Davita Cdc-Springfield

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 40084 Based on the scope and severity of deficiencies related to infection prevention and control, the facility failed to substantially comply with this condition. See tags V-0113 Based on observations, interview and document review, it was determined the facility failed to follow infection control and prevention practices related to hand hygiene (HH) and glove changing. Specifically, hand hygiene (HH) was not performed and gloves were not changed, per policy, during four (4) infection control observations of discontinuation of dialysis with an arteriovenous (AV) fistula and staff moving from one patient treatment station to another. V-0115 Based on observation, interview and document review, it was determined the facility failed to ensure Personal Protective Equipment (PPE) was worn, per policy, to prevent contamination while in the patient treatment area. V-0122 Based on observations, interview and document review, it was determined the facility failed to ensure that dialysis stations and chairs were appropriately and completely disinfected between patients in three (3) out of three (3) observations. In addition, the facility failed to completely remove tape residue present on many chair side tray tables. V-0143 Based on observation, interview and document review, it was determined the facility failed to remove expired medications so they are not available for patient use in the dialysis facility. V-0401 Based on observations, interview and document review, it was determined the facility failed to maintain a safe environment by not disposing of contaminated sharps at the point of use in one (1) out of three (3) observations when deaccessing a patient (MR) with a fistula or graft. V-0550 Based on observations, interview and document review, it was determined the facility failed to properly care for arteriovenous (AV) grafts/fistulas according to the facility’s policy. Specifically, in one (1) out of three (3) observations, facility staff touched the cannulation site of arteriovenous (AV) fistulas when discontinuing dialysis.”

“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: 49355 Based on observations, interview and document review, it was determined the facility failed to follow infection control and prevention practices related to hand hygiene (HH) and glove changing. Specifically, hand hygiene (HH) was not performed and gloves were not changed, per policy, during four (4) infection control observations of discontinuation of dialysis with an arteriovenous (AV) fistula and staff moving from one patient treatment station to another. The findings: A review of the facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy: 1-05-01, revision date April 2023, reads, in part: “Hand Hygiene 1. All teammates...will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves, ... d. after patient and dialysis delivery system contact, ... f. between patients even if the contact is casual, ... g. before touching clean areas such as supplies, supply car and chairside keyboard/mouse ... PPE ... 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station.... a. Gloves should be changed when: ... ii. When going from a ‘dirty’ area or take to a ‘clean’ area or task ... iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system. ... Disinfection ... c. Dialysis delivery systems with computers/keyboards mounted on top, the computer and keyboard are considered ‘dirty’ equipment ... 15. The chair side cart, terminals mounted on the counter, monitor and keyboard are considered clean areas.” A review of the facility’s procedure entitled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles,” procedure: 1-04-01B, revision date April 2023, reads, in part: ... “1. Perform hand hygiene. Put on PPE. Hand hygiene protects patient and teammate from cross contamination. PPE is worn to protect teammate.” On July 7, 2025, at 2:57 P.M., while discontinuing dialysis on Patient (MR) 7 at station #11, Employee (EMP) 4 did not remove gloves, perform HH and don clean gloves prior to removing the cannulation needles. Several times on July 7, 2025, between 10:08 A.M. and 3:57 P.M., this surveyor observed EMP4 fail to perform HH and change soiled gloves, to include: *At 10:08 A.M., EMP4 donned a single glove to silence an alarm on the dialysis machine at station #15. EMP4 removed the glove, did not perform HH and used the clean keyboard, not attached to the machine. *At 11:09 A.M., EMP4 went from station #13 to station #15, wearing the same gloves, to silence an alarm. EMP4 returned to station #13 with the same gloves, never changing gloves or performing HH. *At 3:57 P.M., EMP4 touched MR7’s chair and shoe at station #11 and then proceeded to flush MR7’s fistula, never changing gloves or performing HH. During separate interviews on July 7, 2025, and July 8, 2025,respectively, EMP9 and EMP10 indicated glove changes and HH should have occurred in these instances.”

“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: 49355 Based on observation, interview and document review, it was determined the facility failed to ensure Personal Protective Equipment (PPE) was worn, per policy, to prevent contamination while in the patient treatment area. The findings: A review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” policy 1-05-01, revision date April 2024, reads, in part: ... “PPE (i.e. gown, gloves, eye protection, face shield) 5. 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. ... 6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physician (NPP) and visitors in the treatment area.” At 10:51 A.M. on July 7, 2025, Employee (EMP) 7 entered the patient treatment floor but failed to don a gown. EMP2 confirmed, at that time, that EMP7 should be wearing a gown.”

