Davita Tyson’s Corner Dialysis

“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: 42929 Based on observations, interviews, and facility document review, it was determined the facility failed to label spray bottles containing a clear liquid used for disinfection. Findings: During the flash tour on 05/20/2024 at 10:03 a.m., the surveyors observed two (2) spray bottles filled with a clear liquid on a rack near the lab area of the treatment floor. The bottles were not labeled with the contents. A staff member stated that the spray bottles were used by the biomedical technician. Later that day, Staff Member #1 notified the surveyors that the two (2) spray bottles were discarded and should not be used in the treatment area. On 05/21/2024 at 9:50 a.m., the surveyor observed one (1) spray bottle filled with a clear liquid on a rack near the lab area of the treatment floor. On 05/21/2024, Staff Member #1 notified the surveyors that a spray bottle was found on the treatment floor today, after the two (2) spray bottles from the prior day had been discarded. Staff Member #1 determined that the spray bottles were from housekeeping. Staff Member #1 stated that Staff Member #1 would notify housekeeping that bottles need to be labeled with contents and that all spray bottles for housekeeping need to be stored in the housekeeping closet. The facility’s policy titled “Infection Control” last revised April 2023 states in part: ... Spray bottles containing cleaning solutions are single use and cannot be reused or refilled.... Pressurized washers, spray bottles, or sprayers for cleaning purposes will not be used on wall boxes or the adjoining area.... The above concerns were discussed with Staff Member #1 and Staff Member #10 at the exit conference on 05/21/2024 at 3:45 p.m.”

“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: 36946 Based on three (3) infection control observations, interview, and document review, it was determined that facility staff failed to follow required infection control and prevention practices related to hand hygiene. Findings: During the flash tour on 05/20/244 at 10:24 a.m., Staff Member #8 silenced the alarms on the machine at station #3 without wearing gloves. At 10:45 AM on 05/20/24 the surveyor observed Staff Member #7 putting one glove on to silence the machine alarm and removing the glove. No hand hygiene was performed after removing the glove. At 10:50 AM on 05/20/24, Staff Member #8 decannulated the patient at station #12. The Staff Member went to the sink to perform hand hygiene. Staff Member #8 immediately rinsed soap from hands without lathering and rinsed their hands with water for approximately five (5) seconds. The facility’s policy, Infection Control for Dialysis Facilities was reviewed and reads in part, All teammates, physicians, and non-physicians will perform hand hygiene...prior to gloving and immediately after removal of gloves. The above noted findings were discussed an confirmed with staff member #1 during interviews on 05/20/24 and 05/21/24.”

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the facility failed to have a sufficient number of sinks available for handwashing. Findings: A flash tour was conducted the morning of 05/20/24. The facility had three (3) sinks on the treatment floor labeled as clean sinks. One sink at the nurses’ station contained standing water, did not drain, and was not functional at the time of the tour. A second sink at the back of the treatment floor did not turn on and had no paper towels or soap. Observations revealed one (1) functioning sink for fifteen (15) treatment stations the morning of 05/20/24. Interviews conducted with Staff Member #1 on 05/20/24 and 05/21/24 revealed the sink at the nursing station had stopped draining the morning of 05/20/24 and a plumber was called to repair the sink on 05/20/24. The sink at the back of the treatment floor has never worked as a sink as the sink was never plumbed with hot or cold water. Staff Member #1 confirmed only one (1) functioning sink was available for use during treatments on 05/20/24. Observations on 05/21/24 revealed techs waiting in line to use the sink to perform hand hygiene after patient care due to lack of sufficient number of sinks. The facility’s policy, Infection Control for Dialysis Facilities was reviewed and reads in part, “Sinks should be easily accessible and readily available in the treatment area and in other appropriate areas such as the medication area, home training room, and isolation area/room. a. Sinks must be plumbed with both hot and cold water....c. Soap and a supply of paper towels protected from contamination must be available at each clean sink.””

