Uva Lynchburg Dialysis

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 46466 Based on interview and facility document reviews, the facility failed to follow facility policy related to patient care plan (Patient #9). The findings include: On March 25, 2025 at 9:00 AM, a review of Patient #9’s medical record was conducted. Patient #9’s most recent Plan of Care (POC) was dated January 10, 2024 and classified Patient #9 as stable. POC was signed by the patient and all members of the Interdisciplinary Team (IDT). On March 25, 2025 at 11:20 AM, Staff Member #6 explained that “stable” patients have POC developed on annual basis. Staff Member #6 confirmed that at the time of survey, Patient #9’s did not have an updated POC completed on/before/after January 10, 2025. A review of the facility’s policy “Patient Assessment and Care Plan Outpatient Dialysis SOP”, last revised 2/23/2024, stated in part “...The interdisciplinary team will complete a comprehensive interdiction assessment and plan of care with all patients (including AKI status) at the following intervals...Annually if stable...”.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 46466 Based on observation and facility document review, the facility failed to maintain aseptic technique when cannulating patient’s arteriovenous (AV) graft/fistula. The findings included: On March 24, 2025 at 12:16 PM, a staff member was observed initiating cannulation of patient’s AV graft/fistula in Bay D at patient station #7. The staff member applied antiseptic to the patient’s skin over the cannulation site, palpated the site after disinfection and didn’t repeat the application of antiseptic prior to inserting the needle. On March 24, 2025 at 12:25 PM, a staff member was observed initiating cannulation of patient’s AV graft/fistula in Bay E at patient station #6. The staff member applied antiseptic to the patient’s skin over the cannulation site, palpated the site after disinfection and didn’t repeat the application of antiseptic prior to inserting the needle. On March 24, 2025 at 12:50 PM, Staff Member #12 was observed initiating cannulation of patient’s AV graft/fistula in Bay B, patient station #7. Staff Member #12 applied antiseptic to the patient’s skin over the cannulation sites, palpated the site after disinfection and didn’t repeat the application of antiseptic prior to inserting the needle. A review of the facility’s policy “Initiation of Dialysis for Fistula or Graft - Braun Machine No. DP544”, approved 3/2024, indicated in part: “...2. Staff members need to maintain aseptic technique when cannulating the patient’s vascular access and the initiation of hemodialysis...”.”