Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 852560	(X3) Date Survey Completed 02/22/2024
Name of Provider or Supplier Poplar Dialysis	Street Address, City, State 2301 Newnan Crossing Blvd, Ste 180, Newnan, 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 Survey was conducted at Poplar Dialysis from February 20, 2024 through February 22, 2024. The survey revealed that the facility was in compliance with 42 CFR Part 494.62, Conditions for Coverage for Emergency Preparedness Plan for End Stage Renal Disease facilities. No deficiencies were cited.
V0000	{CORE} A Recertification survey was conducted at Poplar Dialysis from February 20, 2024 through February 22, 2024. The survey revealed that the facility was in substantial compliance with 42 CFR Part 494 Conditions for Coverage for End Stage Renal Disease Facilities. However, the following standard level deficiencies were cited which resulted from the facility's noncompliance related to the survey:
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, staff interviews, and a review of facility Policy and Centers for Disease Control and Prevention (CDC) Recommendations, it was determined that the Infection Control Committee failed to ensure that one of two Patient Care Technicians (PCT CC) and one of two Registered Nurses (RN BB), observed, performed hand hygiene (washed hands or used an alcohol based hand sanitizer) after removal of contaminated gloves, between glove changes and after touching contaminated equipment. This failure increased the risk for cross contamination with the potential to expose all staff and 52 in-center hemodialysis patients who dialyzed at this facility, to blood borne pathogens in the dialysis environment. Findings were: During observation in the Patient Treatment Room on 2/20/24 between 9:30 a.m. and 12:30 p.m., the following was revealed: - RN BB was observed while providing care for a patient at Station (S) 15. She removed her gloves and did not perform hand hygiene after glove removal and prior to obtaining gauze from the clean supply cart. During observation in the Patient Treatment Room on 2/21/24 between 6:00 a.m. and 12:00 p.m., the following was revealed: - RN BB administered intravenous medication to a patient at S18. When finished, she removed her gloves and did not perform hand hygiene prior to donning a new pair of gloves. - PCT CC provided care for a patient at S1. She left S1 and retrieved a marker from the clean supply cart while she wore contaminated gloves. - PCT CC touched the dialysis machine panel at S2. She removed her gloves and did not perform hand hygiene. - PCT CC donned clean gloves, touched the patient's blanket, adjusted the chair footrest, handed the television remote control to the patient at S3, and then proceeded to initiate patient's dialysis treatment with the same gloves. During an interview with RN BB and Staff CC on 2/21/24 at 7:00 a.m., RN BB stated that she thought she was following the facility policy. A review of Policy: 1-05-01 titled, "Infection Control for Dialysis Facilities" dated April 2023 stated: Hand Hygiene 1. All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene: b. Prior to gloving and immediately after removal of gloves, c. After contamination with blood or other infectious material, d. After patient and dialysis delivery system contact... g. Before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. According to CDC recommendations, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal.
V0147	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: Based on observation, a review of policy, and staff interviews, it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse (RN NN) observed during initiation of dialysis through a Central Venous Catheter (CVC - a large plastic tube placed in a vein in the neck or groin for exchange of blood to and from the hemodialysis machine during the hemodialysis treatment) access, adhered to facility policy pertaining to CVC. This deficient practice increased the relative risk for bacteremia in patients with dialysis catheters, and had the potential to affect all current and future facility patients with CVC. Findings were: During observation in the Patient Treatment Room on 2/21/24 between 11:00 a.m. and 12:00 p.m, the following was revealed: - At 11:08 a.m., RN NN initiated dialysis treatment on Patient (P) #21 with a CVC access at Station (S) 6. When cleansing the CVC limb hubs (end of CVC that connects to the blood lines or cap), RN NN scrubbed each hub for 4 seconds only. - At 11:40 a.m., RN NN changed the CVC dressing of P#15 at S 8. She cleaned the exit site with 2% Chlorhexidine Gluconate 70% Isopropyl Alcohol swab for 10 seconds only. - At 11:45 a.m., RN NN initiated dialysis treatment on P#15 via CVC. When cleansing the CVC limb hubs, RN NN scrubbed each hub for 10 seconds only. A review of Policy 1-04-02B titled, "Central Venous Catheter (CVC) with Cleaguard HD Antimicrobial End Caps and Tegaderm CHG Dressing Procedure" dated October 2023 stated: For initiation of hemodialysis: Scrub each hub for 15 seconds including the sides, threads and end of hub thoroughly. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate 70% Isopropyl Alcohol swab for a minimum of 30 seconds. The Facility Administrator was informed of the above findings on 2/21/24 at approximately 12:35 p.m. The findings were discussed with RN NN on 2/21/24 at 12:45 p.m.
