Usrc South Phoenix

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 45999 Based on a review of policy/procedure, observation, and staff interview, the Department determined that the facility failed to ensure: 1. Staff aseptically cleansed (3) of (3) patients (Patients #9, and #11) vascular access prior to cannulation with fistula needles. 2. staff aseptically performed central venous catheter (CVC) care and dressing changes for one (1 of 2) patient (patient #10). Failure to practice safe aseptic technique when cleansing and disinfecting a patient’s vascular access increases the risk for vascular access and bloodstream infection if bacteria are not sufficiently reduced at the cannulation sites prior to needle insertion. Findings include: 1. The facility policy titled “Assessment and Needle Placement for Existing and New Fistula and Graft” requires: “...Access preparation...Disinfect each assess site separately with one of the below options: Alcohol prep pad in a rubbing motion for at least 30 seconds immediately prior to needle insertion....” Observation on February 5, 2024, revealed Employee #1 prepared to cannulate Patient #’9’s vascular access. Employee # used an alcohol pad to disinfect the arterial cannulation site for 27 seconds prior to cannulation the site. Employee # used an alcohol pad to disinfect the venous cannulation site for 34 seconds prior to cannulation the site. Observation on February 5, 2024, revealed Employee # 3 prepared to cannulate Patient #11’s vascular access. Employee # used an alcohol pad to disinfect the arterial cannulation site and the venous cannulation site at the same time for 19 seconds and then proceeded to immediately stick the access. Employee #1 confirmed on February 8, 2024, that Employees #1, and #3, did not clean the patient’s access sites as per policy and procedure. 2. The facility policy titled “ ...The facility policy titled “Dialysis Catheter Dressing Change” requires: “...Remove and discard old exit site dressing...Using aseptic technique, cleanse the skin surrounding the exit site with the appropriate skin antiseptic...Acceptable cleansing agents include: ...ChloraPrep...Povidone iodine...ExSept...Using aseptic technique apply the appropriate dressing to the site....” The facility policy titled “Accessing and De-Accessing the Dialysis Catheter” requires: “...Follow policy C-TI-0070 for Dialysis Catheter Dressing Change Procedure....” Observation on February 5, 2024, revealed, that Employee #2 performing CVC care and dressing change for Patient #10. Employee #2 removed the old CVC dressing and cleansed the skin surrounding the exit site with one 70% isopropyl alcohol swab stick for 5 seconds. Employee #2 completed the skin asepsis and then proceeded to access the dialysis catheter prior to placing a new CVC dressing. The catheter hubs were cleaned, opened, waste withdrawn, saline flushed, and heparinized prior to the application of a new dressing. Employee # 1 confirmed on February 8, 2024, that employee #2 did not clean the patient’s access site as per policy and procedure.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 49430 Based on review of facility policy and medical records, it was determined that the facility administrator failed to ensure: 1. registered nurse notify the patient’s nephrologist when the patient’s weight deviated one (1) or more kilograms from the estimated dry weight (EDW). 2. staff administer clonidine based on physician’s orders 3. staff monitor patient blood pressures every 15 minutes for one hour after being administered clonidine based on physician’s orders. This lack of reporting EDW not achieved and neglecting to assess and respond to hypertension increases the risk for inadequate treatments, fluid overload, dehydration, hospitalizations, stroke and death. Findings include: 1. Policy titled “In-center Standing Orders-Arizona Only” requires “If variance > or < 1 kg from EDW, notify MD...”. 1. Patient #1 medical records reveal leaving (1) of (6) treatments greater than 1 KG over the EDW without any documentation of physician notified. 1. Patient #2 medical records reveal leaving (3) of (6) treatments greater than 1 KG over the EDW without any documentation of physician notified. 1. Patient #3 medical records reveal leaving (1) of (6) treatments greater than 1 KG over the EDW without any documentation of physician notified. 1. Patient #6 medical records reveal leaving (1) of (6) treatments greater than 1 KG over the EDW without any documentation of physician notified. 1. Employee #1 confirmed absence of documentation of physician aware. 