Ft Smith Regional Dialysis Ctr

“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: 37145 Based on observation, policy review and interview, it was determined two (Registered Nurse (RN) # 2 and Certified Clinical Hemodialysis Technician (CCHT) # 1) of three (RN #2, RN # 3 and CCHT #1) direct patient care staff failed to don new gloves or perform hand hygiene before providing patient treatment/assessment or after removing their contaminated gloves. The failed practice promoted the spread of infection. The failed practice had the likelihood to affect all 195 in-center hemodialysis patients on census, visitors, and staff. The findings were: A. Review of the facility’s policy titled, “Infection Control Hemodialysis Catheter: Site Care/Dressing Change” with a revised date of 07/21/21 showed, “The Dialysis Center will minimize risk of infection related to hemodialysis catheters by adhering to strict infection control process while performing catheter care. Catheter dressings will be changed every hemodialysis treatment, unless otherwise ordered. Mask self and mask patient. Make sure the nose and mouth are both covered. Perform hand hygiene, don new clean gloves. Open supplies to be used. With clean gloves, remove all dressings and tape from the insertion site. Discard old dressings in an appropriate biohazard container. Remove gloves, perform hand hygiene. With new clean gloves, cleanse the skin starting at the exit site.” B. Review of the facilities policy titled, “Initiation of Dialysis Treatment Policy,” with a revised date of 04/29/21, showed, “Clean AVF (arteriovenous fistula) arm with antiseptic towelette, then clean selected cannulation sites with sterile alcohol. Do not retouch cleaned sites.” C. Observation of shift change in the Suite A treatment area on 08/28/24 from 10:50 AM to 12:08 PM with the Director of Clinical Operations showed: 1. On 08/28/24 at 10:50 AM, during observation of initiation of dialysis treatment for Patient #16 , CCHT # 1 touched the AVF site after cleansing with alcohol immediately before cannulating the arterial and venous sites. 2. On 08/28/24 at 12:08 PM, during observation of catheter care for Patient #17, RN #2 removed the catheter site dressing, removed their gloves, applied new gloves then cleaned the catheter site without performing hand hygiene between the glove changes. D. The findings of C were confirmed in observation and interview with the Director of Clinical Operations on 08/28/24 at 12:08 PM.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) 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. This Standard is not met as evidenced by: 37145 Based on observation and interview, the facility failed to ensure that the integrity of all physical surfaces were intact, clean, and free from damage. The failed practice promoted the spread of infection and had the likelihood to affect all 195 in-center hemodialysis patients on census, 71 peritoneal dialysis patients on census, visitors, and staff. The findings were: A. On 08/26/24 from 10:45 AM through 11:30 AM, the following observations were made on tour of the facility: 1) The Suite B treatment area showed: a) Throughout the suite multiple dialysis treatment stations had a rust color from the acid line down to the bottom of the stations. b) Five of seven chairs had multiple rips in them. c) Seven of seven chairs had a rust color above the casters. 2) The water room showed the testing supply cart had a buildup of white residue, and multiple random items were stored beneath the cart. 3) The Mixing room showed: a) Throughout the room, there was a buildup of white residue, rust color, and grime. b) There was a rust color in four of four floor vents. c) There were purple color stains, grime, and holes in the walls. d) There were missing ceiling tiles. e) There was a water leak from the return pipe for Suite A. f) The floor was not sealed and had multiple rust colored stains. 4) The Peritoneal Dialysis Training rooms showed: a) The clean sinks had a buildup of white reside. b) The cabinets had visible splatters down the front of them and dirt and grime buildup underneath the sinks. B. During an interview on 08/26/24 at 11:30 AM, the findings in A were verified with the Director of Clinical Operations #1.”

