Initial Comments:
Based on the findings of an unannounced, onsite Medicare recertification survey conducted July 29 through August 1, 2025, Eynon Dialysis was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services - Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an unannounced, onsite Medicare recertification survey conducted July 29 through August 1, 2025, Eynon Dialysis Childs was identified to have the following standard level deficiencies which were determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D: Conditions for Coverage for End-Stage Renal Disease Facilities.
Plan of Correction:
494.30(a)(1) STANDARD
IC-WEAR GLOVES/HAND HYGIENE
Name - Component - 00
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.
Observations:
Based on review of facility policy/procedure, observation, and interview with the facility administrator (Employee #9), the facility failed to ensure two (2) of six (6) hemodialysis (HD) staff members performed hand hygiene in accordance with facility policy/procedure. (Employees #1 and #2)
Findings include:
On August 1, 2025 at approximately 2:06 PM, review of facility policy/procedure 1-05-01 titled 'Infection Control for Dialysis Facilities" revealed the following under "Hand Hygiene":
1. All teammates...will perform hand hygiene...
b...immediately after removing gloves,
d. after patient and dialysis system delivery contact...
g. before touching clean areas such as supplies...
Observation of HD patient care revealed the following on July 29 and July 30, 2025:
July 29, 2025 at approximately 10:12 AM: After removing the first HD access needle and applying a HD access site clamp to the insertion site for the HD patient at station #2, the patient care technician (PCT-Employee #1) removed and discarded gloves. The PCT then obtained supplies from a white supply bucket without performing hand hygiene. The PCT then returned to station #2, removed the second HD access needle and removed and discarded gloves. Without performing hand hygiene, the PCT proceeded to complete data entry on the computer located between HD stations #1 and #2.
July 29, 2025 at approximately 10:33 AM: After completion of the access needle insertion process for the HD patient at station #7, the PCT (Employee #1) removed and discarded gloves. Without performing hand hygiene, the PCT obtained a new pair of gloves from the clean glove box.
July 30, 2025 at approximately 10:02 AM: After disconnecting the first blood line from the central venous catheter for the hemodialysis patient at station #8, the PCT (Employee #2) removed and discarded gloves. Without performing hand hygiene, the PCT obtained a new pair of gloves from the clean glove box and returned to HD station #8.
Based on the aforementioned observation findings, there was no evidence employees #1 and #2 performed hand hygiene in accordance with facility policy/procedure on the above referenced dates/times.
During interview conducted on August 1, 2025 at approximately 3:12 PM, the Administrator confirmed employees #1 and #2 failed to perform hand hygiene in accordance with facility policy/procedure.
Plan of Correction:
The Facility Administrator held mandatory in-services for all clinical teammates starting on 08/05/25. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 1) All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves ... d. after patient and dialysis delivery system contact ... g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify teammates perform hand hygiene with glove wearing and glove changing per policy: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly infection control audits. Instances of non-adherence will be corrected immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
494.90(b)(4) STANDARD
POC-PTS SEEN BY MED STAFF 1X/MO
Name - Component - 00
The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician's assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis.
Observations:
Based on review of facility documentation and medical records and based on interview with the responsible party of a hemodialysis (HD) patient (Patient #1) and the Administrator (Employee #9), the facility failed to ensure the medical record included documentation which provided evidence one (1) of five (5) HD patients were seen by the treating nephrologist or advanced nephrology practitioner at least monthly. (Patient #1)
Findings include:
On August 1, 2025 at approximately 3:07 PM, review of facility document titled Medical Record QA Checklist Hemodialysis" revealed the following under "Progress Note (per Davita P&P or State Regulations)": Physician-Monthly Per Policy...
Patient #1: During interview conducted on July 30, 2025 at approximately 9:00 AM, the responsible party (parent) of the patient reported that monthly nephrology visits are conducted at the private office of the patient's nephrologist and not at the HD facility.
Between July 31, 2025 at approximately 9:18 AM and August 1, 2025 at approximately 1:13 PM, review of the medical record failed to reveal that nephrology progress notes were maintained for the months of March, April and May 2025.
During interview conducted on August 1, 2025 at approximately 3:12 PM, the Administrator confirmed the medical record for patient #1 failed to include nephrology progress notes for the months of March, April and May 2025.
Plan of Correction:The Facility Administrator held a mandatory in-service for all clinical teammates starting on 8/5/2025. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-02-17 "Progress Note Policy" with emphasis on but not limted to: 1) Physician: The attending Nephrologist is required to record progress notes at least monthly and for any clinical event, which must be recorded in a timeframe that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Medical Director will review the "Progress Note Policy" with all physicians to remind them that a progress note should be completed with date and signature, when the patients are seen monthly.
The Facility Administrator or designee will audit one hundred percent (100%) of patients' medical records to verify documentation of physician rounding, as evidenced by physician monthly progress note: monthly for three (3) months. Ongoing compliance will be monitored with monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.
The Facility Administrator will discuss audit findings with the Medical Director in monthly Quality Assessment Performance Improvement meeting known as Facility Health Meeting, with supporting ocumentation in the meeting minutes. The Facility Health Meeting minutes and activities will be reviewed in Governing Body meetings to monitor ongoing compliance. Actions plans to be developed according to audit results, and new plans developed when needed until sustained compliance is acheieved. The Facility Administrator and Medical Director are responsible for the compliance with this plan of correction.
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