Renal CARE Group - Danville

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 45736 Based on observation and facility policy review, the facility failed to remove expired supplies from the emergency cart and ensure the emergency cart was locked. The findings include: During the flash tour on July 28, 2025, the surveyor reviewed the contents of the facility’s emergency cart, which was not locked. The following medications/supplies were identified as expired: Two (2)- Solu-Cortef 100mg/2mL single use vial- expired June 30, 2025 Four (4) Glutose 15 3 tubes per box- expired June 30, 2025 Five (5)- Standard infusion sets/Volumet Line- expired October 18, 2023 This surveyor notified Staff Member #7 of the expired items during the flash tour. The surveyor also notified Staff Member #1, the afternoon of July 28, 2025, of the expired items and that the emergency cart was not locked. A facility policy, Emergency Medication, Equipment and Supplies, last revision July 7, 2025, was reviewed and revealed, in part: “...Emergency cart:...The emergency cart must be:...Locked when not in use. Checked monthly or after use for contents, expiration dates...Items approaching expiration must be recorded and replaced prior to the actual expiration date...””

“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: 45736 Based on facility document review and interview, the facility failed to meet the requirements to participate in and/or conduct an emergency preparedness (EP) exercise annually or participate in a full scale community exercise or table-top drill every two years. The findings include: The surveyor conducted a review of the facility’s EP plan on July 28, 2025. The review indicated that an EP mock code was conducted “March 2024.” No full scale community exercise or table-top drill could be found. During an interview with Staff Member #1, the morning of July 29, 2025, when the surveyor asked about the EP testing requirements, Staff Member #1 indicated that they were aware they needed to be conducted but since taking over the clinic recently, they are still trying to catch up on things that were missed and have not completed this requirement. A facility policy, Guidelines for Emergency Preparedness, last revision July, 3, 2023, was reviewed and revealed, in part, “...Community Based Drill: Annually each facility MUST participate in a community-based disaster drill...Mock Table Top Drill: In addition to the community drill, facilities must select an event of high likelihood and conduct a table top drill...””

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 45736 Based on medical record review, interview and document review, the facility failed to provide documentation of training in Emergency Preparedness (EP) for nine (9) of nine (9) In-Center Hemodialysis (ICHD) patients. The findings include: Surveyors reviewed ICHD patient medical records on July 28, 2025 and July 29, 2025. During the review, the surveyors identified that nine (9) of nine (9) patients did not have appropriate EP training per facility policy. During an interview in the morning of July 29, 2025, Staff Member #1, indicated that everyone must receive EP training during their orientation to the facility and quarterly for fire drills and disaster training. Staff Member #1 indicated that when they came to the facility, they identified that there was an issue with EP training for patients and have recently created an action plan that was presented to, and approved by, the Governing Body on June 25, 2025. The action plan presented to the surveyors the morning of July 29, 2025 revealed, in part, “Meeting Content: Emergency Patient Participation in Fire/Disaster Drills were not documented for March 2025 and June 2025. Staff will review with patients and have forms completed by July 31, 2025 and placed in each patient’s file. Plan of Correction: Staff will be educated on frequency requirements (quarterly) and the importance of reviewing with patients March, June, July {sic}, December and on admittance. A schedule has been set by Clinical Manager...that Emergency Patient Participation in Fire/Disaster Drill will be completed on the 2nd Wednesday quarterly...” A facility policy, Guidelines for Emergency Preparedness, last revised July 3, 2023, revealed, in part, “...Patient Education: Facility Staff must educate patients on: Evacuation procedures. Emergency Disconnection Procedures. Emergency Meal Plan. Facility Contact Information. Shelter Information. Transportation Information. Emergency preparedness...””

“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: 45736 Based on observation and facility document review, the facility failed to follow facility policy and procedures for safety and infection control protocols. The findings include: During the flash tour on July 28, 2025, the surveyor observed Staff Members #9 and #10 to have fingernails longer than the facility’s allowable 1/4 (one quarter) of an inch long. A facility policy, Employee Dress Code, last revision June 18, 2021, was reviewed and revealed, in part, “...Patient Care/Lab Environments: To ensure employees maintain a work environment that adheres to safety and infection control protocols, the following applies...Fingernails must be clean and no more than 1/4 of an inch beyond the tip of the finger...””