“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: 49355 Based on observations, interview and document review, it was determined the facility failed to ensure that dialysis stations and chairs were appropriately and completely disinfected between patients in three (3) out of three (3) observations. In addition, the facility failed to completely remove tape residue present on many chair side tray tables. The findings: A review of the facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy: 1-05-01, revision date April 2023, reads, in part: ... “Disinfection ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair...).... ... ii. Priming containers are to be emptied prior to disinfection.” ... b. Dialysis station must be completely vacated by the previous patient before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station and set up for the next patient”. On July 7, 2025, at 11:37 A.M., Employee (EMP) 4 failed to disinfect the inside of the prime waste container at station #17. EMP4 also failed to remove tape residue on the chair side tray tables. On July 7, 2025, at 3:27 P.M., EMP13 failed to disinfect the outside of the dialysis chair, underneath each side tray. On July 7, 2025, at 4:01 P.M., EMP6 began to clean station #3 while the patient was still seated in the dialysis chair. This surveyor observed tape residue on many of the dialysis chair side tray tables, making it difficult to completely disinfect the trays. On July 8, 2025, at 8:55 A.M., EMP2 agreed the gummy substance on the chair side tables was due to tape residue. EMP2 informed this surveyor that once patient treatments were completed on this date, all side tables would be cleaned with an appropriate product. EMP2 later informed this surveyor that a vendor had been contacted on the appropriate removal of the tape residue.”

“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: 49355 Based on observation, interview and document review, it was determined the facility failed to remove expired medications so they are not available for patient use in the dialysis facility. The findings: The facility’s policy entitled, “Medication Policy,” policy 1-06-01, revision date October 2023, reads, in part: ... “Policy: ... 30. All medications in the facility are checked monthly. All medications are checked monthly for expiration dates. ... 32. Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations.” On July 7, 2025, one (1) single dose vial of Vancomycin 1 gram/vial for injection, NDC #00409-6533-21, with an expiration date of July 1, 2025, was discovered in one of the facility’s medication storage drawers on the treatment floor. Employee (EMP) 9 witnessed the discovery and agreed the medication had expired and should have been removed from the active stock.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 49355 Based on observations, interview and document review, it was determined the facility failed to maintain a safe environment by not disposing of contaminated sharps at the point of use in one (1) out of three (3) observations when deaccessing a patient (MR) with a fistula or graft. The findings: A review of the facility’s policy entitled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles,” reads, in part: ... “Procedure ... 8. With safety device engaged, dispose of safety fistula needle in the sharps container.” On July 8, 2025, at approximately 9:15 A.M., Employee (EMP) 3 deaccessed MR9’s fistula at station #5 and placed the contaminated needle on the chair side tray table. After applying gauze to the exit site, EMP3 disposed of the needle in the adjacent sharps container. EMP3 repeated the above process after removing the second contaminated fistula needle. During an interview on July 8, 2025, EMP10 confirmed each contaminated fistula needle should be immediately place into a sharps container immediately after removal.”

“PA-MSW-PSYCHOSOCIAL NEEDS CFR(s): 494.80(a)(7) The patient’s comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker. This Standard is not met as evidenced by: 49355 Based on medical record reviews, interview and documentation review, it was determined the facility failed to document a quarterly note by the social worker to evaluate a patient’s psychosocial health status, per policy, in one (1) out of five (5) medical records reviewed, Patient (MR) 4. The findings: The facility’s document entitled, “Social Work Intervention and Documentation Requirements,” Procedure 1-14-03A, revision date October 2023, reads, in part” ... “Social Work Progress Note- Quarterly or more frequently as needed.... Documentation is individualized and reflects the specific social work needs of the patient, current and/or anticipated social work problems, education provided to the patient, implementation of planned intervention, patient comprehension, and response to treatment/intervention.” A review of the medical record for MR4 on July 8, 2025, revealed the last documented social work note was dated March 26, 2025. During an interview on July 8, 2025, Employee (EMP) 2 agreed the last documented social work note was as noted above and per policy, documentation of a note from the social worker should be present at least once quarterly.”

