| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852542 | (X3) Date Survey Completed 05/18/2021 |
| Name of Provider or Supplier Red Hills Dialysis | Street Address, City, State 201 Old Albany Road, Thomasville, GA | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| E0000 | A Recertification (CORE) and COVID-19 Focused Infection Control Survey was conducted by Healthcare Management Solutions, LLC on behalf of Centers for Medicare and Medicaid Services (CMS). An unannounced on-site recertification survey (ASPEN ID #EHU611) was conducted at the above-named End Stage Renal Disease (ESRD) facility from 05/17/21-05/18/21 resulted in a finding of no deficiency respective to the Emergency Preparedness Program Condition for Coverage under 42 CFR 494.62. Survey Dates: 05/17/21-05/18/21 Total Facility Census: 85 In-Center Hemodialysis: 85 Home Hemodialysis (HHD): 0 Peritoneal Dialysis (PD): 0 Nocturnal: 0 Pediatrics: 0 Sample Size: 8 Network 6 was contacted after entrance. |
| V0000 | A Recertification (CORE) and COVID-19 Focused Infection Control survey was conducted by Healthcare Management Solutions, LLC on behalf of Centers for Medicare and Medicaid Services (CMS). An unannounced on-site recertification survey (ASPEN ID #EHU611) conducted at the above-named End Stage Renal Disease (ESRD) facility from 05/17/21-05/18/21 resulted in a finding of substantial compliance respective to applicable Conditions for Coverage (CfC) under 42 CFR 494, Subpart A through D with the following standard-level deficiencies listed below. Total Facility Census: 85 In-Center Hemodialysis: 85 Home Hemodialysis (HHD): 0 Peritoneal Dialysis (PD): 0 Nocturnal: 0 Pediatrics: 0 Sample Size: 8 Network 6 was contacted after entrance. |
| V0113 | 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: Based on observation, interview, and record review, the facility failed to ensure hand hygiene was completed by patients after holding pressure on their access sites in one of two survey days. This failure could negatively impact all 85 patients receiving dialysis at the facility. Findings include: Observation on 05/17/21 at 9:45 AM revealed the unsampled patient at Station 37 applied pressure to left upper arm access sites. After bleeding had stopped the patient walked to the scale and retrieved weight. The patient left the facility without washing or sanitizing hands Observation on 05/17/21 at 11:19 AM, revealed Patient (P) 6 was wearing gloves while holding pressure on his/her access site after completion of dialysis. Once P6 was deemed medically stable by the staff, he/she got out of the recliner and ambulated over to the weight scale, weighed, gathered his/her items and proceeded to exit the treatment area through two sets of double doors. A review of an informational/educational document posted at the sink area (closest to weight scale) stated, "Do all patients have to wash their access? Yes After - The patient must wear a glove if they are holding their site. The patient must wash their hands after removing their gloves when finished holding their site. Teammates can assist the patient to use hand hygiene gel provided there is no visible blood on patient's gloves or hands." During an interview on 05/18/21 at 11:20 AM, with the Clinical Coordinator (CC), he/she stated patient handwashing after holding their access was important to keep transmission of blood pathogens down and prevent cross contamination. CC said some patients are good about handwashing after their dialysis treatment and other patients need to be encouraged by staff to wash their hands. A review of the facility's policy titled, "Infection Control for Dialysis Facilities," revised 10/2020 stated, "Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. . .Teammate/Patient Safety. . .35. Patients are encouraged to wash their hands. . .after treatment before leaving the treatment area." 28297 |
| V0143 | 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: Based on observation, interview, and policy review, the facility failed to ensure an open vial of medication was dated and labeled as required for one of two survey days. The failure to date and label the medication vial had the potential for staff to use a medication that was expired and could affect 85 in-center patients. Findings include: Observation on 05/18/21 at 9:50 AM revealed an open vial of Purified Protein Derivative (PPD) (medication used to test patient for Tuberculosis), that was unlabeled in the medication refrigerator. During an interview with Registered Nurse (RN) 8 on 05/18/21 at 9:55 AM, he/she stated the medication should have been labeled with date of opening and initials of person opening. RN8 stated the medication was only good for 30 days after opening and that could not be determined if it was unlabeled. Review of the facility's policy titled, "Intradermal Tuberculin Skin Test (TST)- Purified Protein Derivative (PPD) Mantoux Test," revised April 2021, revealed the following, "Tubersol manufacturer product insert states "A vial of Tuberculin (PPD) which has been entered and in use for 30 days should be discarded because oxidation and degradation may have reduced the potency." |
| V0403 | 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: Based on observation, interview, and policy review, the facility failed to ensure strips used to detect residual disinfectant were not expired for one of two survey days. The failure to discard expired strips had the potential for staff to used strips that may not yield accurate results and could affect 85 in-center patients. Findings include: Observation on 05/17/21 at 1:45 PM revealed one bottle of "Minncare" HD Testing Strips, (used in testing residual Minncare HD (Disinfectant) levels in water was stored in a drawer across from Station 10 with an expiration date of 04/24/21. Observation on 05/17/21 at 1:55 PM revealed two bottles of "Minncare" HD Testing Strips was stored in a drawer at the medication preparation area that were expired 12/11/20 and 09/19/20. During an interview on 05/17/21 at 1:55 PM, the Clinic Coordinator Registered Nurse stated staff should be checking the expiration dates and throw out expired strips. He/she acknowledged if they were expired they could give false results. Review of the facility's policy titled, "Residual Minncare HD Testing Using Residual Minncare HD Acid Test Strips," revised April 2021, revealed the following, "Verify that strips are not expired. The expiration date is printed on the side of the vial." |
| V0504 | PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient's comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This STANDARD is not met as evidenced by: Based on interview, record review, and policy review, the facility failed to ensure one of eight patients (Patient (P) 4), was monitored every 30 minutes as required. The failure to monitor patients every 30 minutes had the potential to not capture an adverse event in a timely manner and could affect 85 incenter patient. Findings include: Review of the medical record for P4 revealed the facility admitted the patient on 01/28/19 with diagnosis including end stage renal disease. Review of six dialysis flow record for P4 from 04/30/21- 05/14/21 revealed on 05/03/21 the patients treatment was initiated at 7:08 AM. The patients' blood pressure was not checked again until 8:32 AM. One hour and 24 minutes later. On 05/07/21 The patients blood pressure was checked at 8:00 am and not again until 9:30 AM. One hour and thirty minutes later. The blood pressure was checked at 10:00 AM and not again until 11:00 AM. One hours later. During an interview on 05/18/21 at 1:20 AM, the Clinic Coordinator Registered Nurse stated patients should be always monitored and documented every 30 minutes to ensure patients are safe. Review of the facility's policy titled, "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment," revised April 2021, revealed the following, "Vital Signs and treatment monitoring: For non-nocturnal treatments is completed at least every 30 minutes. . ." |