“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: 45736 Based on observations, interview and facility document review, the facility failed to properly label four (4) of seven (7) bleach solution containers per facility policy and failed to follow facility policy on the cleaning and disinfecting of one (1) of three (3) dialysis machines. The findings include: During the flash tour on July 28, 2025, the surveyor conducted observations on one (1) of two (2) patient treatment areas. Four (4) of seven (7) bleach solution containers were not labeled with the strength of the solution, date, time and preparer’s initials. During an interview in the afternoon of July 28, 2025, Staff Member #1 indicated that all bleach solutions should be labeled with strength, date, time of mixing and initials of the preparer according to the facility policy. Staff have been provided with this education, including the mixing ratios/measurements. A facility policy, Mixing Bleach, last revision February 3, 2025, was reviewed and revealed, in part, “...Procedure...4. Label opaque container with “Bleach Solution,” strength of solution, date and time prepared and preparer’s initials...7. Discard solution daily at end of treatment day or more often if needed...” During the flash tour July 28, 2025, the surveyor conducted observations of Staff Member #5 cleaning the dialysis machine at Station #26. The patient had not vacated the dialysis chair for this station. A facility policy, Cleaning and Disinfecting the Dialysis Station, published September 5, 2023, version 14, was reviewed and revealed, “...Vacating the Machine: To prevent cross-contamination between patients, it is important that the previous patient completely vacate the station before staff begin cleaning and disinfection of the station and set up for the next person...””

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 19883 Based on facility personnel file review, staff interview, and facility document review, the facility failed to ensure that annual competency training was completed within a 12 month period for four (4) of 18 facility clinical staff members; and that annual infection control training was completed within a 12 month period for two (2) of 18 facility clinical staff members; and that annual water training was completed within a 12 month period for two (2) of 18 facility clinical staff members. The findings include: Four (4) of 18 facility clinical staff members did not have documentation of current annual competency training, (Staff Members #6, #14, #15, and #16). Staff Member #6’s most recent date of competency training completion was 5/23/24. Staff Member #14’s most recent date of competency training completion was 6/4/24. Staff Member #15’s most recent date of competency training completion was 6/4/24. Staff Member #16’s most recent date of competency training completion was 7/23/24. During an interview with Staff Member #1 on 7/29/25, they acknowledged and verified that the annual competencies training was not up to date for Staff Members #6, #14, #15, and #16, and should have been completed within 12 months from the last training completion date. Two (2) of 18 facility clinical staff members did not have documentation of annual infection control training, (Staff Members #6 and #13). Staff Member #6’s most recent date of infection control training was 4/22/24. Staff Member #13’s most recent date of infection control training was 3/28/24. During an interview with Staff Member #1 on 7/29/25, they acknowledged and verified that the annual infection control training was not up to date for Staff Members #6 and #13, and that the infection control training should have been completed within 12 months from the last training completion date. Two (2) of 18 facility clinical staff members did not have documentation of water training, (Staff Members #14 and #15). Staff Member #14’s most recent date of water training was 4/12/24. Staff Member #15’s most recent date of water training was 4/12/24. During an interview with Staff Member #1 on 7/29/25, they acknowledged and verified that the annual water training was not up to date for Staff Members #14 and #15, and that the water training should have been completed within 12 months from the last training completion date. Review of the facility’s policy titled: “Knowledge, Skills, and Competency Evaluation for Clinical Staff” with a published date of 06/04/24, reads in part: “...Employees are required to successfully complete all skills requirements, including an annual skills validation, within the given timeframe.””

“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: 45736 Based on observation and facility document review, the facility failed to ensure one (1) medication vial was labeled appropriately and according to a facility policy. The findings include: During the flash tour on July 28, 2025, the surveyor observed one (1) multi-dose vial of Heparin 30,000 units/30 ml (units per thirty milliliters) 1,000 units/ml (one-thousand units per milliliter) on the medication area counter that was opened and was not labeled according to the facility policy. A facility policy, Medication Preparation and Administration, published July 7, 2025, version 10, was reviewed and revealed, in part: “...Labeling Vials: When preparing medications, if the vial is not used immediately in it’s entirety, the nurse or PCT (Patient Care Technician) (If allowed by state regulations) must place the date and time the medication was opened on the medication label with their initials. Note: To ensure all open vials are properly marked, the nurse must never walk away from an opened multi-dose vial without writing the dare and time the vial was opened. Label any open multi-dose vial that is not used immediately and store vial accordingly...””

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 19883 Based on medical record review, staff interview and facility document review, the facility failed to obtain pre and post standing blood pressures for one (1) of 10 patients in the survey sample. The findings include: For Patient #9, six (6) dialysis treatment records, covering a period of 7/7/25 through 7/23/25, were reviewed. On 7/11/25 and 7/14/25, Patient #9’s pre and post standing blood pressures were documented as “cannot assess.” Patient #9’s ambulation status is documented as “Ambulates w/o (without) assistance.” There was no documentation in Patient #9’s 7/11/25 or 7/14/25 treatment records to indicate why Patient #9’s pre and post standing blood pressures were not obtained. Staff Member #1 reported during an interview on 7/28/25 that if pre and post standing blood pressures are not obtained on a patient who ambulates without assistance, the facility staff is supposed to document the reason why the standing blood pressures were not obtained. Review of the facility’s policy titled: “Determination of Blood Pressure” with a most recent published date of 02/7/22 reads in part: “...Obtain blood pressure readings pre-and post-dialysis sitting and standing (if applicable) as well as at regular intervals during the hemodialysis treatment and as indicated.””