“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: 37145 Based on observation, policy review and interview, the facility failed to ensure blood pressure (BP) cuffs were maintained in that there was a build-up of threads in the hook portion of the Velcro which did not allow for effective cleaning and disinfection. The failed practice promoted the spread of infection from cross contamination. The failed practice had the likelihood to affect all 195 in-center hemodialysis patients on census and staff. The findings were: A. Review of the facility policy titled, “Infection Control Cleaning/Disinfection of the Patient Station,” revised 02/27/2023 showed, “Any item taken into the dialysis station should be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before taken to a common area or used on another patient. Items taken to a patient’s dialysis station include those items placed on the top or sides (in baskets) of dialysis machines or on dialysis chairs. After use, all equipment and supplies must be considered as potentially blood contaminated, and should be separated, handled with caution, and either disinfected or discarded.” B. On 08/28/24, observation of initiation and termination of dialysis in Suite A treatment area, showed BP cuffs at Station #2, #5, and #8 had a build-up of threads in the hook portion of the Velcro which did not allow for effective cleaning and disinfection between patients. C. During an interview on 08/28/24 at 12:08 PM, the Director of Clinical Operations # 2 confirmed the findings in B. 44854 Based on observation and interview, it was determined the facility failed to maintain a safe environment in that two of two (one Treatment B area emergency exit door and one Supply receiving door) doors to the outside had a gap at the bottom which allowed pests to enter. The failed practice promoted the spread of infection and had the likelihood to affect all in-center hemodialysis patients and all home therapy patients on census. Findings follow: A. Observation on 08/26/24 at 11:00 AM showed there was a gap at the bottom the door under the emergency exit door in Treatment Area B and under the Supply receiving door exiting to the outside. B. During an interview on 08/26/24 at 11:00 AM, Director of Clinical Operations # 1 confirmed the findings in A at the time of the observation.”

“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: 51002 Based on clinical record review, policy review, and interview, it was determined the Registered Nurse (RN) failed to assess, treat, and/or notify Physician of the blood pressure (BP) for four (#2, #3, #5 and #6) of ten (#1-# 10) in-center hemodialysis patients and one (#11) of three (#11-#13) home peritoneal dialysis patients reviewed. The failed practice placed patients at risk for complications related to un-managed blood pressure. The failed practice had the likelihood to affect all 195 in-center hemodialysis patients and all 71 peritoneal dialysis patients on census. The findings were: A. Review of the facility’s policy titled, “Clinical Care and Patient Safety Fluid Management and Hypertension (HTN)” showed, “The Dialysis Center’s Interdisciplinary Team (IDT) will provide the necessary care and services to manage the patient’s volume status. Goal: Euvolemic with blood pressure (BP) 130/80 post-treatment and gaining less than 3 kg (kilograms) between treatments. A patient at their EDW (estimated dry weight) should be asymptomatic and normotensive on minimum blood pressure medications, while preserving organ perfusion and maintaining existing residual renal function. If patient shows signs/symptoms of fluid overload such as shortness of breath, edema, or high blood pressure (140/90), the nurse (RN) may challenge the EDW by up to 500 ml (milliliters). Any challenge greater than 500 ml must be specifically ordered by a Physician. Failure to achieve the target weight through the dialysis treatment will be documented, as well as the reason, and any action taken to correct such EDW adjustment, medication changes, or treatment adjustments. Patients blood pressures must be monitored pre, during, and post treatment. Abnormally high or low values must be addressed. Unless there is a unique