Usrc Pearland Luxury Dialysis

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility governing body failed to ensure all staff participated in quarterly fire drills in the facility in 2 of 5 personnel files reviewed: Biomedical Technician (E) and Social Worker (F) Findings: Review of facility’s current policy and procedure on Fire Prevention and Fire Drills Policy # C-EM-0011, effective 01/2020, revision date 07/2023 directs staff as follows: “POLICY: 3. Fire Drills: will be conducted every 3 months and documentation of the drill will be recorded on C-FORMS-0480 Fire Drill Report. Documentation and assessment will provide information on steps that need practice and improvement for increased staff and patient safety ... 2. When the fire alarm sounds, all staff will proceed immediately to the treatment floor, closing all doors behind them to assist with evacuation of patients. 3. Staff will proceed with emergency evacuation as per Staff Assignments During Emergency Evacuation in policy C-EM-0010 Emergency Evacuation. 4. All individuals evacuating the building will proceed to the Emergency Designated Meeting Place as per policy C-EM-0010 Emergency Evacuation. 5. Ensure that staff attends to all patients who require assistance. Office and technical staff will assist with evacuation of patients out of the building ...” Biomedical Technician (D) On 11/12/2024 and 11/13/2024, Biomedical Technician (D) was observed in the Biomed room typing on the computer. Review of Biomedical Technician (D’s) personnel file revealed a date of hire of 07/25/2022. Review of the facility’s In-Service Tracking Form C-EM-0010 Emergency and Fire Drill Procedure, C-EM-011 Fire Prevention Plan: dated 01/04/2024, 04/15/2024, 07/01/2024 and 10/01/2024 revealed, no documentation of participation by Biomedical Technician (D). The log did not include Biomedical Technician (D’s) signature. Interview on 11/12/2024 at 2:30 p.m. with Biomedical Technician (D) revealed he said, “I have not participated in a fire drill at this facility.” Social Worker (F) On 11/12/2024, Social Worker (F) was observed on the treatment floor talking with patients. Review of Social Worker (F’s) personnel file revealed a date of hire of 09/01/2021. Review of the facility’s In-Service Tracking Form C-EM-0010 Emergency and Fire Drill Procedure, C-EM-011 Fire Prevention Plan on 01/04/2024 revealed the most current documentation of participation by Social Worker (F) as evidenced by her signature. There was no documented participation by Social Worker (F) on 04/15/2024, 07/01/2024 and 10/01/2024. The in-service forms did not include Social Worker (F’s) signature. Interview on 11/12/2024 at 3:20 p.m. with Social Worker (F) revealed she said, “I know they are done quarterly but I have not participated in one lately.” On 11/13/2024 the Surveyor notified the Facility’s Administrator that there was no documentation that Biomedical Technician (D) and Social Worker (F) participated in the facility’s quarterly fire drill. No evidence was provided.”

