30/24 at 10:20 AM, revealed Licensed Vocational Nurse (LVN)1 initiating Central Venous Catheter (CVC-(type of fixed access used for hemodialysis patients) access for Patient (P)1 at Station 13. LVN1’s lower torso was exposed during initiation of treatment when the disposable gown lower two closure snaps were left open. During an interview on 10/30/24 at 10:35 AM, LVN1 verified his/her gown had not been completely snapped and closed prior to patient care and that the facility policy is staff are to ensure the staff wore his/her disposable gown completely snapped and closed during the initiation treatment to provide protection from blood and other fluids during initiation of treatment. 2. Observations of the hemodialysis treatment area on 10/30/24 at 10:45 AM, revealed LVN2 initiating CVC access for P5 at Station 15. LVN2’s lower torso was exposed during initiation of treatment when the disposable gown lower one closure snaps were left open. During an interview on 10/30/24 at 11:00 AM, LVN2 verified his/her gown had not been completely snapped and closed the prior to patient care and that the facility policy is staff are to ensure the staff wore his/her disposable gown completely snapped and closed during the initiation treatment to protection from fluids during initiation of treatment. 3. Observations of the hemodialysis treatment area on 10/31/24 at 1:00 PM, revealed Registered Nurse (RN)1 discontinuing CVC access for P8 at Station 23. RN1’s lower torso was exposed during initiation of treatment when the disposable gown lower three closure snaps were left open. During an interview on 10/31/24 at 1:10 PM, RN1 verified his/her gown had not been completely snapped and closed the prior to patient care and that the facility policy is staff are to ensure the staff wore his/her disposable gown completely snapped and closed during the initiation treatment to protection from blood during initiation of treatment. Review of the facility’s policy/procedure titled, “Infection Control For Dialysis Facilities,” revision date April 2023, indicated, “Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas...Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates...””

“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: 27438 Based on observation, interview, and review of policy, the facility failed to ensure that each patient treatment chair was appropriately disinfected for the next patient’s use. This deficient practice had the potential to cause harm by transmission of bloodborne pathogens (infectious microorganisms in human blood that can cause disease in humans) from one patient to another in seven of 24 dialysis stations, which could negatively impact patients receiving incenter dialysis treatments in this facility. Findings included: During observations on 10/31/24 between 10:00 AM and 2:00 PM, reclining treatment chairs at Stations 1, 4, 6, 11, 17, 19, and 22 were observed to have multiple tears and cracks in seats and/or arm rests of the non-permeable (does not allow liquid to pass through) material. The reclining treatment chairs are used for multiple patient treatments and to be cleaned and disinfected at the end of each treatment. During an interview on 10/31/24 at 11:20 AM, Manager of Clinical Services confirmed the observation of multiple tears and cracks in the seats and/or arm rests at Stations 1, 4, 6, 11, 17, 19, and 22. The Manager of Clinical Services verified the staff would be unable to fully disinfect the reclining treatment chairs at the end of the treatment. The Manager of Clinical Services stated the facility had multiple chairs on order, however, the ordered chairs had not been received. Review of a provided vendor requisition indicated, “Dialysis Equipment Furniture,” dated September 22, 2023, indicated, “six units ordered.” During an interview on 10/31/24 at 1:50 PM, the Facility Administrator confirmed the treatment chairs ordered on September 22, 2023, had not been delivered or reordered. Review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” revision date April 2023, indicated, “Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or potentially infectious materials ...surfaces to disinfect include but are not necessarily limited to ...dialysis chair.””

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 27438 Based on observations, interview, and policy reviews, the facility failed to ensure facility staff used personal protective gowns (used to decrease risk of contamination) correctly when Central Venous Catheters (type of assess used in dialysis (CVC) care is provided for one of two observations. Failure to ensure proper use of protective gowns provided a mode of cross contamination with the potential spread of infection which could negatively impact all CVC patients receiving dialysis treatments in this facility. Findings include: Observations of the hemodialysis treatment area on 10/30/24 at 10:20 AM, revealed Licensed Vocational Nurse (LVN)1 initiating CVC access treatment for Patient (P)1 at Station 13. LVN1 failed to ensure the protective gown sleeve covered his/her dangle bracelet and prevented it from dragging across the clean moisture proof barrier, when the CVC lines are open and exposed to potential contamination. During an interview on 10/30/24 at 10:30 AM, LVN1 confirmed the dangle bracelet should be covered by the gown sleeve during CVC treatment initiation. LVN1 confirmed he/she was aware of the facility policy that requires staff to ensure protective gowns are used appropriately during CVC procedures. Review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” revision date April 2023, indicated, “Appropriate fluid resistant/fluid impervious (not allowing fluid to pass through) gowns will be worn by all teammates...when caring for the patient or touching the patient’s equipment at the dialysis station.””

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 27438 Based on observation, interviews, and policy review, the facility failed to ensure patient’s hemodialysis access site was uncovered and visible for one of three days of the survey. The dialysis access site (tubing/needle insertion sites and line connections) for all patients on treatment must always be visible to staff to ensure the lines and tubing/needles do not become dislodged or disconnected and could affect all 84 hemodialysis patients receiving treatment in the facility. Findings include: Observations on 11/01/24 between 9:20 AM and 9:40 AM, revealed the Patient (P)8 at Station 5 had his/her dialysis access site covered by a blanket. During an interview on 11/01/24 at 9:42 AM, the Certified Clinical Hemodialysis Technician (CCHT)1 acknowledged that P8’s access should always be uncovered for safety purposes. During an interview on 11/01/24 at 9:40 AM, the Facility Administrator acknowledged the staff are to ensure patient access is to be visible during treatment. Review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment,” revision date April 2024, indicated, “The vascular site, blood line connections and the patient’s face should be visible throughout the dialysis treatment.””