order addressing elevated BP for the specific patient, an RN will notify physician if the patient has a systolic BP trend (6 treatments) less than 100 or greater than 140/ or diastolic BP trend (6 treatments) of less than 40 or greater than 90 during or post-treatment.” B. Review of MAT (Measures Assessment Tool) showed the Euvolemic, and pre-treatment BP was to be < 140/90 and post-treatment was to be BP < 130/80. C. During an interview on 08/27/24 at 3:50 PM, the Director of Clinical Operations #1 confirmed findings in A and B. D. Patient #2 1) Review of six TFS (treatment flow sheets), five of six treatments, 08/09/24 - 08/26 /24, showed no evidence the RN assessed the patient’s pretreatment, intradialytic, and/or post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 08/09/24 - Predialytic 163/78, Intradialytic 153/72. b) 08/12/24 - Predialytic 169/85, Intradialytic 149/79 and Post treatment 144/72. c) There was no evidence of an RN assessment for hypertension or notification of the Physician.. 2) During the interview on 08/27/24 at 3:30 PM, the Director of Clinical Operations # 1 confirmed the findings in D. E. Patient #3 1) Review of six TFS, four of six treatments, 08/09/24 - 08/26/24, showed no evidence the RN assessed the patient’s pretreatment, intradialytic, and/or post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 08/09/24 - Predialytic 115/79, Intradialytic 186/80, postdialytic 165/86. b) 08/12/24 - Intradialytic 155/88, Postdialytic 158/82 c) 08/21/24 -Intradialytic 166/94, Post treatment 151/78. d) 08/26/24 - Intradialytic 171/88, Post treatment 167/79. 2) There was no evidence of an RN assessment for blood pressures out of range, provided treatment, and/or notified Physician of findings. 3) During the interview on 08/27/24 at 3:45 PM, the Director of Clinical Operations #1 confirmed the findings in E. F. Patient # 5 1) Review of six TFS, three of six treatments, 07/16/24 - 08/22/24, showed no evidence the RN assessed the patient’s pretreatment, intradialytic, and/or post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 07/16/24 - Pretreatment 175/62, Intradialytic 195/71, Post treatment 160/57. b) 07/23/24 - Pretreatment 196/73, Intradialytic 204/91, Post treatment 130/53 c) 08/24/24 - Pretreatment 179/71, Intradialytic 181/71, Post treatment 154/65 2) There was no evidence of an RN assessment for HTN, provided treatment, and/or notified Physician of findings. 3) During the interview on 08/27/24 at 3:50 PM, the Director of Clinical Operations #1 confirmed the findings in F. G. Patient # 6 1) Review of six TFS, six of six treatments, 08/09/24 - 08/23/24, showed no evidence the RN assessed the patient’s pretreatment, Intradialytic, and/or Post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 08/09/24 - Pretreatment 117/41, Intradialytic 73/54,92/49 1, Post treatment 121/47. b) 08/12/24 - Pretreatment 135/60, Intradialytic153/55, 87/55, Post treatment 154/64. c) 08/14/24 - Pretreatment 147/76, Intradialytic 167/103,46/20, Post treatment 128/73. d) 08/16/24 - Pretreatment 154/45, Intradialytic 131/44, 149/37, Post treatment 133/57. e) 08/21/24 - Pretreatment 126/37, Intradialytic 140,117, 99/57,Post treatment 116/54. f) 08/23/24 - Pretreatment 135/59, Intradialytic 97/54,118/43, Post treatment 105/71. 2) There was no evidence of an RN assessment for HTN, provided treatment, and/or notified Physician of findings. 3) During the interview on 08/27/24 at 3:50 PM, the Director of Clinical Operations #1 confirmed the findings in G. H. Patient # 11 1) Review of six TFS (treatment flow sheets), six of six treatments, 06/21/24 - 06/25/24, showed no evidence the RN assessed the patient’s pretreatment and/or post treatment BP, provided treatment, and/or notified Physician of findings. BP Examples: a) 06/21/24 - 190/90 at 5:30 PM. 178/88 at 10:00 PM, and 185/88 at 7:00 AM. b) 06/22/24 - 202/97 at 3:00 PM, 185/90 at 10:00 PM, and 181/90 at 7:00 AM. c) 06/23/24- 202/104 at 3:00 PM, 188/92 at 7:30 PM, 198/93 at 10:00 PM, and 186/91 at 7:15 AM. d) 06/24/24-197/90 at 3:00 PM, 192/92 at 7:00 PM, 176/98 at 10:00 PM and 182/94 at 7:00 AM. e) 06/25/24-230/115 at 3:15 PM, 234/119 at 7:15 PM, 187/91 at 10:00 PM, and 178/88 at 7:00 AM. c) There was no evidence of an RN assessment for hypertension and no evidence of notification of the Physician for the trend of hypertension. 