Nova Dialysis Canterbury

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 49355 Based on observations, interviews and document review, it was determined the facility failed to ensure in-clinic dialysis chairs were appropriately disinfected between patients in one (1) out of three (3) observations and a policy/procedure was available for disinfection of dialysis chairs used in Long-Term Care (LTC) patient transport. The findings include: In the facility’s policies: “Housekeeping and Disinfection: Patient Treatment Area,” revised March 2010 states, in part: “... Policy: ... 3. All patient workstations will be disinfected at the end of each patient treatment. Areas to be disinfected include the patient chair....” “Cleaning and Disinfection: Exterior Surfaces of the Delivery System,” revised March 2025 states, in part: “... Policy: ... 2. All exterior surfaces of all delivery systems, patient chairs...will be disinfected at the end of the patient treatment before setting up for the following patient treatment.” On April 2, 2025, at 10:48 A.M., the surveyor observed employee (EMP) 7 disinfecting the chair at station #5. EMP7 lowered the chair side tables, cleaned both outer sides of the chair and raised each chair side table to the upright position, but never cleaned the sides under each chair side table. The findings were discussed with EMP3 and EMP4, both of whom agreed the sides under the chair side tables must be cleaned as part of the disinfection process. On April 2, 2025, at 9:22 A.M., the surveyor interviewed EMP9 regarding the process of cleaning dialysis chairs that are used to transport LTC patients. EMP9 indicated that a LTC employee, not an employee of the dialysis clinic, transports the patient to dialysis. EMP9 indicated that the patient is returned to the floor in the dialysis chair that the patient had their treatment in, and either the patient is left at the nurse’s desk, or EMP9 takes the patient directly back to their room. EMP9 indicated that they clean the used chairs before returning to the ESRD clinic with the next patient, but sometimes the nurse may clean them if EMP9 left the patient at the nurse’s desk. EMP9 indicated that they have never been visually audited on how they were performing the disinfection process. EMP9 stated that there are three (3) extra dialysis chairs in the LTC facility, in case a chair can’t be disinfected before the next dialysis patient needs to be transported to the clinic. EMP9 indicated they use alcohol wipes to disinfect the chairs, but if blood is visualized on the chair, EMP9 has been instructed to return the chair to the dialysis clinic so they could clean it. During an interview on April 2, 2025, at 12:20 P.M.,EMP4 indicated that there wasn’t a specific policy for the LTC transporters to follow when disinfecting dialysis chairs used in transporting patients back to the LTC after dialysis treatment nor was there documentation of audit validation of the cleaning process by transporters. EMP4 indicated that there is a checklist that the dialysis staff uses when cleaning chairs and that information could be shared with the administrator of the LTC facility. EMP4 indicated that their understanding is all new hires at the LTC facility are oriented on chair cleaning by the LTC facility.”

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 49355 Based on medical record review, interview and document review, it was determined the facility failed to provide documentation of a comprehensive assessment for one (1) of two (2) medical records reviewed, Patient (MR) 2. The findings include: The facility policy entitled, “Comprehensive Interdisciplinary Assessment and Care Plan,” revised January 2017, reads, in part: “... Policy: The Comprehensive Interdisciplinary Assessment and Care Plan (CIA) will be completed no later than the 30th day or 13th treatment of the patient’s admission. The CIA will include input from each member of the multidisciplinary team. The entire team will review the entire content of the assessments and care plan with input from the patient. The entire team and the patient will sign the CIA. ... The time frame is as follows: 1. Initial CIA must be completed by the 13th treatment or 30th day whichever is later.” A review of the medical record on April 2, 2025, revealed MR2 started dialysis at this facility on November 4, 2024. MR2 was admitted to the hospital on January 19, 2025. No documentation was present in the medical record that a comprehensive assessment was prepared for MR2. Employee (EMP) 3 confirmed a comprehensive assessment for MR2 was not present in the medical record.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 49355 Based on medical record review, interview and document review, it was determined the facility failed to provide documentation that a plan of care was developed in one (1) of two (2) medical records reviewed, for patient (MR) 2. The findings include: The facility policy entitled, “Comprehensive Interdisciplinary Assessment and Care Plan,” revised January 2017, reads, in part: “... Policy: The Comprehensive Interdisciplinary Assessment and Care Plan (CIA) will be completed no later than the 30th day or 13th treatment of the patient’s admission. The CIA will include input from each member of the multidisciplinary team. The entire team will review the entire content of the assessments and care plan with input from the patient. The entire team and the patient will sign the CIA. ... The time frame is as follows: 1. Initial CIA must be completed by the 13th treatment or 30th day whichever is later.” A review of the medical record on April 2, 2025, revealed MR2 started dialysis at this facility on November 4, 2024. MR2 was admitted to the hospital on January 19, 2025. No documentation was present in the medical record that a plan of care was prepared for MR2. Employee (EMP) 3 confirmed a plan of care for MR2 was not present in the medical record.”