2. Patient #3 treatment sheet dated 01/24/2024, reveals continuous hypertension (193/106, 190/101, 182/103, 199/88, 189/104...). Clonidine given (15:28) 2 hours and 37 minutes after start of treatment (12:51). 2. Patient #3 treatment sheet dated 01/31/2024, reveals continuous hypertension (196/90, 189/79, 182/88, 204/181, 185/88, 196/86, 191/101, 188/89 and 186/93) throughout treatment without Clonidine given or offered and refused by patient. 2. Patient #3 treatment sheet dated 02/22/2024, reveals continuous hypertension (195/99, 197/100, 187/93, 187/99, 196/99, 196/92, 191/91, 198/87, 188/92, 200/89, 189/78, 189/99 and 189/88). Clonidine given at 13:21. No second dose documented for continuing hypertension. 2. Patient #4 treatment sheet dated 01/27/2024, reveals continuous hypertension (182/118, 182/118, 175/124, 178/113, 183/113, 186/115, 170/111, 179/104 and 165/103) throughout treatment without Clonidine given or offered and refused by patient. 2. Patient #6 treatment sheet dated 01/27/2024, reveals continuous hypertension (197/116, 197/120, 180/116, 190/100, 179/103, 180/108, 174/105, 184/100, 184/98, 191/107, 187/103 and 195/108) throughout treatment without Clonidine given or offered and refused by patient. 2. Patient #6 treatment sheet dated 01/30/2024, reveals continuous hypertension (201/117, 184/115, 176/117, 185/107, 174/111, 177/103, 185/104, 193/99, 193/99 and 189/114) throughout treatment without Clonidine given or offered and refused by patient. 3. Patient #3 treatment sheet dated 01/24/2024, reveal Clonidine given at 15:28. Vital signs documented greater than every (15) minutes thereafter. 3. Patient #3 treatment sheet dated 01/26/2024, reveal Clonidine given at 13:54. Vital signs documented greater than every (15) minutes thereafter. 3. Patient #3 treatment sheet dated 02/02/2024, reveal Clonidine given at 1400 and 15:20. Vital signs documented greater than every (15) minutes thereafter. 3. Patient #3 treatment sheet dated 02/22/2024, reveal Clonidine given at 13:21. Vital signs documented greater than every (15) minutes thereafter.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 49430 Based on facility policy review and record review, the facility failed to conduct a comprehensive initial assessment for a newly admitted patient (Patient #4) within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session Finding includes: Policy Titled “Medical Records” requires “...H&P must be reviewed and authenticated (agree with ESRD diagnosis and treatment plan) as evidence by documentation of concurrence no later than 30 days from date of the H&P...” Medical records indicate patient was admitted as Acute Kidney Injury (AKI) 03/18/23. The History/Physical (H/P) found in patients chart dated 03/11/2023, was not performed by the patient’s nephrologist. Pt nephrologist signed H&P 04/20/2023 which is greater than 30 days of the date the H&P was performed.”

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- (1) At least annually for stable patients; This Standard is not met as evidenced by: 49430 Based on policy review, medical record review and staff interview, it was determined the facility failed to require a History and Physical (H&P) be done annually for 2 of 5 current patients reviewed (Patient #1 and #5). Findings include: Policy titled “Medical Records” require “ii. Arizona...require a H&P on admission and at least annually.” Patient #1 H&P signed 07/28/2022. The next H&P signed 10/23/2023 making this H&P more than a year from the previous H&P. Patient #5 H&P signed 02/28/2022. The next H&P was signed 03/29/2023 making this H&P more than a year from the previous H&P. During an interview conducted 02/06/2024, Employee confirmed the dates between the H&P to be greater than 1 year.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 49430 Based on review of policies and procedures, medical records and interview with staff, it was determined the facility failed to ensure Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA) was updated to reflect changes in 3 of five (3/5), patients #1, #4 and #5, patient’s health status. The failure to identify, assess and update the CIPA significantly increases the risk of hospital admissions, hospital readmissions and death to the dialysis patient population. Findings include: Policy titled “Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA/POC)” requires “9. Unstable patients will be identified by the governing body to include at minimum patients meeting one or more of the below criteria: a. Extended hospitalization(s): hospitalization longer than 15 days; b. Frequent