2) During the interview on 08/27/24 at 3:30 PM, the Director of Clinical Operations #1 confirmed the findings in H.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 51002 Based on clinical record review, policy review, and interview, it was determined the Interdisciplinary Team (IDT) failed to modify the patient’s plan of care (POC) for four (#2, #3, #5 and #6) of ten (#1-#10) in center hemodialysis patients and one (#11) of three (#11-#13) patients reviewed when the patients’ blood pressure was outside established parameters. The failed practice placed patients at risk for complications related to un-managed blood pressure and fluid volume. The failed practice had the likelihood to affect all 195 in center hemodialysis and 71 home peritoneal dialysis patients. The findings were: A. Review of the facility Clinical Care and Patient Safety Fluid Management and Hypertension (HTN) policy showed, “The Dialysis Center’s Interdisciplinary Team (IDT) will provide the necessary care and services to manage the patient’s volume status. Goal: Euvolemic with blood pressure (BP) 130/80 post-treatment and gaining less than 3 kg (kilograms) between treatments. A patient at their EDW (estimated dry weight) should be asymptomatic and normotensive on minimum blood pressure medications, while preserving organ perfusion and maintaining existing residual renal function. If patient shows signs/symptoms of fluid overload such as shortness of breath, edema, or high blood pressure (140/90), the nurse (RN) may challenge the EDW by up to 500 ml (milliliters). Any challenge greater than 500 ml must be specifically ordered by a Physician. Failure to achieve the target weight through the dialysis treatment will be documented, as well as the reason, and any action taken to correct such EDW adjustment, medication changes, or treatment adjustments. Patients blood pressures must be monitored pre, during, and post treatment. Abnormally high or low values must be addressed. Unless there is a unique order addressing elevated BP for the specific patient, an RN will notify physician if the patient has a systolic BP trend (6 treatments) less than 100 or greater than 140/ or diastolic BP trend (6 treatments) of less than 40 or greater than 90 during or post-treatment.” B. Review of MAT (Measures Assessment Tool) showed the Euvolemic, and pre-treatment BP was to be < 140/90 and post-treatment was to be BP < 130/80. C. During an interview on 08/27/24 at 3:50 PM, the Director of Clinical Operations #1 confirmed the findings in A and B. D. Patient #2 1) Review of six TFS (treatment flow sheets), five of six treatments, 08/09/24 - 08/26 /24, showed the following BP examples: a) 08/09/24 - Predialytic 163/78, Intradialytic 153/72, intradialytic pulse 91 at 12:32 PM. b) 08/12/24 - Predialytic 169/85, Intradialytic 149/79 and Post treatment 144/72. 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 08/27/24 at 3:30 PM, the Director of Clinical Operations #1 confirmed the findings in D. E. Patient #3 1) Review of six TFS, four of six treatments, 08/09/24 - 08/26/24, showed the following BP examples: : a) 08/09/24 - Predialytic 115/79,Intradialytic - 186/80, postdialytic 165/86. b) 08/12/24 - Intradialytic -155/88, Postdialytic 158/82 c) 08/21/24 -Intradialytic 166/94, Post treatment 151/78. d) 08/26/24 - Intradialytic 171/88, Post treatment 167/79. 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 08/27/24 at 3:45 PM, the Director of Clinical Operations #1 confirmed the findings in E. F. Patient # 5 1) Review of six TFS, three of six treatments, 07/16/24 - 08/22/24, showed the following BP examples: : a) 07/16/24 - Pretreatment 175/62, Intradialytic 195/71, Post treatment 160/57. b) 07/23/24 - Pretreatment 196/73, Intradialytic 204/91, Post treatment 130/53 c) 08/24/24 - Pretreatment 179/71, Intradialytic 181/71, Post treatment 154/65 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters. 3) During the interview on 08/27/24 at 3:50 PM, the Director of Clinical Operations #1 confirmed the findings in F. G. Patient # 6 1) Review of six TFS, six of six treatments, 08/09/24 - 08/23/24, showed the following BP examples: a) 08/09/24 - Pretreatment 117/41, Intradialytic 73/54,92/49 1, Post treatment 121/47. b) 08/12/24 - Pretreatment 135/60, Intradialytic153/55, 87/55, Post treatment 154/64. c) 08/14/24 - Pretreatment 147/76, Intradialytic 167/103,46/20, Post treatment 128/73. d) 08/16/24 - Pretreatment 154/45, Intradialytic 131/44, 149/37, Post treatment 133/57. e) 08/21/24 - Pretreatment 126/37, Intradialytic 140,117, 99/57,Post treatment 116/54. f) 08/23/24 - Pretreatment 135/59, Intradialytic 97/54,118/43, Post treatment 105/71. 