“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: 49355 Based on interviews and document review, it was determined that the facility failed to maintain a full-time nurse manager for the facility. The findings include: A review of the facility’s job description for “Director of Nursing,” revised March 2025, reveals: “Job Description Responsible for quality patient care, leadership of clinical staff and day to day operations in the areas of clinical outcomes, cost controls and human resources to ensure effective, efficient and safe operations in accordance with...federal, state and local regulations.” During an interview the morning on April 1, 2025, Employee (EMP) 2 indicated that the same nurse manager is responsible for two dialysis clinics. This clinic provides dialysis treatments three (3) days a week while the other clinic provides dialysis services six (6) days a week. EMP2 indicated that the charge nurse at this clinic is being trained to be the nurse manager, but that employee is currently out on eight (8) weeks medical leave, so training has been halted. During an interview on April 2, 2025, at 10:14 A.M., EMP3 indicated that they usually come to this clinic once a week, sometimes every ten (10) days. EMP3 indicated that the current charge nurse at this facility was being trained as the nurse manager, but that employee is currently out on medical leave. EMP3 is hopeful that the training will continue once that charge nurse returns.”

“GOV-ELECTRONIC DATA SUBMISSION REQUIRED CFR(s): 494.180(h) (8) Effective February 1, 2009, the dialysis facility must furnish data and information to CMS and at intervals as specified by the Secretary. This information is used in a national ESRD information system and in compilations relevant to program administration, including claims processing and reimbursement, quality improvement, and performance assessment. The data and information must- (1) Be submitted at the intervals specified by the Secretary; (2) Be submitted electronically in the format specified by the Secretary; (3) Include, but not be limited to- (i) Cost reports; (ii) ESRD administrative forms; (iii) Patient survival information; and (iv) Existing ESRD clinical performance measures, and any future clinical performance standards developed in accordance with a voluntary consensus standards process identified by the Secretary. This Standard is not met as evidenced by: 49355 Based on interview and document review, it was determined the facility failed to comply with reporting an End Stage Renal Disease (ESRD) patient’s death to the Centers for Medicare and Medicaid Services (CMS) within 2 weeks from the date of death, per CMS regulations. The findings include: A review of the CMS Form 2746 entitled, “ESRD Death Notification,” with an expiration date of March 31, 2027, reads in part: “Complete this ESRD Death Notification form within 2 weeks of the date of death. If the patient was a dialysis patient, the dialysis facility last responsible for the patient’s maintenance dialysis (or home dialysis) must complete this form.” As reported by Other #1, the date of death for patient (MR) 2 was January 28, 2025. During an interview on April 2, 2025, employee (EMP) 3 indicated that the form should be completed and submitted to CMS within fourteen (14) days. EMP3 indicated that the dialysis clinic frequently does not know when patients expire. During an interview on April 2, 2025, EMP4 indicated that the ESRD facility does not have a policy covering CMS notification of death using Form 2746, but that CMS should be notified within 14 days of the death of an ESRD patient. Upon consultation with Quality Insights (QI), the surveyor learned that QI does not have a completed CMS Form 2746 recording MR2’s death.”