Rai - Mechanicsville Trnpk-Richmond

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 46466 Based on interviews, medical record reviews and facility document reviews, the facility failed to provide Emergency Preparedness Training, per facility policy, to one (1) of twelve (12) patients included in the medical records sampled. The findings include: On December 16, 2025, Patient #9’s medical record was reviewed. The record contained an “Incenter HD Patient Participation in Emergency and Disaster Preparedness Form”, with no date that indicated “Pt (patient) not able” and “The patient was unable to correctly verbalize one or more of the above. Verbal reinforcement of training and education and/or patient hand-outs were provided on the following: (RN to perform retraining if needed). The form was signed by a staff member, but the quality of the copy made the signature illegible. There was no other documentation found that the patient was educated to take-off procedures prior to this documentation. There was no provided documentation in Patient #9’s record to indicate that the patient was identified as needing assistance to disconnect during evacuation. On December 16, 2025, at 1:30 PM, an interview was conducted with Patient #9. Patient #9 was verbal and stated they were never taught how to remove themselves from the dialysis machine in the event of an emergency. The patient indicated that staff would remove them. Patient #9 also stated that the facility never had a fire drill during the two (2) years the patient was treated there. A review of the facility policy “Fire Drill”, published August 2, 2017, indicated in part: “...Patient Assistance in Evacuation, Some patients, due to medical or cognitive impairments may be unable to perform or verbalize how they would disconnect and evacuation {sic}. The Interdisciplinary Team (IDT) will identify, patients who need assistance in disconnection and evacuation during an emergency and document in the patients’ medical record...the need for assistance...”. A review of the facility’s policy “Guidelines for Emergency Preparedness”, published September 2, 2025, indicated in part: “...QAI Documentation: Quarterly, all...patients must receive fire drill and emergency evacuation training...Patient Education: Facility staff must educate patients on: Evacuation procedures, Emergency Disconnection Procedures...It is important for staff to engage patients in disaster drills and emergency procedures...”.”

“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: 46466 Based on interviews, medical record and facility documentation review, the facility failed to provide guidelines for Emergency Preparedness (EP) training to newly admitted patients, per Center for Medicaid/Medicare (CMS) federal regulations, in their policies and procedures. The facility also failed to provide evidence of EP training for one (1) newly admitted patient included in the records sampled. The findings include: Patient #3’s medical record evidenced an admission date of September 11, 2025. The record did not contain any documentation that EP education was performed. On December 16, 2025, at 1:45 PM, an interview was conducted with Patient #3. Patient #3 stated that staff had never reviewed any fire drill evacuation or education with them on how to remove themselves from the machine in the event of an emergency. On December 16, 2025, at 3:00 PM, Staff Member #1 stated that the facility performs EP education with patients on a quarterly basis and the reason for Patient #3 not having EP education was because they were newly admitted and the EP education had not occurred in the 4th quarter yet. Staff Member #1 stated that orienting a new patient to EP training would be a good idea. A review of the facility’s policy “Guidelines for Emergency Preparedness”, published September 2, 2025, indicated in part: “...QAI Documentation: Quarterly, all...patients must receive fire drill and emergency evacuation training...Patient Education: Facility staff must educate patients on: Evacuation procedures, Emergency Disconnection Procedures...It is important for staff to engage patients in disaster drills and emergency procedures...”. The policy did not include guidelines on orienting newly admitted patients to the facility’s EP.”

“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: 46466 Based on observations and facility document review, the facility failed to maintain a safe environment for patients and employees by using a personal cell phone on the treatment floor while patients were dialyzing. The findings include: A review of the facility policy “Use of Portable Electronic Communication Devices”, no publish date, indicated in part: “Employees in clinical settings are permitted to use portable communication devices during break or meal periods, however: Devices must be kept out of sight of patients and clients, and used only in a break room or other non-public locations...”. On December 15, 2025, at 11:25 AM, Staff Member # 7 was observed on the treatment floor in Personal Protective Equipment (PPE) sitting in a chair approximately 12 feet from a patient dialyzing on a machine. Staff Member #7 was looking at their personal cell phone. The staff member was in full view of patients.”

