Central Florida Kidney Center-East Orlando

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 39943 Based on staff interviews, review of patient treatment records, review of Quality Improvement Meeting minutes and review of other facility documents, it was determined that the End-Stage Renal Disease (ESRD) facility failed to comply with the Conditions for Coverage for Plans of Care by failing to identify deficient practices which could impact patient health and safety. The ESRD facility failed to ensure all members of the Interdisciplinary Teams were involved and notified of changes in the patient’s individualized treatments for 10 of 10 sampled patients (#1, #2, #3, #4, #5, # 6, #7, #8, #9, and #10)(V542). This pervasive deficient practice resulted a failure to develop plans of care to ensure the development, implementation or accuracy of individualized plans of care based on the patients’ assessments, to meet the needs of the patients. The facility failed to follow prescribed dialysis prescriptions to manage hypertension, post dialysis weights, fluid volume and achieve adequate clearance (V543). The facility also failed to ensure plans of care reflected information from the interdisciplinary team’s evaluation of the patient’s suitability for transplantation referral (V554). The cumulative effect of these systemic problems resulted in the ESRD’s inability to ensure the provision of quality health care in a safe environment and resulted in multiple patients not receiving dialysis treatments as ordered by their physician based on their individual needs and patients not being referred for transplantation appropriately. The findings included: Based on staff interviews and patient medical record and policy review, the dialysis center failed to complete a plan of care for 10 of 10 patients (#1, #2, #3, #4, #5, # 6, #7, #8, #9, and #10). Cross Reference V542 Based on staff interviews and patient medical record and policy review, the dialysis center failed to refer one of one patient (#10) for kidney transplantation who expressed interest for this. Cross Reference V543 Based on treatment record reviews, policy review and interview, the dialysis facility failed to follow hemodialysis treatment orders and failed to provide documentation for not following the prescribed amount of time for the dialysis treatment, blood flow rate (BFR), dialysis flow rate (DFR), post dialysis weight/estimated dry weight (EDW), and/or implement a corrective plan when the EDW was not achieved and failed to ensure abnormal blood pressures were reported to the licensed nurse for 6 of 10 patients reviewed for dialysis prescription, (#2, #3,#7, #8 ,#9, #10 ).dialysis”

“CFC-QAPI CFR(s): 494.110 This Condition is not met as evidenced by: 37965 Based on staff interviews, review of patient treatment records, review of Quality Improvement Meeting minutes and review of other facility documents, it was determined that the End-Stage Renal Disease (ESRD) facility failed to comply with the Conditions for Coverage for Quality Assurance Performance Improvement (QAPI) by failing to identify deficient practices which could impact patient health and safety. The QAPI program failed to ensure that patient’s mortalities were reviewed and included in their facility’s Quality Assessment Performance Improvement program and the facility failed to ensure the identification of the negative outcome of nonexistent or inaccurate plans of care on patient safety and improvement in patient health outcomes (V638) The cumulative effect of these systemic problems resulted in the ESRD’s inability to ensure the provision of quality health care in a safe environment.”

