Fairfax Dialysis Center

“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 staff failed to remove expired supplies from the emergency cart. The findings included: During the flash tour on 3/5/24, a surveyor conducted a review of the contents in the facility’s emergency cart and evacuation kit. The following were discovered during the review: Two (2) - Sodium Bicarbonate 8.4% 50 mEq/5mL, expired 3/1/24. The surveyor notified SM (staff member) #2 of the expired supplies while on the treatment floor. On 3/5/24, a review of the facility’s policy titled, Emergency Medication, Equipment and Supplies, last revision 5/1/23, version 6, read in part: “...Emergency cart: ... The emergency cart must be: ... Checked monthly or after use for contents, expiration dates... Items approaching expiration must be reordered and replaced prior to the actual expiration date...”. At the exit conference on 3/6/24 at 3:10 p.m., the findings were reviewed with SMs #1, 6 and 7.”

“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: 45736 Based on interview and personnel record review, the facility failed to provide annual Emergency Preparedness (EP) training per facility guidelines. The findings included: On 3/6/24 at approximately 9:30 a.m., a review of three (3) personnel records was conducted. One (1) of the three (3) sampled personnel records revealed that EP training was not up to date. SM (staff member) #5 last completed EP training on 2/28/23. The surveyor requested a policy related to EP staff training guidelines and one was not provided. In an interview with SM (staff member) #1 on 3/6/24 at 10:25 a.m., confirmed that SM5 had expired EP training and “they will complete it ASAP (as soon as possible).” At the exit conference on 3/6/24 at 3:10 p.m., the findings were reviewed with SMs #1, 6 and 7.”

“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 record review and interview, the facility failed to ensure complete education and documentation of Emergency Preparedness (EP) training for two (2) of ten (10) In-Center Hemodialysis (ICHD) patients. The findings included: A surveyor conducted a review of ten (10) ICHD (In-center Hemodialysis) patient medical records on 3/6/24. During the review, the surveyor identified that Patients (Pt) #1 and #2 had not received up to date EP training and education. Pt #1, was admitted on 1/12/24 and at the time of survey has not received EP orientation training. Pt #2 had not received their quarterly EP training, last date of training was 9/27/23. The surveyor discussed the findings with SM (staff member) #10, the afternoon of 3/6/24. SM10 verified that Pt #1 and Pt#2 did not have up to date EP training. The surveyor asked SM1 on 3/6/24 at approximately 2:30 p.m., what the expectation for EP training was with ICHD patients. SM1 stated, “On admission and then quarterly.” At the exit conference on 3/6/24 at 3:10 p.m., the findings were reviewed with SMs #1, 6 and 7.”

“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: 45736 Based on observations and document review, the facility staff failed to ensure proper cleaning of prime waste containers on three (3) of three (3) observations of dialysis machine cleaning. The findings included: Observations were conducted the afternoon of 3/5/24, between 2:00 p.m. and 3:00 p.m. The surveyors observed the following: Staff member (SM) 4- cleaned dialysis station two (2), only rinsed and did not disinfect the prime waste container. The prime waste container was taken back to the cleaned dialysis station and placed upside down on top of the disinfected machine. SM2- cleaned dialysis station seven (7), only rinsed and did not disinfect the prime waste container. The prime waste container was taken back to the cleaned dialysis station and placed upside down on top of the disinfected machine. SM5- cleaned dialysis station three (3), only rinsed and did not disinfect the prime waste container. The prime waste container was taken back to the cleaned dialysis station and placed upside down on top of the disinfected machine. A facility policy titled, Use of Priming Buckets, last revision 1/24/24, version 4, read in part, “Procedure...Step 5, Action...After routine surface disinfection with 1:100 bleach solution, replace on machine.” At the exit conference on 3/6/24 at 3:10 p.m., the findings were reviewed with SMs #1, 6 and 7.”

“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: 45736 Based on observations and document review, the facility staff failed to perform proper hand hygiene while conducting direct patient care. The findings included: During the flash tour on 3/5/24, the surveyors observed the following: Staff member (SM) 3 while performing initiation of dialysis with central venous catheter (CVC) in station sixteen (16), SM3 removed gloves, failed to perform hand hygiene and donned new gloves two (2) times between 11:50 a.m. and 11:55 a.m. SM3 was observed performing initiation of dialysis with AV (arteriovenous) fistula in station fifteen (15) when at approximately 12:00 p.m., SM3 removed gloves, failed to perform hand hygiene and donned new gloves one (1) time. A facility policy titled, Hand Hygiene, last revision 11/6/23, version 8, read in part, “Policy: Hand hygiene includes either washing hands with soap and water or using a waterless alcohol based antiseptic hand rub with 60-90% alcohol content...Hands will be...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...When...Before and after direct contact with patients...Immediately after removing gloves...” At the exit conference on 3/6/24 at 3:10 p.m., the findings were reviewed with SMs #1, 6 and 7. 46466 On 3/5/24 at 11:30 a.m., 11:36 a.m., 11:50 a.m., 11:53 a.m., 12:02 p.m., 2:30 p.m., 2:37 p.m. and 2:57 p.m., the surveyor observed Staff Member #4 (SM4) removing their gloves and putting on new gloves without performing hand hygiene between the glove changes.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 46466 Based on observations, and facility document review, the staff failed to ensure that clean areas and supplies were not contaminated by used equipment. Findings: On 3/5/24 at 12:00 p.m., Staff Member #4 was observed taking off their faceshield and setting it on top of an open box of gloves on the clean counter. A review of a facility policy “Dialysis Precautions”, published 01/04/2012, stated in part, “...Clean Versus Dirty Areas: Clean area: An area designated for clean and unused equipment, supplies and medications...”. The findings were discussed with Staff Members #1, #6 and #7 on 3/6/24 at 3:10 p.m.”