“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: 46466 Based on observations and facility document review, the facility staff failed to properly perform hand hygiene between donning and doffing gloves per clinic policy. The findings include: A review of the facility’s policy “Hand Hygiene”, published November 6, 2023, indicated in part: “...Hands will be...Decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water...Entering and leaving the treatment area...After contact with other objects within the patient station or treatment space...”. A review of the facility’s policy “Personal Protective Equipment”, published November 6, 2023, indicated in part: “...Staff must remove gloves and wash hands after...Touching any surfaces within the patient station...”. On December 15, 2025, at 2:50 PM, the surveyor observed Staff Member #9 enter the treatment floor without performing hand hygiene, and touch the screen of a dialysis machine where a patient was dialyzing. Staff Member #9 was not wearing gloves when this occurred.”

“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, the facility failed to maintain a safe environment for dialysis patients by not discarding expired medications, and not properly labeling syringes and open medication vials. The findings include: A review of the facility’s policy “Medication Preparation and Administration”, published July 7, 2025, indicated in part “...All medications in syringes not being administered immediately shall be labeled appropriately with the...time and initials of the person who prepared the medication...When preparing medications, if the vial is not used immediately in its entirety, the nurse or PCT...must place the date and time the vials was opened on the medication label along 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 date and time the vial was opened. Label any open multi-dose vial that is not used immediately and store vial accordingly...Expiration dates for all stored medications are to be monitored monthly basis -Expired medications are to be discarded...CDC immunization program states vaccines are to be discarded per manufacturer’s expiration date...”. On December 15, 2025, at 10:30 AM, four (4) labeled syringes filled with heparin were found on the treatment floor. The labels did not contain the time and initials of the person who prepared the medication. In addition, an opened vial of heparin was also found that did not contain the date, time and initials of the person who opened the vial. On December 15, 2025, at 11:15 AM, an open, multi-dose vial of Epogen was found in the medication refrigerator. The vial did not contain the date or time that the vial was opened. Four (4) boxes of COVID-19 vaccines were also found in the refrigerator with an expiration date of December 2024.”

“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 failed to maintain aseptic technique for CVC (central venous catheter) exit site dressing changes. The findings include: On December 15, 2025, at 10:40 AM, a staff member was observed performing CVC exit site care at a patient station. The staff member removed the old dressing and began to disinfect the exit site. The staff member did not remove their dirty gloves, perform hand hygiene and donn new gloves prior to disinfecting the exit site. A review of the facility’s policy “Changing the Catheter Dressing Procedure”, published May 2, 2025, indicated in part: “... Removal of Dressing and Inspection of Site...5. Inspect and removed the old dressing...8. Discard dressing and remove gloves. Perform hand hygiene...”.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 46466 Based on a facility document review, the facility failed to monitor the total chlorine levels at a minimum of every four hours per CMS regulation and facility policy. The findings include: The facility’s policy titled, “Carbon Filtration Monitoring for InCenter Central Water Systems”, published May 5, 2025, indicated in part: “...Total Chlorine test will be performed prior to initial treatment and every four hours. All testes must be completed within 4 hours. If unable to perform total chlorine testing within 4 hours of the previous test, treatments must be discontinued...”. On December 16, 2025, a review of the facility’s carbon tank logs identified the following: The November 2025 log evidenced four (4) total chlorine tests that were not performed within the four (4) hour maximum time limit, occurring on the 1st, 10th, 23rd, and the 26th. The 1st missed testing at 12:30 PM, and the 10th, 23rd and the 26th missed testing’s at 3:30 PM. The December log evidenced one (1) total chlorine test not performed within the required four (4) hour maximum time limit occurring on December 11, 2025. The 10th missed testing at 8:30 AM and 3:30 PM. Staff Member #1 provided documentation of the November and December 2025 dates and times of when patients completed dialyzing. Patients completed treatments on the following dates and times: November 1 - 4:02 PM, November 10 - 4:12 PM, November 23 - 4:08 PM, November 26th - 4:59 PM, December 11 - 4:25 PM.”