“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: 49355 Based on medical record reviews, document review and interviews, it was determined the facility failed to document abnormal findings and notification to the charge nurse or physician of: 1) unmet target weights (TW) compared to post treatment weights (PTW) in two (2) out of five (5) medical records reviewed; and 2) blood pressure (BP) measurements outside of facility guidelines in two (2) out of five (5) medical records reviewed. The findings: The facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy 1-03-08, revision date April 2024, reads, in part: ... “Intradialytic Date Collection/Assessment ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. ... 11. Abnormal finding or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. ... 13. All findings, interventions and patient response will be documented in the patient’s medical record. ... Abnormal Findings Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. ... Fluid Status: ... Post-treatment: If patient is above or below 1 kg from the target weight ... Blood Pressure-Intradialytic: * Systolic greater than 180 mm/Hg or less than 90 mm/Hg * Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg” A review of the following medical records revealed: Patient (MR) 2: Flowsheet dated June 23, 2025: PTW was documented as 92.9 kg, TW was 94.0 kg, a deviation of 1.1 kg. No documentation was noted on the flowsheet. Flowsheet dated June , 7: PTW was documented as 91.9 kg, TW was 93.0 kg, a deviation of 1.1 kg. No documentation was noted on the flowsheet. MR4: Flowsheet dated June 25, 2025: PTW was documented as 88.3 kg, TW was 87.0 kg, a deviation of 1.3 kg. No documentation was noted on the flowsheet. Flowsheet dated June 25, 2025: PTW was documented as 88.6 kg, TW was 87.0 kg, a deviation of 1.6 kg. No documentation was noted on the flowsheet. Flowsheet dated July 2, 2025: PTW was documented as 88.8 kg, TW was 87.0 kg, a deviation of 1.8 kg. No documentation was noted on the flowsheet. Flowsheet dated July 4, 2025: PTW was documented as 88.1 kg, TW was 87.0 kg, a deviation of 1.1 kg. No documentation was noted on the flowsheet. MR5: Flowsheet dated June 30, 2025: BP was documented at 7:29 A.M. as 141/122 mmHg. No documentation was noted on the flowsheet. MR6: Flowsheet dated June 25, 2025: BP was documented at 7:02 P.M. as 185/93 mmHg, at 7:32 P.M. as 190/92 mmHg and at 7:54 P.M. as 183/94 mmHg. No documentation was noted on the flowsheet. Flowsheet dated June 27, 2025: BP was documented at 6:01 P.M. as 201/103 mmHg, with a notation of “bp recheck needed.” At 6:03 P.M., BP 188/113 mmHg, at 6:31 P.M. 212/118 mmHg, at 6:32 P.M. 179/106 mmHg, at 7:01 P.M. 156/107 mmHg and at 7:31 P.M. 181/94 mmHg. No further documentation was noted on the flowsheet for each of these subsequent readings. During an interview on July 7, 2025, at 2:24 P.M., Employee (EMP) 9 indicated any unmet target weights or abnormal BP readings should be documented in the flowsheet and the charge nurse notified immediately. During an interview on July 8, 2025, at 8:40 A.M., EMP16 indicated it is their expectation that the treatment prescription should be “followed to the ‘t.’” EMP16 stated that includes any deviation from the prescription, including any deviations greater than plus or minus one (1) kg from the patient’s target weight.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 49355 Based on medical record reviews, interviews and document review, it was determined the facility failed to follow physician’s prescription orders and failed to document the reason for the deviation for: 1) prescribed blood flow rate (BFR) and/or dialysate flow rate (DFR) for two (2) out of five (5) medical records reviewed 2) and/or treatment times shorter than the prescribed duration without documentation and/or a completed Against Medical Advice (AMA) form in three (3) out of five (5) medical records reviewed. The findings: The facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy 1-03-08, revision date April 2024, reads, in part: ... “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour.... Prescription components include but are not necessarily limited to: ... b. Treatment time ... f. Blood flow rate g. Dialysate flow rate ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. ... 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record. ... 17. Licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility.” The facility’s policy entitled, “Prescribed Treatment Time Not Met, policy 1-01-09, revision date April 2024, reads, in part: ... “A. Completion of the Early Termination of Treatment Against Medical Advice Form 1. The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. ... 3. The RN will obtain the patient’s signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient’s signature prior to rinse-back, the RN will obtain the patient’s signature on the form prior to the patient’s departure from the facility. 4. A RN must countersign all Early Termination of Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 5. If a patient refuses to sign the Early Termination of Treatment Against Medical Advice form, the RN will document the patient’s refusal with the words “patient refused” in the patient signature box along with the date. Under such circumstances, the RN will sign the form and will also obtain a witness’ signature on the form. 6. This applies only to shortened treatments. ... B. Prescribed Treatment Time Not Met 1. If the shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs. NOTE: Shortened/Early Termination of dialysis treatment includes all reasons the prescribed dialysis time is not met by 30 or more minutes. ... 