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 36946 Based on observation, staff interview and document review, it was determined the facility failed to ensure items taken to the dialysis station were cleaned and disinfected before being taken to a common area. Specifically, dialysis staff failed to disinfect the temporal thermometer after each patient use in two (2) of two (2) observations of thermometer use. Findings: The surveyor observed Staff Member #7 utilize a temporal thermometer at 10:25 AM on 05/20/24 on a patient at station #9. The thermometer was not cleaned or disinfected before returning it to a central computer station. The surveyor observed Staff Member #8 utilize a temporal thermometer on an unsampled patient at 10:55 AM on 05/20/24. The thermometer was not cleaned or disinfected before returning it to a central computer station. The facility’s policy, Infection Control for Dialysis Facilities was reviewed and reads in part: Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. An interview was conducted with Staff Member #5 on 05/20/24 who confirmed the need to clean thermometer after each patient use.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 36946 Based on staff interview, observation, and document review, it was determined the facility failed to ensure proper handling of infectious material. Specifically, the facility failed to properly store patient blood specimens. Findings: During a flash tour on 05/20/24 at 10:30 AM, the surveyor observed two (2) specimen bottles containing patient blood for blood cultures. The specimens were stored in a plain plastic bag, and not labeled as a biohazard. The bag was sitting, unsecured on a table in the back of the treatment floor. The facility’s policy, Obtaining Patient Lab Specimen was reviewed and reads in part, “Blood specimens are to be placed in holders or racks immediately or as soon as possible after collection to prevent breakage and/pr contamination.” An interview was conducted with Staff Member #10 on 05/21/24 who stated that the facility has racks to hold blood tubes, but the blood culture bottles do not fit on those racks. Staff member #10 confirmed the specimens should not be sitting on the tabletop in an unlabeled bag.”

“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: 36946 Based on staff interview, observations, and document review, it was determined the facility failed to ensure staff cleaned and disinfected each dialysis station after use in two (2) of five (5) observations conducted of cleaning dialysis stations. Findings: On 05/21/24 at 10:20 AM the surveyor observed Staff Member #16 cleaning station #13 after patient use. Staff Member #16 failed to clean or disinfect under the tables of the dialysis chair. Staff member #16 failed to clean the wall box after patient use. On 05/21/24 at 10:59 AM the surveyor observed Staff Member #13 cleaning station #1. Staff Member #16 failed to clean or disinfect under the tables of the dialysis chair. Staff member #16 failed to clean the wall box after patient use. The facility’s policy, Infection Control for Dialysis Facilities was reviewed and reads in part: At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g. control panel; top, front and sides of dialysis machines; touchscreens; countertops). The Wall box, drain and waster supply lines are considered part of the dialysis delivery system. An interview was conducted with Staff Member #1 on 05/21/24 who confirmed the entire dialysis station should be cleaned and disinfected after each patient use.”

“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: 36946 Based on observations, interviews, and document review, it was determined the facility staff failed to ensure aseptic technique when preparing and administering medications. Specifically, the facility failed to include all of the necessary components of medication labeling and failed to remove expired medications from use. Findings: During the flash tour on 05-20-2024 at 10:24 AM, a syringe labeled Karsuva 0.5 ml was observed in the medication refrigerator with no documented preparer initials or time of preparation. The facility’s policy titled “Preparation and Administration of IV Difelikefalin (Korsuva)” states in part: ... 13. Label the syringe(s) with the patient’s name, name of the prescribed medication, dose, date, time, and initials of licensed teammate preparing the dose. ... All doses from single dose Difelikefalin (Korsuva) vial(s) must be drawn up and administered within a one (1) hour period .... During a tour of the home dialysis treatment area on 05-20-2024 at 12:16 P.M., the surveyor observed an expired bag of dialysate in the evacuation kit with an expiration date of 04/2024. Four (4) heparin syringes were observed at patient stations with no documented preparer initials or time of preparation on 05/20/24 at 10:50 AM. Two (2) heparin syringes were observed at a patient station with no documented preparer initials or time of preparation at 2:15 PM on 05/20/24. The facility’s policy, Medication Policy was reviewed and reads in part: If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of the teammate preparing the medication. An interview was conducted with Staff Member #1 on 05/20/24 who confirmed medications should be labeled with the preparer’s initials and date and time of administration.”

“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: 36946 Based on observation, interview and document review, it was determined the facility failed to maintain a safe treatment environment, Specifically, the facility failed to ensure it securely stored oxygen tanks while not in use. Findings: A flash tour was conducted on 05/20/24 at 10:20 AM. During the flash tour five (5) oxygen cylinders were observed in the back of the treatment area. Three (3) of the cylinders were secure in a rack, while two (3) cylinders were stored standing up, directly on the floor. An interview was conducted with staff member #5 on 10/20/24 who confirmed oxygen tanks should be stored securely in a rack and not directly on the floor. The facility’s policy, Emergency Equipment Checks was reviewed and reads in part: ...7. The oxygen tank(s) will be checked for an adequate amount of oxygen (500 psi or more) and stored in compliance with local and/or state regulations. A review of the LIS Virginia Law Code of Virginia Administrative Code: Title 4. Conservation And Natural Resources “ Agency 25. Department of Energy “ Chapter 40. Safety and Health Regulations for Mineral Mining “ Part VIII. Compressed Air, Gases, and Boilers-Surface and Underground “ 4VAC25-40-1250. Securing cylinders” states in part: Compressed gas or liquid gas cylinders shall be safely secured in an upright position. A review of the 2015 Virginia Statewide Fire Prevention Code states in part: ...5303.5.3 Securing Compressed Gas Containers, Cylinders and Tanks Compressed gas containers, cylinders and tanks shall be secured to prevent falling caused by contact, vibration or seismic activity. Securing of compressed gas containers, cylinders and tanks shall be by one of the following methods: Securing containers, cylinders and tanks to a fixed object with one or more restraints. Securing containers, cylinders and tanks on a cart or other mobile device designed for the movement of compressed gas containers, cylinders or tanks. Securing of compressed gas containers, cylinders and tanks to or within a rack, framework, cabinet or similar assembly designed for such use...”