hospitalizations: more than 3 hospitalizations in a 30-day period...d. Marked deterioration in health status such as chronic or recurrent infections...symptoms severe enough to prevent completion of the majority (>50%) of dialysis treatments, non-adherence to prescribed treatment, e.g., missed treatments, shortened treatments, excessive fluid gains necessitating extra treatments or additional indicators as defined by the governing body...Frequency if CIPA...Unstable Patient...Full reassessment monthly...” Patient #1 CIPA dated 11/16/2023 labeled unstable. Next CIPA dated 12/19/2023 which is greater than 30 days from previous CIPA. Patient #1 CIPA dated 12/19/2023 labeled unstable. January CIPA requested but not produced by facility. Patient #2 CIPA dated 04/20/2023 labeled unstable. Next CIPA dated 05/25/2023 which is greater than 30 days from previous CIPA. Patient #5 CIPA dated 04/27/2023 labeled unstable. May and June CIPA requested but not produced by facility. Employee #1 confirmed the intervals to be greater than 30 days and the CIPA’s that were not produced did not exist.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 45999 Based on a review of facility documents, personnel records, medical records, and interview, it was determined that the facility administrator failed to ensure that Counseling services were provided to patients as required under Conditions of Participation. This deficient resource increases the risk of hospital admissions, hospital readmissions, and could result in patient death and decreases the risk for adherence to dialysis prescription and treatment plan compliance. Findings include: Document titled “Job Description “requires “ Knowledge of and comply with federal, state, local laws and regulations, including health care professionals practice act requirements...Identify and counsel psychosocial issues ...Complete initial assessment of new patient psychosocial needs in adherence to state/CMS regulations and company policy ....” A request was made for counseling records for the selected patients being reviewed, none was provided. A request for an employee file for a personal member licensed independently to provide Counseling services was requested. None was provided. In an interview conducted on February 7, 2024, with employee #21. Employee #21 confirmed that there is no counseling being conducted with patients so there are no counseling records to review.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 49430 Based on review of facility policies and procedures, medical records, and staff interview, it was determined that the facility failed to: 1. require the entire IDT team sign off the review for (6) of (6) patient’s POC’s reviewed (Patient’s # 1, # 2, # 3, # 4, # 5 and # 6); and 2. require physician(s) signed off POC’s in a timely manner per facility policy for (6) of (6) patients reviewed. The lack of completing POC’s has the potential risk of failure of the IDT to develop an integrated treatment plan and provide an opportunity for the team to develop, coordinate and implement an effective, individualized plan of care. Findings include: 1 and 2. Review of facility policy and procedure “COMPREHENSIVE INTERDISCIPLINARY PATIENT ASSESSMENT/PLAN OF CARE (CIPA/POC)” revealed: “...Each IDT member will work collaboratively to complete the CIPA in order to reach agreement on assessment points and to ensure integration. Designation of specific areas of the CIPA are as follows:... Medical history by the physician or physician extender....Current condition by the nurse (including vital signs, labs and physical assessment)...Invite the patient or his/her legal representative to participate in the plan of care meeting/rounds.” 1. On 01/30/2024, review of (6) of (6) patient medical records (Patient’s 1, # 2, # 3, # 4, # 5 and # 6) revealed the following: Patient # 1’s Plan of Care (POC) meeting date 09/20/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 09/14/2023 08:09, Registered Dietitian (RD) dated 09/20/2023 13:22 and Social Worker (SW) dated 09/06/2023 14:46. Patient # 1’s Plan of Care (POC) meeting date 10/18/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 10/05/2023 06:23, Registered Dietitian (RD) dated 10/13/2023 19:19 and Social Worker (SW) dated 10/03/2023 10:58. Patient # 1’s Plan of Care (POC) meeting date 11/16/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 10/28/2023 15:40, Registered Dietitian (RD) dated 11/09/2023 18:39 and Social Worker (SW) dated 11/01/2023 11:28. Patient # 1’s Plan of Care (POC) meeting date 12/19/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 