“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 interviews, medical record and facility document review, the facility failed to (A) monitor blood pressures pre, intra and post dialysis and alert the Charge Nurse (CN) of abnormal findings; record sitting and standing blood pressures; (B) perform nursing assessments within one (1) hour of initiation of dialysis and; (C) to obtain machine and safety parameters every 45 minutes for patients for seven (7) of 12 patient records sampled. The findings include: Patient #1: (A) Six (6) of six (6) flowsheets reviewed evidenced blood pressures pre/intra/post dialysis, above 180/100 mm Hg without notification to the CN or documentation that the CN assessed and made interventions. There were no ancillary orders found to initiate dialysis if the patient’s blood pressure was less than 200/110 during these dates. Six (6) of six (6) flowsheets reviewed did not evidence assessment of standing blood pressures. Documentation revealed that the patient ambulated without assistance. (B) Two (2) of six (6) flowsheets evidence nursing assessments not completed within one (1) hour of initiation of treatment. (C) One (1) of six (6) flowsheets revealed that machine and safety parameters, to include blood pressure readings, were not performed within 45 minutes. Patient #2: (A) Four (4) of five (5) flowsheets evidenced blood pressures pre/intra/post dialysis, above 180/100 mm Hg without notification to the CN or documentation that the CN assessed and made interventions. There were no ancillary orders found to initiate dialysis if the patient’s blood pressure was less than 200/110 during these dates. Four (4) of five (5) flowsheets did not evidence assessment of standing blood pressures. Documentation revealed that the patient ambulated without assistance. (C) Three (3) of five (5) flowsheets reviewed revealed that machine and safety parameters, to include blood pressure readings, were not performed within 45 minutes. Patient #3: (A) One (1) of six (6) flowsheets evidenced blood pressures pre/intra/post dialysis, above 180/100 mm Hg without notification to the CN or documentation that the CN assessed and made interventions. There were no ancillary orders found to initiate dialysis if the patient’s blood pressure was less than 200/110 during these dates. Six (6) of six (6) flowsheets did not evidence assessment of standing blood pressures. Documentation revealed that the patient ambulated without assistance. (B) One (1) of six (6) flowsheets did not evidence nursing assessments completed within one (1) hour of initiation of treatment. (C) Five (5) of six (6) flowsheets evidenced that machine and safety parameters, to include blood pressure readings were not performed within 45 minutes. Patient #4: (A) Three (3) of six (6) flowsheets did not evidence assessment of standing blood pressures. Documentation revealed that the patient ambulated without assistance. (B) One (1) of six (6) flowsheets did not evidence nursing assessments completed within one (1) hour of initiation of treatment. (C) Two (2) of six (6) flowsheets evidenced that machine and safety parameters, to include blood pressure readings were not performed within 45 minutes. Patient #5: (A) Four (4) of four (4) flowsheets did not evidence assessment of standing blood pressures. Documentation revealed that the patient ambulated without assistance. (C) Two (2) of four (4) flowsheets evidenced that machine and safety parameters, to include blood pressure readings, were not performed within 45 minutes. Patient #8: (C) Three (3) of three (3) flowsheets evidenced that machine and safety parameters, to include blood pressure readings, were not performed within 45 minutes. Patient #9: (C) Six (6) of six (6) flowsheets evidenced that machine and safety parameters, to include blood pressure readings, were not performed within 45 minutes. On December 17, 2025, at 1:45 PM, Staff Member #1 stated that when a patient’s blood pressure and/or weight was over their estimated dry weights per facility policy, the CN should document a note in the patient’s record to indicate that they and the physician were aware and what the “game plan” was for the patient. A review of the facility’s policy “Patient Assessment and Monitoring”, published May 1, 2023, indicated in part: “...Data Collection...If the PCT/LPN note any changes or abnormal findings in the patient’s condition...the registered nurse must assess the patient. The RN will notify the patient’s physician/physician extender of any abnormal findings, if necessary, based on clinical judgement for additional instruction. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. Pre-Treatment...Record blood pressure. Verify: Systolic blood pressures greater than 180 mm/Hg and/or diastolic blood pressures greater than 100 mm/Hg...2. During nursing rounds, the Registered Nurse will review the data collected above and assess the following parameters as needed...Data collected Above...Determine if any clinical interventions are necessary...3. Document findings and interventions in the medical record. Contact the physician as needed for additional orders based on assessment findings and clinical judgement. During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations...Step 1: Blood pressure. Record blood pressure...Report to the nurse: Systolic blood pressures greater than 180 mm/Hg. Diastolic blood pressure greater than 100 mm/Hg...Note: When leaving the treatment room, report off to another staff member to ensure patient observation and monitoring during the dialysis treatment...Post treatment...blood pressure: Ensure vital signs and overall condition are stable for discharge...Lung sounds, edema, heart sounds. The registered nurse will assess/re-assess post treatment as indicated. 2. Document findings in the patient’s record”. A review of the facility’s policy “Nursing Supervision and Delegation”, published 11/6/2023, indicated in part: “...Policy: The registered nurse must evaluate each patient preferably within an hour or according to state requirements...Reporting of Patient Care Findings to the Team Nurse in Charge: The staff member who collects information pre, post and during treatment will document their findings. Any observed changes or abnormal findings in the patient’s condition...must be reported to the registered nurse who will assess the patient...Daily Treatment Record Review...The record must be reviewed for...Blood pressures <100 systolic or greater than 180 systolic addressed by the registered nurse with or documentation present...Documentation: Document all findings in the patient’s medical record...The following criteria can be used as a guideline to identify when a PCT/LPN/LVN or RN shall refer a patient to the Team Leader/Charge Nurse for further assessment pre, during or post treatment...Fluid Status: Any weight gains greater than 4 kg pre-treatment...Any post treatment weight with a variance from the estimated dry weight of 1.0 kg...Blood Pressure: A Systolic blood pressure greater than 180 mm/Hg and/or diastolic blood pressure greater than 100 mm/Hg at any time before, during or after the treatment”