“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: 37965 Based on observations, interviews and policy review the End Stage Renal Disease center (ESRD) failed to ensure that nursing staff utilized personal protective equipment appropriately during care of dialysis patients for 1 of 4 Registered Nurses (RN) observed (RN-M) and 1 of 8 Patient Care Technicians (PCT) observed (PCT-N). The findings include: On 9/10/24 at approximately 10:00 AM an observation was made of the charge nurse, RN-M, during an assessment of the patient at station #15. While working with the patients at station #15 the alarms at station #14 began to alarm. She was observed to step over to station #14 to address alarms but did not change her gloves or perform hand hygiene. On 9/10/24 at approximately 10:37 AM, an observation was made of the charge nurse, RN-M, preparing Heparin at the medication counter in the treatment area behind the nursing station. She was wearing a clean pair of blue gloves. She obtained the Heparin from the counter and walked the length of the treatment floor and approached station #15 and proceeded to secure the heparin syringe to the dialysis machine for infusion during the treatment. She was not observed to change her gloves or perform hand hygiene during the transfer of the heparin from the medication counter or while securing the heparin to the dialysis machine. On 9/10/24 at approximately 10:42 AM, an observation was made of the charge nurse, RN-M, addressing the alarms at dialysis station #14. She was observed to wrap a blue glove around her index finger and press buttons on the machine to stop the alarms. She was not observed to fully donn the glove or perform hand hygiene. On 9/10/24 at approximately 11:06 AM, an observation was made of the charge nurse, RN-M, approaching station #11 with a syringe of heparin while wearing a blue pair of gloves. She was observed to secure the heparin to the machine without changing her gloves or performing hand hygiene. On 9/10/24 at approximately 11:15 AM, an observation was made of PCT-N, who was assisting with the patient at station #11. At this time the alarms at station #13 began to sound and PCT-N was observed to step over to station #13 from Station #11. After making adjustments to the dialysis machine at station #13 he returned to Station 11 to resume cleaning the dialysis access port of the patient. He was not observed to change his gloves or perform hand hygiene. On 9/10/24 at approximately 11:20 AM, an observation was made of the charge nurse, RN-M, obtaining heparin from the medication counter while wearing a clean pair of blue gloves. She obtained the heparin from the counter and the length of the treatment floor and approached station #13 wearing the same gloves carrying the syringe of heparin. She was observed to secure the heparin to the dialysis machine. At no point was she observed to change her gloves or perform hand hygiene prior to securing the heparin. On 9/10/24 at approximately 2:03 PM, an interview was conducted with the charge nurse, RN-M, during which she stated she had training in the downtown ESRD center, which included hand hygiene and appropriate use of PPE such as the use of gloves. She was asked about carrying the syringes of heparin through the dialysis treatment floor from the medication counter and taking it to the dialysis machine without changing gloves. She stated that since she was transporting the medication directly to the patient, she was not required to change her gloves or perform hand hygiene. When asked about wrapping a glove around her index finger to address the alarms on the dialysis machine she stated that if they were just pressing buttons this was allowed. She stated that they should donn the glove in its entirety, but she was in a hurry. She stated that they are supposed to use hand sanitizer between patients, but they get in a hurry sometimes and forget. On 9/11/24 at approximately 4:30 PM an interview was conducted with the ESRD Clinical Manager during which he stated that items should not be carried through the clinic area for use on patients without appropriate hand hygiene or use of gloves. Review of the policy/procedure Infection Control Practices for Dialysis Facilities effective date 9/3/24 indicates “Any item taken to a patient’s dialysis station is considered contaminated and can serve as a vehicle of transmission to other patients either directly or by contamination of the hands of personnel. Therefore, items taken to a patient’s dialysis station, including those placed on top of dialysis machines, will be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being returned to a common clean area or used for other patients. Under Personnel item #2 Hand washing: Hands must be washed before and after each patient contact, between handling different body fluids, when hands are visibly soiled, and before putting on and after removing gloves. Alcohol based disinfectant solution (minimum 60% alcohol) may be used if hands are not visibly soiled. Under item b. iii. Gloves will be worn anytime the dialysis machine is touched, that includes when setting up the clean machine, answering alarms, using the keyboard and cleaning the machine. Item h. Stethoscope bells should be wiped with an alcohol wipe or other antibacterial solution between patients.”