Davita Pilchuck Dialysis

“CFC-INFECTION CONTROL CFR(s): 494.30 This Condition is not met as evidenced by: 22676 Based on staff interviews, review of facility documents, and policy review, the facility failed to meet the requirements of the Conditions for Coverage (CfC) for Infection Control, by failure to: 1) ensure proper hand hygiene was performed on one of the three days. 2) ensure the hemostats and clamps used in patient care were disinfected appropriately and stored appropriately. 3) ensure the wall boxes (dispensing outlets) at 14 of 14 dialysis (Station 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) stations were clean and free of a buildup, ensure one of one water room was clean, and ensure the policies for infection control were followed by all staff and patients in the facility. 4.) Ensure clean all non-disposable items in the patient treatment station when 14 of 14 stations contained a waste receptacle at each station that was not cleaned/disinfected between patients. 5) follow their policy in the care of the patient with a Central Venous Catheter (CVC) One of four patients with a CVC was not offered a mask prior to the start of the procedure to initiate and/or discontinue their treatment. These findings have the potential to cause harm to all patients by increasing the risk of infections. Findings Include: 1. The facility failed to ensure proper hand hygiene was performed on one of three days. Failure to follow their own policy puts all patients and visitors at risk for cross contamination from possible contaminated surfaces. (Refer to V113) 2. The facility failed to ensure the hemostats and clamps used in patient care were disinfected appropriately and stored appropriately. (Refer to Tag V116) 3. The facility failed to ensure the wall boxes (dispensing outlets) at 14 of 14 dialysis (Station 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) stations were clean and free of a build-up of a dark yellow substance, ensure one of one water room was clean, and follow the policies for infection control were followed by all staff and patients in the facility. Failure of staff to follow these infection guidelines put all patients and staff in the facility at risk for cross contamination. (Refer to tag V122) 4. The facility staff failed to clean all non-disposable items in the patient treatment station when 14 of 14 stations contained a waste receptacle at each station that was not cleaned/disinfected between patients. (Refer to tag 121) 5. The staff failed to follow their policy in the care of the patients with a Central Venous Catheter (CVC), one of four patients with a CVC was not offered a mask prior to the start of the procedure to initiate and/or discontinue their treatment. (Refer to tag V147)”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 52064 Based on observation, staff interviews, and policy review, the facility failed to ensure proper hand hygiene was performed on one of three days. Failure to follow their own policy puts all patients and visitors at risk for cross contamination from possible contaminated surfaces. Findings include: During an observation of the patient treatment unit on 12/12/24 from 1:16 PM to 1:49 PM was noted Patient Care Technician (PCT) 10 changed gloves but not sanitize hands between glove changes. On 12/12/24 at 3:25PM Patient (P) 2 and P12 were observed not washing their hands after holding their access prior to leaving the facility. Both patients were observed touching the scale and the facility door. This practice can lead to cross contamination with other patients and family members who touch the objects after the patients. On 12/12/24 at 2:07PM P13 was observed not washing their access or hands upon arrival for treatment prior to cannulation of access as per facility policy. In an interview with PCT10 on 12/12/24 at 1:50 PM during observation in the patient treatment room he/she acknowledged the lack of hand sanitizing with each glove change. He/she stated, “sanitized when necessary but not with every glove change”. In an interview with Clinical Coordinator 3 on 12/13/24 at 11:30 AM he/she acknowledged the patients do not wash their hands or access before or after treatment and touch the patient scale and the door upon leaving the patient treatment room. Review of the facility’s policy titled, “Infection Control for Dialysis Facilities” Revised April 2023, indicated, “Hand Hygiene 1. All teammates. . .will perform hand hygiene b. Prior to gloving and immediately after removal of gloves 2. Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving the treatment area.””

