Davita Newington Home Training

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 42929 Based on interviews and facility document review, it was determined the facility failed to contact the local emergency preparedness agency at least annually. Findings: The facility’s policy titled “Facility Emergency Management Plan” last revised April 2024, states in part: ... 11. The FA [facility administrator], or designee, shall have communication at least on an ANNUAL basis with the following local agencies regarding emergency preparedness, event collaboration and communication, needs of the dialysis patients and facility and reviewing agency’s emergency plan. Communication template available on the DEM webpage. NOTE: documentation of contact is important: a. Local Emergency Management Agency ... On September 17, 2024, the surveyor reviewed the facility’s emergency preparedness documentation provided by Staff Member #1. The last documentation that the facility contacted the local emergency preparedness agency was dated January 29, 2020. On September 17, 2024, Staff Member #1 confirmed that there was no documentation that the facility contacted the local emergency preparedness agency as per the regulation and the facility’s policy. On September 18, 2024, Staff Member #1 provided the surveyor with documentation that Staff Member #1 had contacted the local emergency management agency that day.”

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 42929 Based on observations, interviews, and facility document review, it was determined the facility staff failed to ensure that there were breakaway locks on the evacuation kit as per the facility’s policy. Findings: The facility’s policy titled “Facility Emergency Management Plan” revised April 2024, states in part: ... 8. Evacuation kit will be sealed with a breakaway lock and is only to be opened in the event of an emergency situation, monthly review, and/or the replacement of outdated item.... On September 17, 2024, at 9:17 AM, the surveyor observed the evacuation kit contained no breakaway locks on the evacuation kit to secure the medication and patient’s protected health information (PHI). The surveyors notified Staff Member #1, Staff Member #2, and Staff Member 16 that there were no breakaway locks on the evacuation kit as per the facility’s policy.”

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 42929 Based on interviews and facility document review, it was determined the facility staff failed to provide documentation of the Skilled Nursing Facility (SNF) dialysis staff’s emergency preparedness training and education annually as per the facility’s policy. Findings: On September 18, 2024, the surveyor reviewed the SNF dialysis facility’s emergency preparedness binder provided by Staff Member #2. There was no documentation of SNF dialysis staff’s emergency preparedness training and education in the binder provided. On September 19, 2024, the surveyor met with Staff Member #1 and reviewed the SNF dialysis staff’s personnel records. There was no documentation that the SNF dialysis staff completed the facility’s emergency training as per the facility’s policy. The facility’s policy titled “Emergency Management Plan (EMP)” last revised April 2024 states in part: ... Training and Education. 1. The FA, or designee, is responsible to provide training of EMP. a. Teammates: i. Annually 1. Policy Facility Emergency Management Plan 2. Appropriate hazard policies, per HVA [hazard vulnerability assessment] 3. Clinical emergency policies 4. Facility specific emergency response procedures ii. Quarterly 1. Fire Safety Preparedness iii. Upon Hire iv. Any changes and/or updates to EMP or facility specific emergency procedures v. Document training in teammate file 1. Training/In-service Documentation form ... The above concerns were discussed again with Staff Member #7 and Staff Member #10 at the exit conference on 03/27/2024 at 6:00 p.m.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 42929 Based on interviews and facility document review, it was determined the facility staff failed to analyze the dialysis facility’s response annual exercises. Findings: On September 17, 2024, the surveyor reviewed the facility’s emergency preparedness binder provided by Staff Member #1. There was no documentation of exercises to test the emergency plan documented for 2023. The exercise guide for “Active Shooter” and “Power Utility Outage” were documented as reviewed on July 16, 2024, but there was no documentation that the facility’s response to the exercise was analyzed. The above was discussed with Staff Member #1. There was no documentation that the Skilled Nursing Facility (SNF) dialysis unit participated in any exercises provided at the home program location or that any exercises were completed at the SNF dialysis unit. A review of the facility’s policy titled “Emergency Management Plan” last revised April 2024 states in part: ... Emergency Drills 1. The FA, or designee, will maintain the emergency preparedness training and testing based on the facility EMP 2. EMP training exercises: a. The purpose is to test effectiveness of the facility’s emergency plan, emergency response, hazard and risk assessment, and the support of the patient population served. b. Testing exercises should vary, based on the facility’s requirements, by cycles and frequency of testing. c. The intent is that testing exercise provide a comprehensive testing and training for teammates, volunteers, and individuals providing services under arrangement as well community partners. d. Testing exercise must be based on the facility’s identified hazards, to include natural or manmade disasters. e. Frequency: i. The facility will conduct and/or participate in one (1) exercise to test the facility EMP at least ANNUALLY, conducted on OPPOSITE years (one year full-scale exercise, next year facility-based / exercise of choice): 1. Full-scale exercise that is community-based: a. Required when available b. Defined as an operations-based exercise that typically involves multiple agencies, jurisdictions, and disciplines performing functional (for example, joint field office, emergency operation centers, etc.) and integration of operational elements involved in the response to a disaster event, i.e. “boots on the ground” response activities. c. Participation with any of the following: i. Emergency management agency ii. Local, state, and/or federal emergency response agencies iii. Healthcare coalition 2. Individual facility-based exercise: a. Tabletop exercise that includes a group discussion led by the FA b. Scenario situation must be based on hazards relevant to facility c. Designed to challenge facility EMP d. Actions taken will be simulated and not disrupt patient treatments e. Facility may choose to participate instead in a full-scale community based exercise f. If the facility experiences an actual emergency event or response of sufficient magnitude that requires activation of the relevant emergency plans meets the full-scale exercise requirement and exempts the facility for engaging in their next required community-based full-scale exercise or individual, facility-based exercise for following the actual event. i. Documentation is required 1. Utilize Facility Emergency Plan Activation template and document: a. Event that occurred b. Plan and policies activated c. Evaluation of plan d. Plan revisions required e. Governing Body review ii. Maintain copy with facility EMP...”

