Initial Comments:
Based on the findings of an onsite unannounced Medicare complaint investigation survey conducted on December 11, 2024 and concluded off-site December 13, 2024, Compass Home Dialysis, was identified to have the following standard level deficiency that was determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.
Plan of Correction:
494.60 STANDARD
PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT
Name - Component - 00
The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment.
Observations:
Based on observations and an interview with the Facility Regional Director of Operations and facility staff nurse; the facility failed to maintain the integrity of the walls, the floors, dialysis chairs within the dialysis treatment area for seven (7) of twelve (12) observations. OBS #1-#7.
Findings include:
OBS #1 completed 12/11/24 at 10:00 AM, rust areas noted to metal molding around entire treatment floor. Two (2) rusty water pipes with a green discoloration by window-rust was noted on approximately three (3) inches of pipe, rust to faucet handle and green discoloration approximately one (1) inch on the left side of the wall and green discoloration noted on approximately three (3) inches of pipe on the right side of the wall.
OBS #2 completed 12/11/24 at 10:05 AM, several small circular holes in wall located near multimedia filter. Six (6) small circular holes in wall located near multimedia filter. Multimedia filter is located on treatment room floor in dialysis den.
OBS #3, #4 and # 5 completed 12/11/24 between 10:05 AM-12:40 PM, several areas of water damage noted to corners of dialysis floor between machines. Rust areas and water damage to corners of dialysis floor between machines, located in both corners of treatment floor in the area between three (3) dialysis chairs. Water damage included buckling of floor molding and chipping of floor. No evidence of mold noted.
OBS # 6 completed 12/11/24 between 10:55 AM-11:00 AM, two (2) inches by two (2) inches circular holes and water damage noted under both the clean and dirty sinks. Water damage to both clean and dirty sinks consisting of two (2) inches by two (2) inches circular holes, paint chipping and rust colored stains.
OBS # 7 completed 12/11/24 between 11:00 AM-11:30 AM, dialysis chairs noted with rips in fabric some revealing wood of chair and some with blue tape over the areas. All five (5) dialysis chairs noted to have rips in fabric--areas where all at bottom of chairs and either had blue tape over the ripped area or some areas had no tape present and revealed wood of chair.
Skilled Nursing Facility administrator was made aware of dialysis findings and was copied on all emails between this writer and dialysis center staff.
An interview conducted with the Facility Regional Director of Operations and Facility Staff Nurse on 12/11/24 at approximately 12:40 PM confirmed the above findings.
Plan of Correction:V401
Concerto's Regional Director, Regional Manager, or Clinical Services Department will provide education to the Concerto's RNs, PCTs, and technical team on the following Concerto Policy by 02/14/2025:
Policy CRS 1200-016 Physical Plant
Concerto's Regional Director, Regional Manager and Spring Creek Rehabilitation Administrator and Maintenance Director have and will ensure the following items are addressed. An itemized outline of the concerns in question under this deficiency is below:
Assessment and Repair of Rusted Metal Molding and Water Pipes (OBS #1):
On 12/13/2024, A comprehensive inspection of the treatment floor's metal molding and water pipes was conducted by Spring Creek Rehabilitation Maintenance Director. Rusted areas were identified and treated with appropriate rust removal techniques.
Repair of Walls Near Multimedia Filter (OBS #2):
The six small circular holes near the multimedia filter were patched using suitable wall repair materials. Once patched, the areas were sanded and repainted by the Spring Creek Rehabilitation Maintenance Director on 12/13/2024.
Addressing Water Damage Between Dialysis Machines (OBS #3, #4, #5):
The areas exhibiting water damage were repaired by Spring Creek Rehabilitation Maintenance Director on 12/13/2024 by removing and replacing the damaged tiles and moldings.
Repair of Sinks in Clean and Dirty Utility Areas (OBS #6):
The water damage under both the clean and dirty sinks was repaired by the Spring Creek Rehabilitation Maintenance Director on 12/13/2024 by cleaning and painting the the damaged and stained boards. The circular holes were successfully replaced and patched. A review of the area from a plumbing perspective was also provided, with any leaking of the plumbing also patched.
Maintenance of Dialysis Chairs (OBS #7):
The Spring Creek Rehabilitation Maintenance Director assessed the torn fabric on the dialysis chairs on 12/13/2024. The chairs themselves were repaired on 2/7/2025 with the placement of new coverings over worn/torn areas of the chair (the same upholstery material from the existing chair) from the chair manufacturer.
Please note that photos of all the above repairs can be provided if requested.
To ensure ongoing compliance the Concerto Technical Department will complete a Life Safety audit of the space(s) monthly, beginning 02/10/2025 at Spring Creek Rehabilitation, to ensure no rust is noted, holes in walls remain repaired, any potential water damage remained repaired and resolved, clean and dirty sinks remain intact, and dialysis chairs are suitable repaired and addressed if torn fabric in noted.
Target threshold is 100%. Any non-compliant findings will be addressed immediately, staff will be re-educated, and findings will be reviewed in the monthly QAPI meeting as well as discussed with the SNF maintenance department.
|