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 22676 Based on observation, interview and policy review, the facility failed to ensure the hemostats and clamps used in patient care were disinfected appropriately and stored appropriately. These findings have the potential to cause harm to all 88 patients receiving care at the facility. Findings Include: Observation on the treatment floor on 12/10/24 at 9:45 AM, the hemostats used in patient care were observed to be soaking in the disinfectant in the closed position verses the open position two ensure adequate disinfectant of the interior surface of the clamp. The clean clamps were also observed to be draining in a colander that was beside the receptacle where the dirty clamps were being thrown into the disinfectant which could lead to cross contamination of the clean clamps. The clean vascular clamps used to hold the sites after hemodialysis and numerous peritoneal dialysis clams were observed to be stored in bins that were dirty with a build of white crystals. The carts used to store the bins for storage of the clean clamps were dirty and had mold growing on the cart. An interview with Certified Clinical Hemodialysis Technician (CCHT) 13 at 9:45 AM, confirmed the above findings. He/she stated when asked he/she did not know what position the clamps were to be in. Review of the facility’s policy titled, “Infection Control for Dialysis Facilities,” indicated. non-disposable items are to be disinfected ...Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution ...Cleans areas should clearly be separated from contaminated areas where used supplies and equipment are handled.””

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 52064 Based on observation, staff interviews, and policy review, the facility staff failed to clean all non-disposable items in the patient treatment station when 14 of 14 stations contained a waste receptacle at each station that was not cleaned/disinfected between patients. This practice can lead to cross contamination between all patients who dialyze at the dialysis stations. Findings include: During observation in the dialysis treatment room on 12/12/24 1:00pm-3:45pm it was noted that trash receptacles were not sanitized and disinfected between patients at Stations 1, 2, 4, 8, and 10). These trash receptacles were overflowing with trash from the previous patient dialyzed at the stations. In an interview with Patient Care Technician (PCT) 10 on 12/12/24 at 2:19PM and Certified Clinical Hemodialysis Technician (CCHT) 11 at 3:25PMm in the patient treatment room both acknowledged the trash receptacle is not cleaned between patient treatments and the liner is not changed out even though the trash receptacle is full and overflowing onto the floor. Review of the facility policy titled “Infection Control for Dialysis Facilities” revised April 2023 indicated, “. . .14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses.””

“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: 22676 Based on observation, interview, facility policy review, and review of Centers for Disease Control (CDC) guidance, the facility failed to ensure 1. the wall boxes (dispensing outlets) at 14 of 14 dialysis (Station 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, and 16) stations were clean and free of a build-up of a dark yellow substance, 2. and ensure one of one water room was clean, and 3. the policies for infection control were followed by all staff and patients in the facility. Failure of staff to follow these infection guidelines put all patients and staff in the facility at risk for cross contamination. This deficient practice had the potential to cause bacteria to grow in the wall boxes and could potentially affect the 75 patients receiving in-center hemodialysis at the facility. Findings include: 1. During a tour of the “Water Room on 12/10/24 at 9:30 AM the floor of the water room was dirty and standing in water and crystallized Bicarbonate solution that was leaking on to the floor from a valve on the mixer. Also there was a steady stream of water dripping on the floor from a valve that was on a line to the acid mixer. 2.. During a tour of the facility’s treatment unit on 12/11/24 from 9:50AM-10:30AM the following was observed: a. Four of 14 dialysis chairs at Stations 9, 11, 12, and 13 were observed to have non-intact surfaces on arms, back cushion, seat cushion, or footrest. This can lead to inadequate surface cleaning of potentially infectious body fluids and cross-contamination between all patients who occupy the chair. b. Dried blood was observed on four of 14 sharps containers and four of 14 sharps container holders at Station 3, 4, 9 and 14. This was obserevd on stations that had been cleaned and/or set-up for the patient to start their dialysis treatment. Ineffective cleaning of contaminated surfaces can lead to cross contamination between all patients who occupy the patient station. c. A cushion on a seat in the patient waiting room was observed to have four pieces of tape that was not adhering to the seat cushion. Nonintact surfaces on seating material in the patient areas has the potential for cross contamination between patients due to inadequate cleaning of the surface area. During an interview on 12/10/24 at 9:35 AM, the Administrator confirmed the above findings. He/she agreed with us when we said a dirty water room could lead to contamination of water. 2. During an observation of all wall boxes on 12/10/24 at 11:45 AM, revealed at Stations 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 16 a dark yellow sediment built-up on the bottom of each wall boxes. Review of the “Infection Control Audit,” dated 11/27/24 stated the wall boxes were all clean and free of buildup. 