3. If a patient’s treatment is shortened/early terminated, the RN will document the event in the patient’s electronic health record. Documentation will include, as appropriate: * The amount of time by which the treatment was shortened * A description of why the treatment was shortened * Whether the patient’s nephrologist was notified * A description of the follow-up medical orders provided by the patient’s attending nephrologist (if any) * A description of all other interventions planned to address the shortened treatment, including recommendation to the patient. ... 4. A completed copy of the Early Termination of Treatment Against Medical Advice form will be kept in the patient’s health record. ... 5. Additionally, if the patient’s dialysis treatment is terminated 30 or more minutes prior to the ordered treatment length, the reason must be documented in the patient electronic health record at the time the treatment was terminated while reconciling the treatment times. ... 6. The Facility Administrator (FA)/Designee will verify that all shortened treatments are recorded and trended, and the FA/Designee shall verify that such records are reviewed and discussed at the Facility Health Meetings (FHM), as appropriate.” A review of the following medical records revealed: Patient (MR) 2: Flowsheet dated June 27, 2025: prescribed treatment duration 225 minutes, actual treatment duration 190 minutes, a deviation of 35 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent the medical record. Flowsheet dated June 30, 2025: prescribed treatment duration 225 minutes, actual treatment duration 211 minutes, a deviation of 14 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent the medical record. Flowsheet dated July 2, 2025: prescribed treatment duration 225 minutes, actual treatment duration 207 minutes, a deviation of 18 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent the medical record. Flowsheet dated July 4, 2025: prescribed treatment duration 225 minutes, actual treatment duration 209 minutes, a deviation of 16 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent the medical record. MR4: Flowsheet dated June 23, 2025: prescribed BFR 350 ml/min, actual BFR ranged from 300 ml/min, decreased to 320 ml/min and then further decreased to 275 ml/min for the last 180 minutes of 240 minute prescribed treatment duration. No documentation noted in the flowsheet. MR5: Flowsheet dated July 2, 2025: prescribed DFR 600 ml/min, actual was 500 ml/min for the entire 180 minute prescribed treatment duration. No documentation noted in the flowsheet. Flowsheet dated July 4, 2025: prescribed DFR 600 ml/min, actual was 500 ml/min for the entire 180 minute prescribed treatment duration. No documentation noted in the flowsheet. MR6: Flowsheet dated June 25, 2025: prescribed treatment duration 240 minutes, actual treatment duration 227 minutes, a deviation of 13 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent the medical record. Flowsheet dated June 27, 2025: prescribed treatment duration 240 minutes, actual treatment duration 223 minutes, a deviation of 17 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent the medical record. Flowsheet dated June 30, 2025: prescribed treatment duration 240 minutes, actual treatment duration 205 minutes, a deviation of 17 minutes. Documentation was noted in the flowsheet but a completed AMA form was absent the medical record. Flowsheet dated July 2, 2025: prescribed treatment duration 240 minutes, actual treatment duration 215 minutes, a deviation of 25 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent the medical record. Flowsheet dated July 4, 2025: prescribed treatment duration 240 minutes, actual treatment duration 230 minutes, a deviation of 10 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent the medical record. During an interview on July 7, 2025, at 2:24 P.M., Employee (EMP) 9 indicated any deviations from prescribed BFR/DFR or any shortened treatments should be documented in the flowsheet and the charge nurse notified immediately. EMP9 also stated that an AMA form should be completed any time a patient shortens the prescribed treatment length. During an interview on July 8, 2025, at 8:40 A.M., EMP16 indicated it is their expectation that the treatment prescription should be “followed to the ‘t.’” EMP16 stated that includes any deviation from the prescription, including any deviations from the prescribed DFR/BFR or any time a patient’s prescribed length of treatment is shortened.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49355 Based on observations, interview and document review, it was determined the facility failed to properly care for arteriovenous (AV) grafts/fistulas according to the facility’s policy. Specifically, in one (1) out of three (3) observations, facility staff touched the cannulation site of arteriovenous (AV) fistulas when discontinuing dialysis. The findings: The facility’s procedure entitled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles,” procedure 1-04-01B, revision date April 2023, reads, in part: ... “Procedure ... 5. Remove tape from one needle insertion site. Observe needle site for changes during treatment. Place gauze gently but firmly over needle insertion site. ... 6. Slightly remove needle & slide safety device in place.” On July 7, 2025, at 2:57 P.M., employee (EMP) 4 discontinued dialysis on patient (MR) 7 at station #11. EMP4 pulled the fistula needle and, using a gloved finger, applied pressure to the exit site. Once EMP4 disposed of the needle in the sharps container, EMP4 placed a folded piece of gauze over the exit site. In an interview on July 8, 2025 at 9:16 A.M., EMP10 indicated that once a fistula needle is removed, a folded gauze should immediately be placed over the exit site and pressure applied. EMP10 agreed that a finger should never be used in place of a gauze pad.