“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: 42929 Based on interviews, medical record review, and facility document review, it was determined the interdisciplinary team failed to ensure that the plan of care was signed by the team members including the patient or patient’s designee, or documented on the plan of care the reason the signature was not provided for two (2) of seven (7) patients’ plans of care reviewed. Findings: On 05/21/2024 the surveyors reviewed seven (7) patients’ plan of care. The plan of care for Patient #1 from 04/29/2024 was not signed by the patient and there was no documentation on the plan of care of the reason the signature was not provided. The plan of care for Patient #6 was not signed by the interdisciplinary team or by the patient or patient’s designee. Staff Member #10 stated that the plan of care was completed on 05/20/2024 and confirmed that it had not been signed. The facility’s policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” last revised July 2023 states in part: ... 14. The patient’s plan of care will be completed by the facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided.... The above concerns were discussed with Staff Member #1 and Staff Member #10 at the exit conference on 05/21/2024 at 3:45 p.m.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 42929 Based on interviews, medical record review, and facility document review, it was determined the interdisciplinary team failed to implement the initial plan of care within the latter of thirty (30) calendar days after admission to the dialysis facility or thirteen (13) outpatient hemodialysis sessions beginning with the first outpatient dialysis session for two (2) of two (2) initial patients’ plan of care reviewed. Findings: On 05/21/2024 the surveyors reviewed the initial plan of care (POC) for two (2) patients who started dialysis treatment in the last ninety (90) days. As per Staff Member #10, Patient #1 started dialysis treatment at another facility on 02/22/2024 and transferred to this facility on 02/28/2024. The first plan of care for Patient #1 was dated 04/29/2024, which is more than thirty (30) days and thirteen (13) treatments from the first outpatient dialysis session. The medical record for Patient #6 contained evidence that the patient’s first dialysis treatment was on 03/18/2024 and Staff Member #10 confirmed that the patient’s initial plan of care was finalized on 05/20/2024, which is more than thirty (30) days and thirteen (13) treatments from the first outpatient dialysis session. The facility’s policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” last revised July 2023 states in part: ... 10. An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within [thirty] 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.... The above concerns were discussed with Staff Member #1 and Staff Member #10 at the exit conference on 05/21/2024 at 3:45 p.m.”

“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 observation, interview and document 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 identified during the previous recertification survey. The findings include: Tag V-0113 Current Recertification Survey Based on three (3) infection control observations, interview, and document review, it was determined that facility staff failed to follow required infection control and prevention practices related to hand hygiene. Recertification Survey Ending May 26, 2021 Based on observations, interviews, and a review of the dialysis facility’s policies, it was determined that two (2) staff members failed to follow required infection control and prevention practices related to hand hygiene. Tag V-0143 Current Recertification Survey Based on observations, interviews, and document review, it was determined the facility staff failed to ensure aseptic technique when preparing and administering medications. Specifically, the facility failed to include all of the necessary components of medication labeling and failed to remove expired medications from use. Recertification Survey Ending May 26, 2021 Based on observations, staff interviews and facility document review, it was determined the facility staff failed to ensure two (2) expired medications were not available for patient use. The facility also failed to ensure proper labeling of five (5) opened medication vials according to the facility policy.”

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 42929 Based on observation, interview, and document review, it was determined the facility staff failed to safeguard patient information by not securing a copy of each patient’s treatment orders and medication list inside of the evacuation kit with a breakaway lock, as per the facility’s policy. Findings: During the flash tour on 05/20/2024 at 10:03 a.m., the surveyor observed a binder containing all in-center patient’s treatment orders and medication lists located on top of the facility’s evacuation kit. The evacuation kit was secured with a breakaway lock, but the patients’ health information was not secured inside of the evacuation kit. The facility’s policy titled “Facility Emergency Management Plan” states in part: “... 6. Each evacuation kit(s) should contain: a. Copy of each patient’s treatment orders and medication list.... 8. Evacuation kit will be sealed with a breakaway lock and is only opened in the event of an emergency situation, monthly review, and/or the replacement of outdated item.... The above concerns were discussed with Staff Member #1 on 05-20-2024 at 2:45 p.m. and again with Staff Member #1 and Staff Member #10 at the exit conference on 05/21/2024 at 3:45 p.m.”