“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: 48020 Based on observation, interview and record review: the facility failed to ensure patient’s nephrologist round and assess patient’s every two weeks in 6 of 8 sampled patients: Patient #s 1, 2, 7, 3, 5 and 6 B) the facility failed to ensure that oxygen tanks were stored and identified according to Federal and State laws that regulated medical gases according to “National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities. Six oxygen tank cylinders observed on the treatment floor with regulators attached were not properly identified as full or empty. Findings: Review of facility’s current policy and procedure on Medical Records Policy # C-AD-0440, effective 01/2020, revision date 02/2023 directs staff as follows: “POLICY 4. All patients’ medical records will be maintained in accordance with accepted professional standards, practices and state specific regulations.” Review of “National Fire Protection Association (NFPA) 99, Standard for Health Care Facilities”(2005 edition): showed oxygen cylinders must be secured in racks or by chains, identified as full or empty and stored separately. NFPA 99 Requirements for oxygen cylinders: NFPA 99 requires empty cylinders to be stored separately from full cylinders. This means partially full cylinders must be stored with the empty cylinders or stored separately from full or empty cylinders. “ A cylinder is considered “full” provided it still has its seal from the supplier. Once the seal has been removed, the cylinder is no longer considered full and cannot be stored with full cylinders. “ NFPA 99 requires empty cylinders to be stored separately from full cylinders. This means partially full cylinders must be stored with the empty cylinders or stored separately from full or empty cylinders. Physician Visits: Patient #1 On 11/12/2024 at 09:09 a.m., Patient #1 was observed at station #8 machine #15 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of 800 mL/min via a right lower arm vascular access. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 03/26/2024 with diagnosis of end stage renal disease, hypertension and diabetes mellitus on insulin, on in-center hemodialysis three times weekly. Review of the patient’s clinical record revealed physician progress note dated 10/01/2024 and 10/22/2024. There was no documented physician progress note every two weeks as required by the state regulations. Patient #2 On 11/12/2024 at 09:13 a.m., Patient #2 was observed at station #6 machine #2 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 600 mL/min via a right upper arm vascular access. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 03/25/2022 with diagnosis of end stage renal disease and history of hypertension, on in-center hemodialysis three times weekly. Review of the patient’s clinical record revealed physician progress note dated 10/15/2024 and 11/06/2024. There was no documented physician progress note every two weeks as required by the state regulations. Patient #7 Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 10/25/2021 with diagnosis of end stage renal disease and type 2 diabetes mellitus with diabetic nephropathy, on in-center hemodialysis three times weekly. Review of the patient’s clinical record revealed physician progress note dated 07/15/2024, 08/26/2024, 09/27/2024, 10/01/2024 and 10/14/2024. There was no documented physician progress note every two weeks as required by the state regulations. 30124 Patient ID #3 Review of the patient’s physician progress note revealed a note documented on 09/03/2024, the next physician’s progress noted on 10/17/2024. There was no physician visit between 09/03/2024 and 10/17/2024. No documented physician progress notes every two weeks as required by the state regulations was identified. Patient ID #5 Review of the patient’s physician progress note revealed a note documented on 10/09/2024, the next physician progress noted on 11/04/2024. There was no physician visit between 10/09/2024 and 11/04/2024. No documented physician progress notes every two weeks as required by the state regulations was identified. Patient ID #6 Review of the patient’s physician progress note revealed note was documented on 10/14/2024, the next physician progress noted on 11/06/2024. There was no physician visit between 10/14/2024 and 11/06/2024. No documented physician progress noted every two weeks as required by the state regulations. Interview on 11/13/2024 at with the facility administrator at 12:30 PM, staff ID #A confirmed the above findings. Oxygen Tanks: Observation of the patient care area on 11/12/2024 at 09:30 AM along with the facility administrator, staff ID # A, six oxygen tanks were observed in the patient treatment area. All six oxygen tanks were observed to have been opened for use with regulators attached to the cylinders and were not labeled as full or empty. Interview with staff # A on 11/12/2024 at 09:30 AM confirmed the oxygen tanks were not able to be identified if they were full or empty and oxygen cylinders were not stored and separated to identify full or empty oxygen cylinders.”

“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: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to clean and disinfect all external surfaces of the dialysis machine to include top, sides, front and back, BP cuff basket; dialysate connectors and lines; hand sanitizer and holder; IV pole, items hanging on pole and chase cabinets behind the dialysis stations in 1 of 4 sampled staff: Licensed Vocational Nurse (D) Findings: Review of facility’s current policy and procedure on Disinfection and Cleaning of Dialysis Machine Equipment Policy # C-IC-0080, effective 01/2020, revision date 07/2023 directs staff as follows: “POLICY 4. Complete surface disinfection at the end of each dialysis treatment after the patient has vacated the station. DISINFECTION PROCEDURE: 7. Clean all external surfaces of the dialysis machine to include top, sides, front and back, BP cuffs and basket; dialysate connectors and lines; hand sanitizer and holder; IV pole, items hanging on pole, attached computer monitors and keyboard/mouse. 8. Disinfect all surfaces of the prime waste container, inside and out, with a moistened 1:100 bleach cloth. 9. Clean counter tops behind patient station ...” Licensed Vocational Nurse (D) Station #1 - hemodialysis machine #12 Observation on 11/12/2024 at 9:45 a.m. revealed Licensed Vocational Nurse (D) terminally cleaning station #1 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #12 at station #1, Licensed Vocational Nurse (D) cleaned and disinfected the front of the hemodialysis machine only. Next, she cleaned and disinfected the hemodialysis chair and attached a new extracorporeal set to hemodialysis machine #12 for the next patient. Licensed Vocational Nurse (D) failed to clean and disinfect all external surfaces of the dialysis machine to include top, sides, front and back, BP cuff basket; dialysate connectors and lines; hand sanitizer and holder; IV pole, items hanging on pole and chase cabinets behind the dialysis stations. Immediately, the Surveyor notified Licensed Vocational Nurse (D) that she failed to clean and disinfect the top, sides and back of the hemodialysis machine, BP cuff basket; dialysate connectors and lines; hand sanitizer and holder; IV pole, items hanging on pole and chase cabinets behind the dialysis stations. Licensed Vocational Nurse (D) said, “Okay, so I need to clean everything and throw all of this away.””