3. During observation of the patient treatment room on 12/12/24 from 1:12PM-3:30PM observed the following: a. The computer monitors and keyboards mounted on the cabinet that was located between patient dialysis machines in the potential splash area from the dialyzers and fluid from patient hemodialysis bloodlines. Also attached to the wall by the computers were boxes of gloves and alcohol-based hand sanitizer bottles staff members were using in the care of the patients during their treatment. Patient Care Technician (PCT)10, Certified Hemodialysis Technician (CCHT)11, and CCHT12 were observed touching the keyboard of the computer with ungloved hands and using alcohol-based hand sanitizer from bottles that were located on the counter by the computer keyboard when changing gloves that were located on the wall behind the computer terminal that was mounted on the counter. b. Patient(P)2 and P12 were observed not washing their hands after holding their access prior to leaving the facility. Both patients were observed touching the scale and the facility door. This practice can lead to cross contamination with other patients and family members who touch the objects after the patients. c. P13 was observed not washing their access or hands upon arrival for treatment prior to cannulation of access. In an interview with CCHT13 during the tour of the patient treatment room on 12/11/24 at 9:55am he/she stated the sharps container holders are to be cleaned every Friday but acknowledged the sharps container holders had a large amount of dried blood on them that should have been cleaned at the time of the occurrence. In an interview with Administrator 2 during the tour of the patient treatment room on 12/11/24 at 10:02 AM, it was acknowledged that the material on the dialysis chairs was not intact, and the chairs were to be changed sometime next year. In an interview with Administrator 2 on 12/13/24 at 11:00 AM, in the patient treatment room he/she verified the computer monitors were in a splash zone behind the dialysis equipment and the boxes of gloves and bottles of alcohol-based hand sanitizer were in a “dirty” area also. Review of the facility’s policy titled, “Infection Control for Dialysis Facility “dated April 2023 indicated, “ At the end of each treatment the dialysis station will be cleaned and disinfected. 1.o The wall boxes, Drain and Water Supply lines are considered part of the dialysis delivery system ...” Review of the “CDC Dialysis Safety” located at www.cdc.gov titled, “Wall boxes and Drains” dated October 25, 2019 indicated, “All box surfaces should be disinfected at least daily (e.g., at the end of the day after all patients have dialyzed); cleaning and disinfection might be needed more frequently (e.g., when visibly dirty). Cleaning and disinfection of the wall box should be performed after the patient has left the station, and not during patient care activities ... ...More than one disinfectant wipe or application may be needed to ensure all wall box surfaces are visibly wet with disinfectant to achieve contact time specified by the manufacturer.” Review of the facility’s policy titled, “Infection Control for Dialysis Facilities;” Revised April 2023, indicated, “Hand Hygiene . . .2. Patients and caregivers will be encouraged to ... a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis. b. Perform hand hygiene after treatment before leaving the treatment area. Supplies . . .8. Supplies will be stored in a manner that maintains their integrity. Disinfection . . .12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e., used or brought to the station) ... a. Prior to routine disinfection, remove all visible blood ... iii. Cleaning of visible blood should be performed when first observed. . . 15. The chair-side cart, terminals mounted on the counter, monitor and keyboard are considered clean areas. a. Wipe-able keyboard covers, or medical grade keyboards are to be utilized. b. The chairside cart components will be cleaned at the end of each treatment day... d. Disposable gloves and alcohol-based hand rub containers may be stored on the chairside cart shelves but not stored on counters where terminals are mounted. e. The monitor screen is cleaned as needed and daily at end of treatment day using a disposable wipe moistened with 65-70% isopropyl alcohol solution.” 52064”

“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: 52064 Based on observation, staff interview, and policy/procedure review, the staff failed to follow their policy in the care of the patient with a Central Venous Catheter (CVC) One of four patients with a CVC was not offered a mask prior to the start of the procedure to initiate and/or discontinue their treatment. Failure to follow their policies in regard to wearing masks has the potential to lead to blood stream infections for the patients. Findings include: During observation in the patient treatment room on 12/12/24 at 2:05 PM, Patient Care Technician (PCT)10 failed to ensure Patient (P)10 was wearing a mask when the discontinuation process of the CVC was initiated. In an interview on 12/12/24 at 2:05 PM at the patient station PCT 10 acknowledged that P10 should have been wearing a mask during the procedure. Review of the facility’s procedure titled “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure” revised October 2024 states; “Put on PPE (Personal Protective Equipment) and provide a mask to the patient. Teammate and patient will wear masks covering the nose and mouth during this procedure; These measures are vital to preventing the exposure of the catheter and exit site to nasal droplets and infectious bacteria such as methicillin-resistant Staphylococcus aureus (MRSA).””