“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: 46466 Based on observations and facility document review, it was determined that the facility’s staff failed keep bleach containers closed and to clean and disinfect contaminated surfaces of the medical devices and equipment per policy. The findings included: On 3/5/24 at 11:20 a.m., a bleach container located in a clean sink area was found with the lid propped open and tilted at an angle leaving the container open. The lid was dated 3/4/25. On 3/5/24 at 2:20 p.m., a bleach container used to decontaminate used supplies and located in a dirty sink was found uncovered. On 3/5/24 at 2:35 p.m., Staff Member #4 (SM4) was observed cleaning dialysis station #2. SM4 was observed cleaning the side tray tables of the chair but did not fold the tray tables down to disinfect the area between the arm of the chair and the table. SM4 did not disinfect the chaise wall behind the chair. A review of the facility’s policy “Cleaning and Disinfecting the Dialysis Station”, published 9/5/23, stated in part: “...Procedure...3. Use a cloth wetted with 1:100 bleach solution or EPA- approved disinfectant to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P cuff, hand sanitizer dispenser and holder, chaise wall behind chair)...”. A review of the facility’s “Mixing Bleach” procedure, published 8/25/20, stated in part: “...4. Label opaque container with “Bleach Solution”, strength of solution, date and time prepared and your initials. 5. Cover opaque container with lid. 6. Discard solution daily at end of treatment day or more often if needed”. The findings were discussed with Staff Members #1, #6 and #7 on 3/6/24 at 3:10 p.m.”

“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: 46466 Based on interview and facility document review, the staff failed to perform Infection Control training at least annually as evidenced in one (1) of three (3) personnel files reviewed. The findings include: On 3/6/24 at 10:15 a.m., three (3) personnel files were reviewed. Staff Member #4’s (SM4) training record revealed that SM4 last completed their Infection Control training on 1/18/23. On 3/6/24 at 10:25 a.m., SM4’s overdue Infection Control training date was discussed with Staff Member #1 (SM1). SM1 stated that they were not aware the SM4’s training was overdue but they would have SM4 complete the training either today or tomorrow. A review of the facility’s policy “Bloodborne Pathogen and Infection Control Training”, published 11/2/20, stated in part: “...Training Requirements...Annual: -At least annually, -Within one year of the previous years’ training...”. The findings were discussed with Staff Members #1, #6 and #7 on 3/6/24 at 3:10 p.m.”

“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: 46466 Based on observations and facility document review, it was determined that the facility staff failed to maintain a safe environment for dialysis patients by not discarding expired medications. The findings include: On 3/5/24 at 11:15 a.m., five (5) vials of Cefepime was found in the medication cabinet on the treatment floor. The vials had an expiration date of 2/2024. A review of the facility’s policy “Medication Preparation and Administration”, published 2/6/23, stated in part “...Monitoring Expired Medications: -Expiration dates for all stored medications are to be monitored on a monthly basis. -Expired medications are to be discarded...”. The findings were discussed with Staff Members #1, #6 and #7 on 3/6/24 at 3:10 p.m.”