12/05/2023 09:21, Registered Dietitian (RD) dated 12/12/2023 19:13 and Social Worker (SW) dated 12/01/2023 10:40. Patient #2’s POC’s dated 03/24/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 03/15/2023 13:41, Registered Dietitian (RD) dated 03/15/2023 15:20 and Social Worker (SW) dated 03/20/2023 11:53. Patient #2’s POC’s dated 09/14/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 09/06/2023 13:30, Registered Dietitian (RD) dated 09/13/2023 17:34 and Social Worker (SW) dated 09/05/2023 15:09. Patient #3’s POC’s dated 01/15/2024, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 01/15/2024 16:30, Registered Dietitian (RD) dated 01/12/2024 18:01 and Social Worker (SW) dated 01/11/2024 11:01 Patient #4’s POC’s dated 04/20/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 04/20/2023 12:40, Registered Dietitian (RD) dated 04/19/2023 13:12 and Social Worker (SW) dated 04/18/2023 16:17. Patient #4’s POC’s dated 05/24/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 05/18/2023 07:19, Registered Dietitian (RD) dated 05/17/2023 16:58 and Social Worker (SW) dated 05/08/2023 14:39. Patient #4’s POC’s dated 06/22/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 06/15/2023 21:30, Registered Dietitian (RD) dated 06/19/2023 19:49 and Social Worker (SW) dated 06/07/2023 12:02. Patient #4’s POC’s dated 07/13/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 07/13/2023 07:22, Registered Dietitian (RD) dated 07/12/2023 17:56 and Social Worker (SW) dated 07/05/2023 16:09. Patient #4’s POC’s dated 09/19/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 09/09/2023 19:34, Registered Dietitian (RD) dated 09/18/2023 19:59 and Social Worker (SW) dated 09/05/2023 12:33. Patient #5’s POC’s dated 02/16/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 02/09/2023 12:33, Registered Dietitian (RD) dated 02/10/2023 18:50 and Social Worker (SW) dated 02/06/2023 14:37. Patient #5’s POC’s dated 03/28/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 03/16/2023 09:35, Registered Dietitian (RD) dated 03/13/2023 18:00 and Social Worker (SW) dated 03/13/2023 10:51. Patient #5’s POC’s dated 07/26/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 07/12/2023 11:25, Registered Dietitian (RD) dated 07/24/2023 19:16 and Social Worker (SW) dated 07/07/2023 14:05. Patient #6’s POC’s dated 05/30/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 05/02/2023 08:45, Registered Dietitian (RD) dated 05/19/2023 19:15 and Social Worker (SW) dated 05/11/2023 16:01. Patient #6’s POC’s dated 11/16/2023, was missing the date and time for each Interdisciplinary team (IDT) member on the signature page. Time and date stamps were found within the POC for the Registered Nurse (RN) dated 10/28/2023 15:45, Registered Dietitian (RD) dated 11/09/2023 18:02 and Social Worker (SW) dated 11/02/2023 14:37. 2. Patient #1’s POC dated 09/20/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #1’s POC dated 10/18/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #1’s POC dated 11/16/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #1’s POC dated 12/19/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #2’s POC dated 03/24/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #2’s POC dated 09/14/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #3’s POC dated 01/15/2024; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #4’s POC dated 04/20/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #4’s POC dated 05/24/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #4’s POC dated 06/22/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #4’s POC dated 07/13/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #4’s POC dated 09/19/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #5’s POC dated 02/16/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #5’s POC dated 03/28/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #5’s POC dated 07/26/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #6’s POC dated 05/30/2023; no time or date stamp found within entire POC for Medical Doctor (MD). Patient #6’s POC dated 11/16/2023; no time or date stamp found within entire POC for Medical Doctor (MD). 1 and 2. During staff interview, Employee #1 stated all members of the IDT are present during the meeting and accounted for by the electronic signature page at the end. When asked for date and time of the actual signature, Employee #1 stated the system populates the signature when the IDT member logs into the POC which is the service date in the upper right corner of the documents. Employee #1 unable to produce date and time for signatures.”