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters.. 3) During the interview on 08/27/24 at 3:50 PM, the Director of Clinical Operations #1 confirmed the findings in G. H. Patient # 11 1) Review of six TFS (treatment flow sheets), six of six treatments, 06/21/24 - 06/25/24, showed the following BP examples: a) 06/21/24 - 190/90 at 5:30 PM. 178/88 at 10:00 PM, and 185/88 at 7:00 AM. b) 06/22/24 - 202/97 at 3:00 PM, 185/90 at 10:00 PM, and 181/90 at 7:00 AM. c) 06/23/24- 202/104 at 3:00 PM, 188/92 at 7:30 PM, 198/93 at 10:00 PM, and 186/91 at 7:15 AM. d)06/24/24-197/90 at 3:00 PM, 192/92 at 7:00 PM, 176/98 at 10:00 PM and 182/94 at 7:00 AM. e)06/25/24-230/115 at 3:15 PM, 234/119 at 7:15 PM, 187/91 at 10:00 PM, and 178/88 at 7:00 AM. 2) There was no evidence the IDT modified the POC related to the patient’s BPs outside of established parameters.. 3) During the interview on 08/27/24 at 3:50 PM, the Director of Clinical Operations #1 confirmed the findings in H.”

“POC-MANAGE ANEMIA/H/H MEASURED Q MO CFR(s): 494.90(a)(4) The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level. The patient’s hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient’s anemia management needs. This Standard is not met as evidenced by: 51002 Based on clinical record review, policy review and interview, it was determined the Interdisciplinary Team (IDT) failed to achieve and sustain hemoglobin (Hgb) levels in that patients POC (Plan of Care) was not reviewed/revised when the patient’s hemoglobin (Hgb) dropped or remained less than (<) 10 grams/deciliter (g/dL) for two (#2 and #4) of five (#1-#5 ) patients selected for hemoglobin review and failed to address low iron levels for one (#2) of two(#2 and #4) patients selected for ferritin and transferrin saturation(t-sat) review. The failed practices did not ensure the IDT had assessed patients for contributing factors or barriers to improve the Hgb outcomes. The failed practice had the likelihood to affect all 195 in-center hemodialysis patients on census. The findings were: A. Review of “Mircera Dosing Protocol date revised: 05/17/2021”showed “The dialysis center will administer ESA therapy per protocol or as ordered by the nephrologist to maintain patient Hgb level target range of 10-12 g/dl(Grams per decileter). “ B. Review of “Venofer Dosing Protocol date revised 06/15/2023” showed “ The Dialysis Center will administer Venofer to maintain adequate iron levels to prevent iron deficiency anemia”. “ Goal serum Ferritin level of >200ng/ml and < 800 ng/ml to supporta hemoglobin of 10-12 g/dl. Per protocol or as ordered by the nephrologist.” C. Patient #2: 1) Review of Hgb laboratory data from 6/14/2024 to 08/14/2024 and Ferritin/T-Sat showed: a) 06/14/2024 - 7.7 g/dL. /ferritin 30/ T-Sat 11 b) 07/01/2024 - 7.6g/dL. c) 07/22/2024 - 8.4 g/dL. d) 08/02/2024 - 8.1 g/dL e) 08/14/2024 - 8.6 g/dL 2) Review of base Physician orders and treatment flow sheets dated 06/07/2024 through 08/14/2024 showed no evidence an ESA or Venofer was ordered for this patient. 3) Review of the Interdisciplinary Assessment and Plan of Care dated 06/17/2024, showed, “Anemia, Hgb 7.7, Goal not met. ,Transferrin saturation 11, Goal not met. Ferritin 21%, Goal not met. Anemia Manager following and ESA adjustment per protocol or Physician order. There were no evidence that anemia manager was addressing the hgb or Transferrin Saturation of less than 50. 4) There was no evidence the IDT had revised the POC to address the Hgb levels < 10 gm/dL or Transferrin Saturation of less than 50. 