“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: 42929 Based on observations, interviews, and facility document review, it was determined the Skilled Nursing Facility (SNF) dialysis unit failed to ensure that visitors were wearing gowns when on the treatment floor as per the facility’s policy. Findings: The facility’s policy titled “DSD [Davita SNF Dialysis] Infection Control For Dialysis Facilities” dated April 2024, states in part: ... 6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physician (NPP) and visitors when in the treatment den/bedside area.... On September 17, 2024, at 9:38 AM, the surveyor observed a visitor, who was identified as the patient transporter and a SNF employee, on the treatment floor speaking to patients, and not wearing a gown. On September 17, 2024, at 10:28 AM the transporter donned a gown, brought the patient to the scale, then removed the gown and wheeled the patient back through the treatment floor to access the ramp to transport the patient out of the SNF dialysis unit. On September 17, 2024, at 12:43 PM, three (3) SNF staff members proceeded on to the treatment floor and did not don gowns. The surveyor discussed the above concerns with Staff Member #2 and noted that all visitors and transporters will need to wear gowns on the treatment floor as per the facility’s policy. Staff Member #2 indicated that they could put hooks on the wall and gowns by the dialysis facility’s entrance, so that visitors can don gowns prior to going up the wheelchair ramp and directly on to the treatment floor. The visitors can remove their gowns at the bottom of the ramp before the exit the dialysis facility treatment area.”

“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: 42929 Based on two (2) infection control observations and facility document review, it was determined the facility staff failed to ensure cleaning and disinfecting of contaminated surfaces and equipment. Findings: The facility’s policy titled “DSD [Davita Skilled Nursing Facility (SNF) Dialysis] Infection Control for Dialysis Facilities” dated April 2024, states 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, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops). i. The Wall box, Drain and Water supply lines are considered part of the dialysis delivery system.... ii. Priming containers are to be emptied prior to disinfection.... On September 17, 2024, at 9:54 AM, the surveyor observed Staff Member #11 cleaning dialysis station #5. Staff Member #5 failed to wipe the outside arms of the chair under the tray table. Staff Member #5 wiped the blood pressure cuff, then placed the cuff on the IV (intravenous) pole of the machine that had not been cleaned. The staff member did not wipe the inside of the prime waste bucket and after wiping the outside of the bucket, placed the bucket back on the machine that had not been cleaned. The emergency kit and laminated card on the IV pole, the reverse osmosis (R.O.) unit at the station, wall box, and sharps container were not wiped with a bleach wipe. On September 17, 2024, at 10:33 AM, the surveyor observed Staff Member #11 cleaning dialysis station #4. Staff Member #4 failed to wipe the outside arms of the chair under the tray table. Staff Member #4 wiped the blood pressure cuff, then placed the cuff on the IV (intravenous) pole of the machine that had not been cleaned. The staff member did not wipe the inside of the prime waste bucket and after wiping the outside of the bucket, placed the bucket back on the machine that had not been cleaned. The emergency kit and laminated card on the IV pole, the reverse osmosis (R.O.) unit at the station, wall box, and sharps container were not wiped with a bleach wipe. On September 18, 2024, Staff Member #1 and Staff Member #16 were made aware of the above concerns.”

“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: 42929 Based on observations, interviews, and document review, it was determined the Skilled Nursing Facility (SNF) dialysis unit staff failed to remove expired medications from use. Findings: During the observations at the SNF dialysis facility on September 17, 2024, at 9:15 AM, the surveyor observed forty-one (41) vials of expired Hectorol dated July 2024, in the medication cabinet. Staff Member #1 and Staff Member #10 were made aware of the expired medications available for use. The facility’s policy titled “Medication Policy” dated October 2023, states in part: ... 30. ... 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....”

