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2/16/2010 Survey Tag 0402 Detail for:
Tuesday, May 26, 2020 12:42 AM

Survey Date: 2/16/2010

Regulation Number:0402


Regulation Description: 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.

Surveyor Findings:

Based on observations, document review, patient and staff interviews, the facility failed to maintain the integrity and cleanliness of the physical environment on the treatment floor and the laboratory area.

The findings were:

The following observations were made during the survey on 2/15/10 through 2/16/10:

1. The countertop and sink in the laboratory area had lost the integrity of the surface. The countertop was flaking apart and the sink had rusty spots that appeared to have broken through the surface of the sink.

2. The computer monitor stands on the treatment floor between the patient machines were extremely soiled. The stands were an almond color and there were areas on them that had a collection of black grime and what appeared to be old blood spots. All of the 12 stands had a collection of various types of dirt, grime and dust.

3. The counter working areas in both A and B had areas where pieces of the pressed board were chipped off. The drawers in the counters were dirty with an accumulation of dust and grime.

4. The base boards around the entire treatment floor appeared to be totally rotten.

5. The partition in the center of the treatment floor had discolored areas at the base that also appeared to have rotted through.

6. The computer monitor shelf in the isolation room was dirty and dusty.

The Governing Body meeting minutes for 11/20/09 were reviewed on 2/15/10. The documentation regarding the physical plant stated: "Clinic in disrepair. Clinic has been approved for facelift. Awaiting date for remodel."

The Quality Assessment Improvement (QAI) meeting minutes were reviewed on 2/16/10. The documentation in 3/09 regarding patient complaints stated the following, in pertinent part: "Most common complaints from patients are regarding the facility and equipment (clinic is too cold, too brightly lit, cleanliness, disrepair...)"

The QAI meeting minutes documented on 6/30/09, 8/28/09, 10/23/09, regarding the physical environment, stated that it was "Urgent Priority."

The documentation in the QAI meeting minutes on 1/29/10 stated: "Project manager was in clinic evaluating current situation with leaks in bicarb/acid loop, overall condition of clinic. Project manager has been in facility with construction crews obtaining bids for repairs. Clinic to have face lift beginning in January of 2010."

An interview was conducted with a dialysis patient on 2/16/10 at approximately 7:45 a.m. The patient has been on dialysis for eight years in the facility. The patient stated that some time before Christmas in 2009 the patients were given the opportunity to pick out the new colors to be used on the treatment floor. The remodeling was promised to start before Christmas; however, they were told later that perhaps it would be better to wait until after the holidays and start at the first of the year. The patient continued to state that here it is the middle of February 2010 and still no remodeling. The disrepair of the facility bothered him/her and also the dirty computer monitor stands. (The patient appreciated the care and support of the staff, but was upset regarding the uncleanliness and disrepair of the facility.)

An interview was conducted with the clinical manager on 2/16/10 at approximately 8:15 a.m. The manager stated that approximately two years ago the facility was tested for mold and the results came back negative. At that time, the rotted baseboards had been replaced; however, the wrong materials had been used and now are rotted out again. The manager further stated that he/she was not aware that a definite date had been set to begin the remodeling project.

Information was provided to this surveyor on 2/16/10 at approximately 1:30 p.m. regarding the status of the remodeling project. The project has been let out for bids in 10/09 and again in 12/09. However, no definite date could be provided as to when this remodeling project was to actually get underway.

In summary, the uncleanliness and loss of integrity of many of the building surfaces created the potential for health risks to the patients. The promised starting date of January 2010 documented in the QAI meeting minutes has failed to materialize.

Facility Plan of Correction:

Initial Comments
The Governing Body of this facility takes seriously its responsibility to govern the everyday operations at the facility in such a manner as to ensure the quality of dialysis treatments/operations as well as the health and safety of each patient. As such, the Governing Body, which includes the Medical Director, Director of Operations and Clinical Manager met March 8 2010 to review the Statement of Deficiencies received from the Colorado Department of Public health and Environment to develop the following Plan of Correction.

V402 494.60(a) PE-Building-Construct/Maintain for Safety

A General Contractor has been hired and is to begin the following projects by March 15 20010 Due to the nature and scope of work to be completed; there is an estimated completion of the entire project on or around April 28, 2010.
1. The sink and countertop in the laboratory area will be replaced.

2. New computer stands were ordered on March 8, 2010 . The new stands are expected to arrive around April12 2010 and will be set-up and put into use upon arrival to the facility.

As an interim solution until replacement, the current carts were cleaned and disinfected on March 6, 2010. DPC staff members were educated on March 8, 2010 on policy # FMS-CS-IC-II-155-070A Dialysis Precautions, which includes guidelines for computer cleaning and disinfecting.
3. Countertops and cabinets in working areas A and B will be replaced.
4. All rotted baseboards will be replaced.
5. Treatment floor will be replaced.
6. Computer monitor shelf will be cleaned on March 6, 2010.
Effective Immediately and Ongoing:
The Clinical Manager or designee will inspect the facility at least monthly using the physical environment audit. The results of the audit will be presented at the monthly QAI committee meeting and any issues will have a plan for correction identified and implemented.
The Governing Body appointed the Clinical Manager to monitor, document and report on the implemented action plan for this Statement of Deficiencies directly to the QAI and Governing Body committees through a formalized written report. If sufficient progress to correct the identified deficiencies is not met, the Governing Body through the QAI committee will direct the revision of the action plan until resolution is achieved.
The minutes of the QAI Committee and Governing Body meetings document these actions and are available for review upon request.


Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

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