“BACT CONTROL-DISINFECT 1X/MO/DWELL CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: disinfect monthly/disinfection dwell Routine low-level disinfection of the pipes should be performed to control bacterial contamination of the distribution system. The frequency of disinfection will vary with the design of the system and the extent to which biofilm has already formed in existing systems, but disinfection must be performed at least monthly. A mechanism should be incorporated in the distribution system to ensure that disinfectant does not drain from pipes during the disinfection period. This Standard is not met as evidenced by: 22676 Based on interview, document review, and policy review, the facility failed to ensure the “CWP” Reverse Osmosis (RO) was disinfected for two of 10 weeks reviewed. This had the potential to cause harm to all 75 in-center hemodialysis patients receiving care at the facility by failure to disinfect the “CWP” RO system. Findings include: Review of the “RO waterlogs” from January 10/01/24 through 11/30/20/24, revealed the facility failed to disinfect the CWP for two of 10 weeks reviewed. Further review of the logs revealed that the facility failed to disinfect the water system during the week of 10/01/24 through 10/05/24 and the week of 10/14/24-10/19/24. In an interview with the Biomedical Technician 6 on 12/12/24 at 2:15 PM he/she confirmed the above findings. Biomedical Technician 6 stated that the system is to be disinfected weekly on Saturday night. He/she stated that failure to disinfect could lead to increased infection. Review of facility’s policy titled, “CWP Chemical Disinfection” dated 03/2014 states, “This procedure will be performed on a weekly basis ...Document the chemical disinfection start time on the weekly log ...refer to CWP post chemical start up procedure.””

“MIX SYS-DFU/MONITOR/PM/LOG/SANITIZE CFR(s): 494.40(a) 5.4.4.1 Mixing systems: follow DFU/monitor/PM/log/sanitization If a concentrate mixing system is used, the preparer should follow the manufacturer’s instructions for mixing the powder with the correct amount of water. If a concentrate mixing system is used, the number of bags or the weight of powder added should be determined and recorded. Manufacturer’s recommendations should be followed regarding any preventive maintenance and sanitization procedures. Records should be maintained indicating the date, time, person performing the procedure, and results (if applicable). 6.4.1 Mixing systems: Systems for preparing either bicarbonate or acid concentrate from powder should be monitored according to the manufacturer’s instructions. This Standard is not met as evidenced by: 22676 Based on interview, document review, review of manufacturer’s instructions, and policy review, the facility failed to change the Granuflo (a type of acid base used in dialysis treatments) mixing tanks filter after the sixth batch was mixed for two of two months reviewed. This had the potential to affect all 75 patients receiving in-center hemodialysis patients receiving care at the facility. Findings include: Review of the Granuflo Mixing Log for the month of October 2024 through 11/30/24 revealed there were a total of 15 batches made and there was no documented evidence the Granuflo filter was changed. In addition, review of the logs revealed the staff was not consistently marking the “Granuflo (132 Gallon) Batch Production Record,” appropriately to indicate what batch was mixed. Review of the batch mixed on 10/05/24 and 10/07/24 revealed both days were marked as batch six while the form for the batch mixed on 10/09/25 was marked as batch five and the form for the batch mixed on 10/12/24 was marked as batch one. The three batches mixed on 10/23/24, 10/28/24 and 10/31/24 were all marked as batch number three. The batches made on 11/13/24 and 11/19/24 were both marked as number six. Observation in the Water Room on 12/10/24 at 9:30 AM, revealed the acid filter had an approximately two inch by two inch wide buildup of dried acid crystals all around the opening of the filter and extending down the outer casing of the filter, including on the filter opening wrench, and Granuflo filter was not dated to indicate when it had last been changed. During an interview on 12/10/24 at 9:30 AM, the Administrator confirmed the condition of the acid filter in the Water Room. During an interview with Biomedical Technician 6 on 12/12/24 at 1:15 PM