5) There was no evidence the IDT assessed for potential blood loss causative factors or barriers to the Hgb less than < 10 g/dL. 6) During an interview on 08/27/2024 at 11:00 AM, the Clinical Director of Operations #1 confirmed the findings in B. D. Patient #4: 1) Review of Hgb laboratory data from 06/03/2024 to 08/14/2024 showed: a) 06/03/2024 - 7.7g/dL. b) 06/18/2023 - 7.0 g/dL c) 07/01/2024 - 7.3 g/dL d) 08/02/2024 - 8.2 g/dL e) 08/14/2024 - 8.7g/dL 2) Review of base Physician orders and treatment flow sheets dated 06/03/2024 through 08/14/2024 micera200 mcg is ordered every 2 weeks with treatments. 3) Review of the progress and Physician notes from 06/03/2423 to 08/14/24, the Clinical Director of Operations # 1 showed there was no evidence the Physician assessed to evaluate for causative factors or barriers to the Hgb < 10 g/dL. 4)Review of the Interdisciplinary Assessment and Plan of Care dated 06/17/2024, showed, “Anemia, Hgb 7.7, Goal not met. Anemia Manager following and ESA adjustment per protocol or Physician order.There were no indications that manager was addressing the anemia. 5) There was no evidence the IDT assessed for potential blood loss causative factors or barriers to the Hgb less than < 10 g/dL. 6) During interview on 08/27/24 at 11:15 AM, the Clinical Director of Operations # 1confirmed the findings in B.”

“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: 44854 Based on review of Monthly Interdisciplinary Team (IDT) Meetings and interview, it was determined in six of six (March, April, May June, July, and August 2024) months, there was no evidence the Interdisciplinary Team (IDT) performed a root cause analysis when target goals were not achieved, developed improvement plans with actions that resulted in improved outcomes, and evaluated the success of the improvement plan with revisions as indicated for, blood pressure and fluid volume management. The failed practice did not assure outcomes were improved with sustainability of the outcomes. The failed practice had the likelihood to affect all 195 in-center hemodialysis, 11 home hemodialysis, and 71 home peritoneal dialysis patients. Findings follow: A. Review of the Monthly IDT Meetings from March 2024 to August 2024 showed no evidence of monitoring blood pressure (BP) and fluid management goals. B. In an interview with Director of Clinical Operations #1 on 08/29/2024 at 10:30 AM, it was reported that the Monthly IDT Meetings were focused on data for the previous month. Director Clinical Operations #1 confirmed there was no evidence of monitoring blood pressure and fluid management goals from March 2024 to August 2024.”

“QAPI-INDICATOR-ANEMIA MANAGEMENT CFR(s): 494.110(a)(2)(iv) The program must include, but not be limited to, the following: (iv) Anemia management. This Standard is not met as evidenced by: 44854 Based on review of the Interdisciplinary Dialysis Team (IDT) Meeting Minutes and interview, it was determined there was no corrective action plan to improve hemoglobin outcomes six of six (March 2024 to August 2024) months, there was no evidence the IDT months when the facility and Network 13 goal for less than 10% of patients would have a hemoglobin less than 10 gm/dL (grams/deciliter). The failed practice did not allow for plans to be made by the interdisciplinary team to improve hemoglobin levels and had the likelihood to affect all 195 in-center hemodialysis, 11 home hemodialysis, and 71 home peritoneal dialysis patients. The findings follow: A. Network 13 performance guidance for 2013 and current for hemoglobin was less than 10% of the dialysis patient population would have a hemoglobin level less than 10 gm/dL. B. Review of the IDT Meeting Minutes from March 2024 to August 2024 showed, “Goals: lowest possible percentage of the dialysis patient population having hgb (hemoglobin) levels < (less than) 10 gm/dL.” C. Review of the IDT Meeting Minutes from March 2024 to August 2024 showed the goal of lowest percentage possible of the patient population would have a hemoglobin less than 10 gm/dL was not met as follows: 02/2024-24%, 03/2024-19%, 04/2024-15%, 05/2024-14%, 06/2024-24% and 07/2024-25%. D. The findings were confirmed in an interview with the Director of Clinical Operations #1 on 08/29/2024 at 10:30 AM.”

