Kaiser Health Plan of the Mid-Atlantic States

“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: 01300 Based on observations and interview, the facility failed to ensure proper functioning of boilers for adequate hot water temperatures for handwashing for two (2) out of two (2) observations. The finding include: On 09/22/2025 between 10:30 AM and 12:10 PM the surveyor conducted an observational tour of the facility ’ s Peritoneal Dialysis Treatment Rooms. The following was identified: -Peritoneal Dialysis Treatment Room 10 had a handwashing room hot water temperature was recorded between 90 degrees and 95 degrees Fahrenheit. - Peritoneal Dialysis Treatment Room 11 had a handwashing room hot water temperature was recorded between 95.5 degrees and 100 degrees Fahrenheit. - Hot water temperatures failed to reach the minimum temperature of 105 degrees Fahrenheit. Several attempts were made by Maintenance Staff to elevate hot water temperatures in Rooms 10 and 11 after adjusting mixing valves and boiler. On 09/22/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #4 Life Safety Officer-Manager. Employee #4 indicated that several boiler heating elements were not functional, causing the hot water temperatures to remain below 105 degrees Fahrenheit. Employee #4 indicated that the heating elements would be replaced between September 23, 2025, and September 25, 2025, hot water should be restored after heating elements installed.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 49189 Based on policy review, medical record review, and interview, the facility failed to ensure compliance with weight measurements prior to initiating peritoneal dialysis (PD) for 1 out of 3 patients (Patient #1). Findings Include: A review of the facility’s PD Patient Self-Monitoring Dialysis Data Nurse Review ’ policy, effective 12/2023, revealed: “5.2.2 The PD nurse will assess data for compliance with dialysis prescription and adequacy of PD procedures.” A review of Patient #1’s medical record from 05/01/2025 to 08/25/2025 revealed the following: -From 06/10/2025 to 08/25/2025 Patient #1 failed to document weights prior to initiating peritoneal dialysis. -The medical record lacked documentation of recognizing noncompliance with Patient #1 weighing themselves prior to initiating peritoneal dialysis. On 09/22/2025 at approximately 11:00 AM the surveyor conducted a face to face interview with Employee #1 Peritoneal Dialysis Nurse Manager. Employee #1 acknowledged the above finding.”

“QAPI-INDICATOR-ADEQUACY OF DIALYSIS CFR(s): 494.110(a)(2)(i) The program must include, but not be limited to, the following: (i) Adequacy of dialysis. This Standard is not met as evidenced by: 49189 Based on policy review, supporting documentation review, and interview, facility’s Quality Assessment Performance Improvement (QAPI) program failed to conduct action plans related to noncompliance with dialysis adequacy metrics. Findings Include: A review of the facility’s Comprehensive Interdisciplinary Patient Assessment (CIPA) and Plan of Care (POC) for Peritoneal Dialysis Patients Guideline, policy, effective 07/2022, revealed: “6.2.7 If the expected outcome is not achieved, the interdisciplinary team must adjust the patient ’ s plan of care to achieve the desired outcomes.” A review of the facility’s Peritoneal Dialysis Routine Laboratory Orders Protocol ’ policy, effective 08/27/2025, revealed: “5.2.12 The nurse will conduct kinetic modeling labs after the first 4 weeks of PD and monitor them quarterly. If the patient is not meeting the kt/v adequacy, a review will be conducted with the provider to implement a PD prescription, with the help of Adequest [software tood], to increase the possibility of meeting the Kt/V [parameter to assess dialysis dose].” A review of the facility’s Quality Assessment Performance Improvement program from the year 2024 to 2025 revealed that PD adequacy compliance range to be measured at 94.8 %. Further review revealed failure to reach this measurement with no documentation of an action plan for the following months and years: -Year 2024: May and June. -Year 2025: February, March, April, May, June, July. On 09/23/2025 at approximately 1:30 PM the surveyor conducted a face to face interview with Employee #2 Lead Specialist Accreditation, Regulation, and Licensing. Employee #2 confirmed that areas of noncompliance with the expected adequacy percentage would require and action plan to be enacted and documented in the facility ’ s QAPI.”

“MR-CENTRALIZE ALL INFO;IDT HAS ACCESS CFR(s): 494.170(b)(2) (2) All clinical information pertaining to a patient must be centralized in the patient’s record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient’s condition and prescribed treatment. This Standard is not met as evidenced by: 49189 Based on policy review, medical record review, and interview the facility failed to update order for Peritoneal dialysis after coordinating a change in volume instillation for one (1) out of three (3) patients sampled (Patient #3). Findings Include: A review of the facility’s ‘Comprehensive Interdisciplinary Patient Assessment (CIPA) and Plan of Care (POC) for Peritoneal Dialysis Patients Guideline ’ policy, effective 07/2022, revealed: “6.3 Role of the attending physician includes: 6.3.12 Update orders as needed.” A review of Patient #3’s medical record from 02/04/2025 to 09/21/2025 revealed the following: -On 02/04/2025 Patient #3 had ordered Peritoneal Dialysis prescription that included a fill volume of 2,700 milliliters. -Further review of Patient #3 ’ s provider note dated 03/20/2025 revealed an update to Patient #3 ’ s Peritoneal Dialysis prescription with an updated fill volume of 3,000 milliliters. There is no documentation of the prescription being updated in Patient #3’s order. -Further review of Patient #3’s Peritoneal Dialysis treatment data from 03/21/2025 to 09/21/2025 revealed documentation of average fill for each treatment at 3,000 milliliters. On 09/23/2025 at approximately 1:00 PM the surveyor conducted a face to face interview with Employee #5 Nephrologist. Employes #5 was confirmed as the Nephrologist caring for Patient #3. Employee #5 confirmed that on 03/20/2025 Patient #3’s peritoneal dialysis prescription was modified to increase the fill volume to 3,000 milliliters. Employee #5 acknowledged that the order was not updated in the electronic medical record.”