he/she stated the acid filter is to be changed after the sixth batch is made and the staff are supposed to document the filter change. Biomedical Technician 6 confirmed there was no documented evidence the mixing filter was changed. Review of the facility’s policy titled, “Granuflo Concentrate Dissolution Init )132 Gallon) Mixing Procedure” dated October 2024, failed to include directions for the filter change although the form fused for mixing the acid stated, “replace filter after six batches” The policy stated “Clean the exterior of the Granuflo dry acid dissolution unit with a mild detergent after each mixed batch of concentrate is mixed.” Review of the manufacturer’s instructions dated 2016 states “the filter should be changed after mixing 6 batches.””

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 22676 Based on interview, policy review, and review of the manufacturers direction for use, the facility failed to ensure that one out of three bottles of “E-Z Chek 6.8-8.5” Potential Hydrogen (pH) Test Strips. This had the potential to cause harm to all 75 in-center hemodialysis patients, by failure to ensure the dialysis machine was running the correct pH to all patients receiving care at the facility. Findings include: During a tour of the treatment on 12/10/24 at 9:30 AM revealed one bottle of “E-Z Chek 6.8-8.5” pH test strip manufactures expiration date was 11/30/24 was found in the isolation room. During an interview on 12/10/24 at 9:45AM, Certified Clinical Technician 13, confirmed the pH test strip were expired. Review of the facility’s policy titled, “Testing pH for Acetate Based Dialysate using RPC E-Z Check K 100-117 6.8-8.5 Test Strips, do not use test strips from an opened or unopened bottle after the expiration date printed on the bottle label.””

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 22676 Based on observation, interview, and facility policy review, the facility failed to ensure that supplies were stored away from the electrical pane and away from the exit door. This deficient practice had the potential to result in increased infections to all 88 patients receiving care at this hemodialysis unit by increasing the risk of fire and preventing exit from the fire door. Findings include: Observation in the supply room on 12/10/24 at 9:15 AM revealed numerous boxes stored against the electrical panel. In addition, cardboard boxes were broken down and stacked in front of the fire exit door. An interview with the Administrator on 12/10/24 at 9:15 AM confirmed the above findings. Review of the “Occupational Safety and Health Administration (OSHA),” dated 07/28/23 indicated, “Minimum of 3 feet of clearance in front of the panel and a clear area around the entire footprint of the equipment, preventing any storage of materials directly against or near the electrical pane ...and all fire exits should be cleared of obstruction ....””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 22676 Based on review of glucometer logs, interview, review of glucometer policy, and manufacturer’s instructions, the facility failed to ensure the glucometer was in the control range and follow manufacturer’s instructions for one of one glucometer used in the facility. This deficient practice had the potential to provide incorrect blood glucose results and could result in inaccurate glucose level results to all 75 patients receiving care at the facility. Findings included: Review of electronic “Blood Glucose Logs” for the treatment unit for 11/01/24 through 11/30/24 2024 revealed the following: On 11/02/24, the recorded acceptable low control range was 98-123 the recorded low control was recorded as being 88. On 11/13/24, the recorded acceptable low control range was 93-123, the recorded low control was recorded as being 127. During an interview on 12/12/24 at 1:15 PM, Clinical Coordinator 3 confirmed the findings and agreed the staff did not repeat the low-level control as required by the facility policy and the manufacturer’s instruction. Review of the facility’s policy titled, “Embrace Pro Blood Glucose Monitor Quality Control QC,” dated September 2020, stated “If the control results fall outside the acceptable range, the test must be repeated.” Review of the “Embrace Pro” blood glucose monitoring system manufactures instruction revision date 09/2020 stated “If test fall outside the range printed on the test strip vial, repeat the test must be repeated.””