V0628	QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This STANDARD is not met as evidenced by: Based on a review of Dialysis Facility Report (DFR) for Fiscal Year (FY) 2024, review of facility records, and staff interview, it was determined that the facility failed to track, measure, and analyze quality indicators that reflected processes of care and operations to improve patient care, on six of six months (July - December 2023) Continuous Quality Improvement (CQI) meeting minutes reviewed. Fimdings were: A review of Facility Health Meetings (FMH - CQI) for July through December 2023 revealed the following: The DFR (a report prepared for by the University of Michigan Kidney Epidemiology and Cost - contracted by Centers for Medicare and Medicaid Services, to provide a comparative summary of treatment patterns and patient outcomes for End Stage Renal Disease patients) were not analyzed. At this facility, the Standard Mortality Ratio (SMR) was 1.24, which was 24% more deaths than expected. Among U.S. facitilties, 84% of facilities had a four-year SMR lower than 1.24. The 2019 - 2022 SMR was 1.06 and 1.03 for the state of Georgia and Network respectively. The mortality rate on the facility dashboard was 1.68%. There was no documentation that the facility reviewed, evaluated, and analyzed trends in the causes of patient's deaths; and the relationship to the care received at the facility. There was no documentation in the FHM minutes that the causes of deaths were reviewed and analyzed to ensure that clinical standards were met . During an interview on 2/21/24 at approximately 2:00 p.m., the Facility Administrator (FA) stated that mortality was discussed during the meetings. However, the cause of mortality related to dialysis treatment was not discussed. A review of Policy: 1-14-06 titled, "Continuous Quality Improvement Program" dated April 2021 showed: 7. The facility will measure, analyze, and tract quality indicators or other aspects of performance. The program must include, but not be limited to, the following: ... - Mortality - review of deaths 8. Continuous monitoring of the above indicators will be reflected in the meeting minutes.
V0758	GOV-RN, MSW, & RD AVAIL TO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs; This STANDARD is not met as evidenced by: Based on interviews, it was determined that the Governing Body failed to provide four of four patients (P#1, P#4, P#7 and P19) who were interviewed, access to social work services to meet their psychosocial needs. Findings were: During patient interviews, the following was revealed: On 2/20/24 at 10:14 a.m., P#1 stated she did not see the SW. She could not recall completion of the Kidney Disease Quality of Life Instrument (KDQOL). On 2/21/24 at 6:50 a.m., P#7 stated that she saw a SW once a few months ago and requested some information. The SW stated that he would obtain information and get back with her. P#7 stated that the SW did not return to discuss her concerns. On 2/21/24 at 7:08 a.m., P#4 stated that she did not see the SW. When she expressed concerns or had a question, the SW did not get back to her. On 2/21/24 at 10:30 a.m., P#19 beckoned this surveyor to his Station. He asked if I was from the State. When I confirmed this, he wanted to know if I could provide him with a telephone number for filing complaints. He stated that he rarely saw the SW and that he was trying to get a resolution of issues he was having. Stated the SW had not returned to speak to him about his concerns. An interview with the SW on 2/21/24 at approximately 2:00 p.m. revealed that he spent the majority of his time at his "main unit". He acknowledged that he came to the facility on Fridays and used the telephone to communicate with patients and staff. He could not accurately state the number of KDQOLs that were administered, nor the number of survey refusals. He stated that he did not have adequate time to evaluate and address the pschosocial needs of the dialysis patients at this facility. During an interview with the FA on 2/21/24 at 3:00 p.m., it was revealed that the facility did not have a full time SW and was interviewing candidates for the position. She stated that the substitute SW came to this facility on Fridays. Stated that patients and staff communicated with him by telephone. FA confirmed SW's caseload of 171 patients.