“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: 46466 Based on interview, medical record and facility document review, the facility failed to (A) follow physician’s orders for the prescribed dose of dialysis BFR (blood flow rate) for six (6) of twelve (12) patient records sampled and (B) evaluate and document the rationale for patients requesting to end treatment early for one (1) of 12 patient records sampled. The findings include: A review of the facility’s policy “Patient Assessment and Monitoring”, published May 1, 2023, indicated in part: “...During Treatment: Document machine parameters and safety checks every 30 more minutes or more often as needed but not to exceed 45 minutes...3. Machine Parameters and Extracorpeal Circuit - Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered...”. A review of the facility’s policy “Early Termination or Arriving Late for Treatment”, published June 18, 2025, indicated in part: “...If a patient requests to leave treatment early...will be referred to the supervising registered nurse. The registered nurse (RN) will evaluate the patient and discuss with the patient their reasons for requesting to terminate their treatment earlier than prescribed...The RN who evaluates the patient must document the rational for early termination and reinforce the consequences of not receiving the entire prescribed treatment. The RN is responsible to notify the provider, and document on the “AMA”, or Against Medical Advice form...Against Medical Advice forms are: signed by the patient and witnessed by the supervising nurse, signed with each early termination event and filed in the patient’s medical record...All discussions with the patient including information, interventions, or instructions given, and any notification or discussion with the provider, must be documented in the patient’s medical record. Complete documentation of Early Termination of Treatment Against Medical Advice form...”. Patient #1: (A) The surveyor reviewed six (6) dialysis treatment records from December 3-13, 2025. The record evidenced an order for BFR of 450. On December 3, and 9, the BFR was documented as 400. On December 13, the correct BFR/DFR was recorded once between 11:47 AM and 2:47 PM. The record failed to contain documentation of why the BFR was not being administered as prescribed. Patient #2: (A) The surveyor reviewed six (6) dialysis treatment records from September 25 to October 4, 2025. The record evidenced an order for BFR of 475. On September 25, 27 and October 4, the BFR was documented as 400. On September 30, and October 2, the BFR was documented as 450. The record failed to contain documentation of why the BFR was not being administered as prescribed. (B) Documentation revealed that Patient #2 requested to end treatment early 14 times between June 5, 2025 through October 4, 2025. The medical record evidenced four (4) Against Medical Advice (AMA) forms signed by the patient during those dates and one (1) time was documented that the physician was notified. Patient #3: (A) The surveyor reviewed six (6) dialysis treatment records from December 1 - 13. The record evidenced an order for BFR of 450. On December 9, 11 and 13 the BFR was documented as 400. The record failed to contain documentation of why the BFR was not being administered as prescribed. Patient #4: (A) The surveyor reviewed five (5) dialysis treatment records from November 6-18. The record evidenced an order for BFR of 400. On November 8 the BFR was documented as 350. The record failed to contain documentation of why the BFR was not being administered as prescribed. Patient #5: (A) The surveyor reviewed four (4) dialysis treatment records from December 4-9. The record evidenced an order for BFR of 400. On December 9 and 11 the BFR was documented as 450. The record failed to contain documentation of why the BFR was not being administered as prescribed. Patient #9: (A) The surveyor reviewed six (6) dialysis treatment records from December 2-13. The record evidenced an order for BFR of 450. On December 2, 6, and 9 the BFR was documented as 400. The record failed to contain documentation of why the BFR was not being administered as prescribed. In an interview on December 17, 2025, at 1:45 PM, Staff Member #1 stated that even if there were an ancillary order in a patient’s record to adjust the BFR to maintain arterial pressure, the staff member should still document the reason for the change in the patient’s record. Staff Member #1 also confirmed that Patient #2’s medical record did not contain any other signed AMA’s.”