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 22676 Based on medical record reviews, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for two of five sampled in-center dialysis patients (Patient (P)2, and P4). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact on the effectiveness of the prescribed dialysis treatments for all 75 patients receiving in-center dialysis treatments at this facility. Findings include: 1. A review of P2’s electronic medical record (EMR) revealed a prescribed Blood Flow Rate (BFR) of 400 milliliters per minute (ml/min). A review of one of six “Post Treatment” flowsheets from 11/26/24 through 12/12/24 in the EMR indicated the following: a. On 12/03/24, the BFR was documented at 300 ml/min from 10:35 AM until 2:29 PM. There was no documented rationale for the change to the prescribed BFR. 2. A review of P4’s EMR revealed a prescribed BFR of 400 ml/min. A review of one of six “Post Treatment” flowsheets from 11/28/24 through 12/10/24 in the EMR indicated the following: a. On 12/05/24, the BFR was documented at 300 ml/min from 4:59 AM until 8:30 AM. There was no documentation for the change to the prescribed BFR. During an interview on 12/13/24 at 2:30 PM, Clinical Coordinator 3 confirmed the above findings and confirmed that the staff did not follow the physician’s order for dialysis treatment. A review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated April 2014, revealed, “The prescription along with the nursing assessment within one hour of the initiation of treatment. Prescription components include but not necessarily limited to (f.) Blood flow rate ...””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 22676 Based on interview, record review, and policy review, the facility failed to ensure Plan of Care (POC) participation, and that POC information was provided timely for five of six patients (Patient (P) 1, P2 P3, P6 and P7) reviewed for care planning, In addition, there the two of six patients (P1 and P5) POC was not signed by all of the Interdisciplinary Team. This failure had the potential to negatively impact the effectiveness of the dialysis treatments for the 88 patients receiving dialysis at the facility. Findings include: Review of five of six patients POCs found the following concerns: a. Review of P1’s POC revealed the meeting was conducted on 11/15/24 and there was no documented evidence that the patient was provided with the POC information as of 12/13/24. In addition, the POC signature page was not signed by the Nurse, Social Worker (SW), or the Provider. b. Review of P2’s POC revealed the meeting was conducted on 05/22/24 and the was no evidence documented that the patient was provided with the POC information as of 12/13/24. c. Review of P3’s POC revealed the meeting was conducted on 08/28/24 and the was no evidence documented that the patient was provided with the plan of care information as of 12/13/24. d. Review of 5’s POC revealed the meeting was conducted on 10/28/24 and the was no evidence documented that the patient was provided with the plan of care information as of 12/13/24. In addition, the provider had not signed the POC’s signature page. e. Review of P6’s POC revealed the meeting was conducted on 09/24/24 and the was no evidence documented that the patient was provided with the POC information as of 12/13/24. During an interview on 12/13/24 at 2:30 PM, Clinical Coordinator 3 confirmed the above finding found in the review of the plan of cares. Review of the facility’s form titled, “Comprehensive Interdisciplinary Assessment and Plan of Care” revealed, “ ...the form required a patient signature and the Interdisciplinary Team signature and date that the plan of care was acknowledges and approved by the Interdisciplinary Team which includes the patient.” Review of the facility’s policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated October 2024 revealed, “The facility’s interdisciplinary team (IDT consist of at a minimum, the patients or the patients person representative, a registered nurse, physician or non -physician practitioner (NPP) a social worker and a qualified renal Dietician per CMS.””