“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: 42929 Based on interviews and document review, it was determined that the facility staff failed to ensure the Registered Nurse (RN) was notified when patient’s post treatment weight was above or below 1 kg from target weight for three (3) of three (3) patients, Patient #3, Patient #4, and Patient #5, receiving in-center hemodialysis at the Skilled Nursing Facility (SNF) dialysis unit. Findings: The medical record for Patient #3 revealed on August 23, 2024, August 26, 2024, and September 13, 2024, the patient’s post treatment weight was greater than 1 kg below the target weight and there was no notification to the licensed nurse documented, as per facility policy. The medical record for Patient #4 revealed on September 2, 2024, the patient’s post treatment weight was greater than 1 kg above the target weight and there was no notification to the licensed nurse documented, as per facility policy. On September 6, 2024, September 7, 2024, and September 9, 2024, the patient’s post treatment weight was greater than 1 kg below the target weight and there was no notification to the licensed nurse documented, as per facility policy. The medical record for Patient #5 revealed on August 30, 2024, the patient’s post treatment weight was greater than 1 kg below the target weight and there was no notification to the licensed nurse documented, as per facility policy. A review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated April 2024, states in part: ... Post Treatment Data Collection/Assessment ... 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. ... Abnormal Findings ... the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record.... Post-treatment: if patient is above or below 1 kg from the 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: 42929 Based on interviews, medical record review, and facility policy review, it was determined the facility staff failed to document the reason for and notification to the registered nurse of the change in blood flow rate (BFR) for one (1), Patient #5, of three (3) medical records of Skilled Nursing Facility (SNF) dialysis patients receiving in-center hemodialysis. Findings: The treatment flow sheets for Patient #5 from September 2, 2024, and September 4, 2024, revealed that the blood flow rate was run at 400 mL/min when it was prescribed for 350 mL/min. A review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” dated April 2024, states in part: ...Policy: ...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 of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: ...f. Blood 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....”

“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 Home Program and Skilled Nursing Facility (SNF) dialysis unit staff failed to ensure the initial plan of care (POC) was implemented 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 for three (3) of six (6) patient’s medical records reviewed, Patient #3, Patient #5, and Patient #8. Findings: The facility’s policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” dated 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 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.... The medical record for Patient #3, a SNF dialysis patient, revealed that the patient started treatment on July 22, 2024, and did not have an initial plan of care completed. Staff Member #2 confirmed that the patient had completed seventeen (17) treatments as of September 17, 2024. The medical record for Patient #5, a SNF dialysis patient, revealed that the patient started treatment on August 5, 2024, and did not have an initial plan of care completed. Staff Member #2 confirmed that the patient had completed eighteen (18) treatments as of September 17, 2024. The medical record for Patient #8, a home-hemodialysis (HHD) patient, revealed that the patient started home-hemodialysis on June 27, 2024. The patient changed modalities, from in-center to HHD. The initial POC was completed on August 7, 2024, greater than 30 days from the initial treatment. The surveyor discussed the above findings with Staff Member #1, Staff Member #2, and Staff Member #16.”

“PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This Standard is not met as evidenced by: 42929 Based on observation, interviews, and document review, it was determined the facility failed designate a nurse manager who is responsible for nursing services in the facility. Findings: The home dialysis program services include home-hemodialysis (HHD), peritoneal dialysis (PD), and a dialysis den in a skilled nursing facility (SNF). The facility employs two (2) full-time home-hemodialysis (HHD) registered nurses (RN), one (1) full-time PD RN, two (2) full-time SNF dialysis facility RNs, and one part-time regional operations manager RN for the SNF dialysis facility, who also covers two (2) other SNF dialysis facilities. The job descriptions for all the full-time registered nurses of the home program to included the registered nurses at the SNF dialysis facility, revealed that none of the nurses were designated as the Clinical Nurse Manager for this facility. On September 18, 2024, Staff Member #1 and Staff Member #16 confirmed that none of the nurses are designated as the Clinical Nurse Manager at this facility, although there is a Clinical Nurse Manager for the in-center dialysis facility at the same location as the home program, but that facility has a different CMS provider number. Staff Member #16 indicated that Staff Member #17 performs most of the functions of the clinical nurse manager position, but that RNs job description currently designates that employee as “Registered Nurse HHD Expert”. Staff Member #16 provided the surveyor with the facility’s job description for the Clinical Nurse Manager position.”

“MR-CENTRALIZE ALL INFO;IDT HAS ACCESS CFR(s): 494.170(b)(2) (2) All clinical information pertaining to a patient must be centralized in the patient’s record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient’s condition and prescribed treatment. This Standard is not met as evidenced by: 42929 Based on interviews, medical record review, and facility document review, it was determined the Skilled Nursing Facility (SNF) dialysis unit failed to ensure all clinical information pertaining to patients was centralized in the patient record so that all members of interdisciplinary team have access, for two (2) of three (3) patients, Patient #3 and Patient #4. Findings: The facility’s policy titled “Progress Note Policy” dated October 2023, states in part: ... 4. Progress notes should be readily accessible to every authorized member of the healthcare team.... The surveyor requested the past three months of physicians’ progress notes for SNF dialysis facility Patient #3, Patient #4, and Patient #5. Staff Member #2 was unable to provide physician progress notes for Patient #3 and Patient #4. Staff Member #2 indicated that some of the physicians document progress notes in a different electronic medical record (EMR) system that does not connect with the SNF dialysis facility’s EMR system. The physician must send the progress notes to the facility or the facility staff must request them from the physician. Staff Member #2 indicated that the SNF dialysis facility had not received physician notes for Patients #3 and Patient #4.”