Virginia Beach Home Dialysis

“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: 42043 Based on observation, interview and facility policy review, the facility staff failed to maintain supplies in the evacuation kit in date, five (5) of five (5) normal saline bags were expired. The findings included: During the flash tour on 11/27/23, the survey team inspected the contents of the facility’s evacuation kit. The evacuation kit contained five (5) 1 liter bags of normal saline, all with expiration date of 8/2023. SM #1 confirmed that the box is checked on monthly basis, staff uses a checklist to document completion of the task and verify expiration dates, quantities present and if items are in good condition for use. The survey team reviewed the “Emergency Box Contents YEAR 2023” checklist that documented the following in part, “Material: Saline bags, QTY 5, UoM All licensed stations, Exp Date 8/23” The checklist contained on the line for saline checkmarks for January - November . The survey team notified SM #1 of the expired supplies who promptly removed them and stated they will replace supplies by the following business day. On 11/28/23, the survey team reviewed the facility policy titled, Emergency Medications, Equipment and Supplies (published 5/1/2023) that stated in part, “An emergency evacuation box must:... Be checked monthly or after use for contents, expiration dates and cleanliness...” ON 11/28/23 SM #1 provided to the survey team with an updated checklist document that evidence the saline bags were replaced and will expire in October 2024. The above noted findings were discussed again with SM #1 and”

“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: 40084 Based on record review and interview, it was determined the facility failed to test for color blindness one (1) of three (3) staff members who conduct water quality testing. The findings include: A surveyor conducted a review of personnel/medical records for staff member #2, 4, and 5 on November 28, 2023. During that record review, the surveyor could not find documented color blindness testing for Staff Member #4. At 3:00 p.m., the surveyor spoke with Staff Member #1 about the missing document. Staff Member #1 advised that Staff Member #4 was not in the facility that day and they did not want to “look through [their] stuff.” A review of the facility policy titled “Color Blindness Testing” states in part: “The manager or designee is responsible for administering and recording the results of the Ishihara Test for Color Blindness on the business specific scoring sheet. The manager is responsible for confirming the test results are documented and placed in the employee’s medical file.””

“GOV-RESPONDS TO NW REQUEST/WORKS TOWARD GOALS CFR(s): 494.180(i) The governing body receives and acts upon recommendations from the ESRD network. The dialysis facility must cooperate with the ESRD network designated for its geographic area, in fulfilling the terms of the Network’s current statement of work. Each facility must participate in ESRD network activities and pursue network goals. This Standard is not met as evidenced by: 40084 Based on document review and interview, it was determined the facility failed to participate in ESRD network activities and pursue network goals. The findings include: On 11/28/2023, the surveyor conducted a review of the facility’s Quality Assurance and Performance Improvement Program (QAPI) with Staff Member #1. During that review, the surveyor inquired if the facility is participating in a specific project with the renal network. Staff Member #1 advised the facility was not currently participating in an ESRD network project. The surveyor reached out to the renal network to determine if the facility is actively communicating and participating in network activities. On 11/28/23, the network advised the facility is currently not enrolled in an ESRD network project and additionally the facility last accessed their facility report in September 2023. The facility is required to access this ESRD network report on a monthly basis.”