“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: 46466 Based on observations and document review, the facility staff failed to maintain aseptic technique for a CVC (central venous catheter) dressing change. The findings include: On 3/5/24 at 11:55 a.m., Staff Member #2 (SM2) was observed performing CVC exit site care for patient in station #10. The patient arrived to the dialysis station with no bandage covering the CVC site. SM1 cleansed the exit site with antiseptic, then proceeded to remove the bandage covering the CVC hubs. SM1 disinfected the CVC hubs, connected the sterile syringes and then picked up the sterile bandage and covered the patient’s exit site. SM1 did not remove their gloves, perform hand hygiene, and donn new gloves prior to covering the exit site with the new bandage. A review of the facility’s policy “Changing the Catheter Dressing Procedure”, published 2/5/24, stated in part: “...Timing of Exit Site Dressing Change: Catheter exit site disinfection and dressing change is to be completed prior to cap and hub connector disinfection...”. The findings were discussed with Staff Members #1, #6 and #7 on 3/6/24 at 3:10 p.m.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 45736 Based on observations and document review, the facility staff failed to ensure proper procedures were followed for pH conductivity and failed to remove expired pH strips. The findings included: During the flash tour on 3/5/24, the surveyors observed the following: Staff Member (SM) #3 conducted pH conductivity testing prior to dialysis initiation in station 16, failed to obtain a second verifier for pH. SM4 conducted pH conductivity testing prior to dialysis initiation in station 12, failed to obtain second verifier for pH. A facility policy titled, Checking Conductivity of pH of final Dialysate, last revision 4/11/22, version 9, read in part, “Test Verification Prior to Treatment. Incenter setting: 2 staff members will verify the conductivity and pH parameters prior to treatment.” The surveyor also observed pH test strips with expiration date 9/14/22 on the counter that were accessible for use by staff. A facility policy titled, Storage of Supplies, last revision 4/5/21, version 2, read in part, “Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated or damaged....Supplies must be rotated First in-First out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date.” At the exit conference on 3/6/24 at 3:10 p.m., the findings were reviewed with SMs #1, 6 and 7.”

“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: 46466 Based on clinical record review, and facility document review, the facility staff failed to ensure that the Registered Nurse (RN) assessed patients within an hour of dialysis treatment per facility policy. The findings include: Patient #2 (Pt.#2): On 3/6/24, a review of Pt. #2’s six (6) treatment flowsheets dated 2/19/24 through 3/4/24 was conducted. 2/23/24: Treatment began at 6:08 a.m., the RN evaluation was documented at 8:15 a.m. 3/4/24: Treatment began at 6:17 a.m., the RN evaluation was documented at 7:43 a.m. Patient #5 (Pt.#5): On 3/6/24, a review of Pt. #5’s six (6) treatment flowsheets dated 2/21/24 through 3/4/24 was conducted. 2/21/24: Treatment began at 6:12 a.m., the RN evaluation was documented at 7:59 a.m. 2/23/24: Treatment began at 5:58 a.m., the RN evaluation was documented at 8:13 a.m. 2/28/24: Treatment began at 6:10 a.m., the RN evaluation was documented at 8:05 a.m. 3/4/24: Treatment began at 6:05 a.m., the RN evaluation was documented at 7:42 a.m. Patient #9 (Pt.#9): On 3/6/24, a review of Pt. #9’s six (6) treatment flowsheets dated 2/9/24 through 3/4/24 was conducted. 2/9/24: Treatment began at 11:45 a.m., the RN evaluation was documented at 1:37 p.m. 2/16/24: Treatment began at 11:45 a.m., the RN evaluation was documented at 1:14 p.m. 3/4/24: Treatment began at 11:44 a.m., the RN evaluation was documented at 1:02 p.m. A review of the facility’s policy “Nursing Supervision and Delegation”, published 11/6/23, stated in part: “...Policy: The registered nurse must evaluate each patient preferably within an hour or according to state requirements...”. The findings were discussed with Staff Members #1, #6 and #7 on 3/6/24 at 3:10 p.m.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 45736 Based on observations, document review and interview, the facility staff failed to listen to the arteriovenous (AV) access prior to cannulation. The findings included: During the flash tour on 3/5/24, the surveyor observed the following: Station #13 at 11:20 a.m.- SM (staff member) #3 did not listen to the patient’s AV access, only palpated the area, then cannulated. Station #16 at 11:50 a.m.- SM3 did not listen to the patient’s AV access, only palpated the area, then cannulated. A review of the facility’s policy, Access Assessment and Cannulation, last revised 7/5/22, version 3, read in part, “Assessment of Vascular Access...6. LISTEN: Bruitt high pitch/whistle...Document in treatment record. NOTE: Staff/patients/care partners who have been trained to auscultate vascular access should listen to the entire length of the access for changes in the sound of the bruitt- a normal low pitch bruitt should be present...” In an interview with SM (staff member) #1 on 3/6/24 at 3:05 p.m., the surveyor asked about the correct process for listening to the AV access prior to cannulation. SM1 told the surveyor, “Feeling it is a must, they don’t always listen.” At the exit conference on 3/6/24 at 3:10 p.m., the findings were reviewed with SMs #1, 6 and 7.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 45736 Based on medical record review and document review, it was determined that the Interdisciplinary Team (IDT) failed to ensure the Plan of Care (POC) was signed by the patient. The findings included: Medical record review evidenced that one (1) of ten (10) medical records did not contain the patient’s signature on their POC. Patient #6 (Pt #6) POC (dated 12/28/23) didn’t contain Pt#6 signature and/or reason for a refusal of the patient to sign. A review of the facility’s policy titled, Comprehensive Interdisciplinary Assessment and Plan of Care, last revised 7/3/23, version 6, read in part, “General Policy for Patient Assessment and Plan of Care Review...The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record.” At the exit conference on 3/6/24 at 3:10 p.m., the findings were reviewed with SMs #1, 6 and 7.”