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 40084 Based on interview and record review, it was determined the facility’s Quality Assurance and Performance Improvement (QAPI) program failed to take action to ensure sustained improvement over time. Specifically, the QAPI program failed to correct known issues related to hand hygiene, cleaning of the dialysis station, expired medications, and documenting as well as taking action to address abnormal findings. The findings include: Tag V-0113 The current recertification survey Based on observations, interview and document review, it was determined the facility failed to follow infection control and prevention practices related to hand hygiene (HH) and glove changing. Specifically, hand hygiene (HH) was not performed and gloves were not changed, per policy, during four (4) infection control observations of discontinuation of dialysis with an arteriovenous (AV) fistula and staff moving from one patient treatment station to another. Recertification survey ending February 16, 2022 Based on staff interview and document review, it was determined the facility staff failed to ensure appropriate hand washing or use of alcohol based sanitizer during two (2) of three (3) observations conducted. Tag V-0121 and V-0141 The current recertification survey Based on observations, interview and document review, it was determined the facility failed to maintain a safe environment by not disposing of contaminated sharps at the point of use in one (1) out of three (3) observations when deaccessing a patient (MR) with a fistula or graft. Recertification survey ending February 16, 2022 Based on staff interview and surveyor observation, it was determined the facility staff failed to ensure the implementation of infection control precautions to include the handling, storage and disposal of potentially infectious waste. Specifically, the facility staff failed to ensure that needles were discarded in the sharps contained at the point of use during one (1) of three (3) observations of discontinuation of dialysis for an AV fistula or graft. Additionally, the facility staff failed to ensure proper handling of infectious waste. Tag V-0122 The current recertification survey Based on observations, interview and document review, it was determined the facility failed to ensure that dialysis stations and chairs were appropriately and completely disinfected between patients in three (3) out of three (3) observations. In addition, the facility failed to completely remove tape residue present on many chair side tray tables. Recertification survey ending February 16, 2022 Based on observations, interviews, and a review of the dialysis facility’s policies, it was determined the facility staff failed to follow standard infection control precautions related to cleaning and disinfection of contaminated surfaces, medical devices, and equipment. Specifically, the facility staff failed to adequately disinfect each dialysis station after use during two (2) of three (3) observations of cleaning stations. Tag V-0143 The current recertification survey Based on observation, interview and document review, it was determined the facility failed to remove expired medications so they are not available for patient use in the dialysis facility. Recertification survey ending February 16, 2022 Based on observation and facility policy review, it was determined the facility staff failed to ensure two (2) expired medications were not available for patient use. Tag V-0543 The current recertification survey Based on medical record reviews, document review and interviews, it was determined the facility failed to document abnormal findings and notification to the charge nurse or physician of: 1) unmet target weights (TW) compared to post treatment weights (PTW) in two (2) out of five (5) medical records reviewed; and 2) blood pressure (BP) measurements outside of facility guidelines in two (2) out of five (5) medical records reviewed. Recertification survey ending February 16, 2022 Based on interview, record review, and facility document review, it was determined that the facility staff failed to address abnormal findings identified during or at post-treatment for three (3) of the six (6) in-center patients reviewed.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 49355 Based on observations, interviews and document review, it was determined that the facility failed to follow policy related to the use of clamps in one (1) hemodialysis patient. The findings: The facility’s policy entitled, “Utilizing Vascular Access Clamps,” policy 1-04-08, revision date April 2019, reads, in part: ... “Policy: ... 3. Vascular access clamps should not be used routinely. However, if a patient is unable to hold his/her own sites, it is recommended that only one (1) clamp is used at a time and should not be left on longer than 20 minutes.” On July 7, 2025, at 10:00 A.M., patient (MR) 1 at station #17 was observed with two (2) clamps on the left arm over a fistula site. A review of the medical record for MR1 revealed no documentation for an order for clamp usage. During an interview on July 7, 2025, at 2:24 P.M., employee (EMP) 9 indicated the facility policy stated only one (1) clamp should be used at a time and orders for clamp usage would need to be obtained prior to application. During an interview on July 8, 2025, at 8:40 A.M., EMP16 indicated that an order for the usage of clamps should always be obtain prior to using clamps and one (1) clamp should be sufficient.”