“QAPI-INDICATOR-VASCULAR ACCESS CFR(s): 494.110(a)(2)(v) The program must include, but not be limited to, the following: (v) Vascular access. This Standard is not met as evidenced by: 44854 Based on review of Monthly Interdisciplinary Dialysis Team (IDT) Meetings and interview, it was determined in six of six (March, April, May June, July, and August 2024) months, there was no evidence the IDT performed a root cause analysis when target goals were not achieved, developed improvement plans with actions that resulted in improved outcomes, and evaluated the success of the improvement plan with revisions as indicated for vascular access management. The failed practice did not assure outcomes were improved with sustainability of the outcomes. The failed practice had the likelihood to affect all 195 in-center hemodialysis, 11 home hemodialysis, and 71 home peritoneal dialysis patients. A. Review of the Monthly IDT Meetings from March 2024 to August 2024 showed no evidence of monitoring Central Venous Catheter vascular access greater than 90 days to be less than 10%. B. Review of the IDT Meeting Minutes from March 2024 to August 2024 showed the goal of 10% of the patient population would not have a Central Venous access and was not met as follows: 02/2024-40%, 03/2024-41%, 04/2024-45%, 05/2024-39%, 06/2024-41% and 07/2024-41%. C. In an interview with Director of Clinical Operations #1 on 08/29/2024 at 10:30 AM, it was reported that the Monthly IDT Meetings were focused on data for the previous month. Director of Clinical Operations #1 confirmed there was no evidence of monitoring vascular access goals from March 2024 to August 2024.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 44854 Based on review of Monthly Interdisciplinary Team (IDT) Meetings and interview, it was determined in six of six (March, April, May June, July, and August 2024) months, there was no evidence the IDT performed a root cause analysis when target goals were not achieved, developed improvement plans with actions that resulted in improved outcomes, and evaluated the success of the improvement plan with revisions as indicated for blood pressure and fluid volume management. The failed practice did not assure outcomes were improved with sustainability of the outcomes. The failed practice had the likelihood to affect all 195 in-center hemodialysis, 11 home hemodialysis, and 71 home peritoneal dialysis patients. A. Review of the Monthly IDT Meetings from March 2024 to August 2024 showed no evidence of monitoring blood pressure (BP) and fluid management goals for all patient on census. B. In an interview with Director of Clinical Operations #1 on 08/29/2024 at 10:30 AM, it was reported that the Monthly IDT Meetings were focused on data for the previous month. Director of Clinical Operations #1 confirmed there was no evidence of monitoring blood pressure and fluid management goals from March 2024 to August 2024.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 37145 Based on record review and interview, the facility failed to ensure the current peritoneal dialysis prescription treatment orders were updated and complete to reflect treatment for one (#11) of three (#11, #12 and #13) home peritoneal dialysis patients reviewed. The failed practice did not accurately reflect the patients’ treatments to ensure the physician’s order was followed for adequacy of dialysis. The failed practice had the likelihood to affect all 71 home peritoneal dialysis patients on census. The findings were: A. On 08/27/24 at 9:00 AM, record review of Patient #11’s CAPD (continuous ambulatory peritoneal dialysis) Physician orders dated 06/04/24 showed, “1 overnight exchange 2000 ml (milliliters) Icodextrin.” The clinical record had no evidence of the current dialysis prescription documented. 1. Record review of the Peritoneal Dialysis Monthly Comprehensive rounding note dated 06/13/24, showed, “Interval history: she was in the hospital 2 weeks ago with a GI (gastrointestinal) bleed and required IV (intravenous) fluids. Much swelling since then and we have been trying to get this off. She will try short dwells of 2.5 % with drain after 1 hour and see if this helps remove her volume.” 2. Record review of the Peritoneal Dialysis Monthly Comprehensive rounding note dated 07/11/24, showed, “She is having less edema than in the past, but still has had swelling. Has tried 2.5 and 4.25 % exchanges and these have not removed volume. She will try an additional 2-3-hour exchange with Icodextrin during the day to see if we can remove fluid. She feels that this has helped in the past.” 3. Record review of the Icodextrin flow sheets dated 06/03/24 through 06/25/24 showed 1 overnight exchange with extra exchange with drain after a 2 to 4 hour interval each evening. B. The findings in A were confirmed with the Director of Clinical Operations #2 on 08/27/24 at 9:15 AM.”