“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: 49430 Based on document review and interview, it was determined that the administrator failed to ensure that there was a documented discharge summary within 30 days of the patient’s discharge for (1) of (2) patients (Patients #7), which poses the potential risk of lack of coordination and continuity of care. Findings Include: Facility policy titled “Medical Records” revealed: “...CLOSED RECORDS...transferred, transplanted...etc... All closed records must include...A discharge summary completed within 30 days after the patient is inactivated/discharged or as required by state regulations...which includes...Date of discharge...Prognosis and diagnosis at discharge clearly identified by the attending physician...Cause and location of death, transplant or relocation....” Patient’s Discharge summary dated 10/31/2023 was not signed by the Medical Director until 12/29/2023. Employee #1 confirmed the date signed by Medical Director was more than 30 days past the discharge date.”

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 49430 Based on review of medical records and staff interview, it was determined the facility failed to ensure the medical record contained a MD note and/or MD signed Interdisciplinary Care Plan, Registered Nurse (RN) note, Registered Dietitian (RD) and Social Worker (SW) note. Failure to ensure a patient’s MD, RN and SW completes and signs a monthly notes and care plans may disrupt continuity of patient care due to an incomplete medical record. Findings include: Patient #1 missing September, 2023, October, 2023 and December, 2023 MD and RN notes. Patient #2 missing MD note for October 2023. Missing RN, SW and RD notes for December 2023 and January 2024. Patients # 4 missing November, 2023 MD note. Employee #1 confirmed the absences of thee notes.”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 45999 Based on a review of facility policies and procedures, observations, and staff interviews, it was determined that The Governing Body failed to ensure that the facility administrator actively maintained oversight and implementation of the facility’s policies and procedures for adequate staffing requirements to protect the health and safety of patients on dialysis and provide adequate clinical oversight during facility hours of operation. Findings include: Facility policy “GOVERNING BODY BY-LAWS” requires: “...Ensuring the facility employees the number of qualified personnel needed...for the safe provision of patient care....” Facility policy “STAFFING POLICY” revealed: “...adequately staff for safe and effective provision of patient care...Sufficient direct care staff shall be on-site to meet the needs of the patients. The ratio of direct care staff shall be one (1) to four (4) patients per shift....” A review of six patient schedules for October 7, 2023, October 27, 2023, November 21, 2023, December 4, 2023, December 18, 2023, and December 29, 2023, revealed that two of the six schedules had the ratio of one (1) to five, (5) and one schedule had a ratio of three technicians to twenty patients. Upon review of five patient records for each schedule reviewed (October 7, 27, November 21, December 4, 18, and 29, 2023) there was a total of 129 instances where the automatically recorded blood pressure was taken every twenty minutes, but the patient was not assessed in the appropriate time. Of those 129 instances, there were 21 instances where the blood pressure check was not reviewed for at least thirty minutes after being recorded and there was a total of twenty-three instances where a patient had a high or low blood pressure reading without notification to the registered nurse. In an interview on February 5 and 6, 2024, conducted with employee’s #3, #4 and #5, employees confirmed that when they are short of staff the will run patients with a ratio of one to five or more, and that blood pressures are not being addressed at the times set by policy and procedures.”

“GOV-RESPONDS TO NW REQUEST/WORKS TOWARD GOALS CFR(s): 494.180(i) The governing body receives and acts upon recommendations from the ESRD network. The dialysis facility must cooperate with the ESRD network designated for its geographic area, in fulfilling the terms of the Network’s current statement of work. Each facility must participate in ESRD network activities and pursue network goals. This Standard is not met as evidenced by: 49430 Based on review of facility documentation and staff and Network staff interviews, it was determined that the dialysis facility’s governing body did not require that the medical director adhere to requirements for lost to follow up, by failing to participate with the local ESRD Network in providing Patient #7 with a timely notice of lost to follow up. Patient’s “DISCHARGE SUMMARY” is dated 10/31/2023. Reason for discharge listed as “lost to follow up”. Social Worker, Registered Nurse and Registered Dietitian notes support the Lost to Follow-up discharge designation. Facility policy titled “Admission/Discharge of patients and end of treatment day discharge” requires “Discharge of patients...d. Lost to follow-up...iii...may be used only in conjunction with Network approval...”. Interview conducted with Employee #2 on 02/06/2024, confirmed Patient #7 was a Lost to Follow-up Discharge. Interview conducted on 02/06/2024, with Network Staff (Employee #22), confirmed the facility did not contact the Network at any time to inform of Lost to Follow-up discharge.”