Uva Orange Dialysis

“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: 49355 Based on interviews and document review, it was determined the facility failed to provide documentation that local agencies were contacted, at least annually, to confirm awareness of the facility to insure cooperation and collaboration with emergency preparedness processes during disaster or emergency situations. The findings: During review of the Emergency Preparedness binder with employee (EMP) 1 and EMP2 on June 24, 2025, a copy of a letter to the Town of Orange Water Treatment facility dated February 6, 2025, was reviewed. There was no documentation in the binder that any other agencies were notified for 2025. There was a copy of a letter dated April 5, 2024, to the Town Of Orange Fire and Rescue. There was no other documentation in the binder that any other agencies were notified for 2024. No documentation was found for 2023. During interviews on June 24, 2025, EMP1 and EMP2 were not aware of any additional documentation available to demonstrate the facility had contacted local emergency preparedness agencies to confirm the facility’s emergency needs in 2025, 2024, and 2023.”

“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 that dialysis stations and chairs were appropriately disinfected between patients in one (1) out of two (2) observations. The findings: A review of the facility’s policy entitled, “Cleaning of the Dialysis Station Dialysis SOP,” revised date August 19, 2024, reads, in part: ... “Procedure: ... 5. Chair: Use Super Sani wipes to clean the chair to include: a. Front, sides, and back of chair and headrest ... c. Trays on both sides (Tops, sides, and underneath).” A review of the facility’s policy entitled, “Dialysis Specific Infection Prevention and Control SOP,” approved date December 1, 2024, reads, in part: ... “D. Environmental Cleaning: A. After a patient completes their treatment, the station will have disposable supplies discarded and the surfaces of all equipment must be thoroughly cleaned/disinfected....” On June 23, 2025, at 2:52 P.M., employee (EMP) 6 failed to disinfect the outside of the dialysis chair and underneath each side tray at station #1. During separate interviews on June 23, 2025, EMP3 and EMP5 agreed the outsides of the dialysis chairs, underneath the side trays, should be disinfected.”

“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: 49355 Based on observation, interviews and document review, it was determined the facility failed to follow appropriate infection control measures, per policy, when providing care to a central venous catheter (CVC) patient in one (1) out of three (3) observations. The findings: A review of the facility’s policy entitled, “Catheter Disconnect with Tego Cap - Braun Machine number DP505-AL,” effective date April 26, 20219, reads, in part: ... “F. Procedure: ... 27. Scrub Tego cap with alcohol prep using aggressive circular motion to the right for at least 15 seconds.” On June 23, 2025, at 10:15 A.M., employee (EMP) 4 wiped each CVC hub in a circular motion with an alcohol prep pad for approximately seven (7) seconds. During an interview on June 23, 2025, at 8:17 A.M., EMP3 indicated that the CVC hubs should be scrubbed for fifteen (15) seconds as per facility’s policy. During an interview on June 23, 2025, at 2:15 P.M., EMP1 agreed that CVC hubs should be scrubbed for fifteen (15) seconds and this process had been a focus of the facility’s infection control audit.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 49355 Based on observation, interviews and document review, it was determined the facility failed to ensure the access site for a dialyzing patient was visible during the dialysis treatment. The findings: The facility’s policy entitled, “Machine Verification and Hourly Patient Check DP536,” effective date June 2001, reads, in part: ... “D. Supportive Data: ... 4. Hourly patient checks are reviewed and signed in the EMR [electronic medical record] (note: frequency of checks may be done more often at the nurse’s discretion). Document that lines intact, connections secure using ‘hp’ smart phrase and that patient access is visible using ‘pave’ smart phrase.” During observations on June 23, 2025, at 9:51 A.M., the access site for a central venous catheter (CVC) was covered with a blanket on patient (MR) 10 at station #2. The site was covered from 9:51 A.M. until the surveyor left the treatment floor approximately twenty-four (24) minutes later. During an interview on June 24, 2025, at 8:17 A.M., employee (EMP) 3 indicated that access sites should remain visible at all times while the patient is receiving dialysis treatment.”