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 37965 Based on observations, interviews and record review the End Stage Renal Disease center (ESRD) failed to ensure that multiple use items such as stethoscopes and clipboards were dedicated for use on one patient or disinfected before use on patients or being placed on the dialysis chair or dialysis machine for 2 of 2 stethoscopes and for 16 of 16 patient clipboards. The findings include: On 9/10/24 at approximately 10:00 AM an observation was made of the charge nurse, RN-M (Registered Nurse-M), at station #14. She was observed to be assessing the lung sounds of the patient with a pink stethoscope she had obtained from the counter at the nursing station. She was not observed to clean the stethoscope prior to assessing the patient’s lung sounds. She returned the stethoscope to the nursing station without disinfecting or cleaning the stethoscope. On 9/10/24 at approximately 10:30 AM, an observation was made of the charge nurse, RN-M, at station #15. She was observed to be assessing the lung sounds of the patient with a pink stethoscope she had obtained from the counter at the nursing station. She was not observed to clean the stethoscope after obtaining it from the nursing station or prior to assessing the patient’s lung sounds. On 9/10/24 at approximately 10:48 AM, Patient Care Technician-N (PCT-N) was observed setting up two dialysis machines for oncoming dialysis patients. He was noted to obtain two clipboards from the nursing station, placing them on top of each other and carrying them to and placing them on the tray tables of stations #11 and #9. At this time, it was noted that a third clipboard for a discharged patient was laying on the nursing counter, which contained documented pre and post dialysis vital signs and weights. At no time were the clipboards observed to be disinfected. Also, at this time it was noted that RN-M, obtained a clipboard from station #14 with ungloved hands and without sanitizing her hands or the clipboard, she was observed to make notations on the paper attached to the clipboard. On 9/10/24 at approximately 10:56 AM, an observation was made of charge nurse, RN-M, and PCT-N assisting a dialysis patient to station #11. PCT- N, had a clipboard in his ungloved hands. The nurse stopped at the nursing station to obtain a pink stethoscope from the counter and begin to assess the patient’s lung sounds. At no point was she observed to clean the stethoscope before assessing the patient. She returned the stethoscope to the nursing station placing it next to three clipboards stacked on top of each other with patient notations on them. At this time observations were made of clipboards throughout the center being housed on the dialysis machines behind the monitors, on tray tables and at the nursing station. (photographic evidence obtained) On 9/10/24 at approximately 11:06 AM, an observation was made of PCT-N, holding a clipboard without gloved hands and making notations on the paper secured to the board. He returned the clipboard to the dialysis machine without disinfecting the clipboard. On 9/10/24 at approximately 11:15 AM, an observation was made of the charge nurse, RN-M, assisting a patient to station #13. She obtained a pink stethoscope from the nursing station and then began to assess the patients lung sounds. She was not observed to clean or disinfect the stethoscope before or after assessing the patient. On 9/11/24 at approximately 11:26 AM, PCT-O was observed to obtain a clipboard from station 4, where a patient was actively receiving dialysis. She placed the clip board at the nursing station and sat down at a computer housed on a rolling table. She moved the clipboard between the nursing station counter and the rolling computer table while documenting on a computer. She then returned the clipboard to station 4 without cleaning or disinfecting it. On 9/11/24, at approximately 12:41 PM, an observation was made of charge nurse RN-P, who was assessing a patient at station #6. RN-P was observed to remove a black stethoscope from around his neck to conduct the assessment, and was not observed to clean the stethoscope prior to assessing the patient. On 9/11/24 at 12:42 PM, an interview was conducted with PCT-O, during which she stated staff are supposed to use a 1:100 bleach mixture to clean multiple use items such as stethoscopes between uses. She stated that most staff have their own stethoscopes, but they should still be cleaned between uses. She stated the clipboards are cleaned at the end of the day and they have patient information on them such as prescription information and pre/post dialysis weights and vitals. The clipboards are housed in a rack where they are returned at the end of the day. She reported that she has never been informed to clean them if they leave the dialysis station or are taken to the nursing station. She again stated they are cleaned at the end of the day. On 9/11/24 at 12:51 PM, an interview was conducted with PCT-Q. He stated that the clipboards are at the stations when the patients arrive for dialysis. They contain patient specific information and have changes that may have been made since the last dialysis treatment. They are cleaned at the end of the day. PCT-Q stated they use a 1% bleach solution to clean things like stethoscopes but the clipboards are not cleaned during treatment. On 9/11/24 at approximately 1:04 PM an interview was conducted with PCT-N, during which he stated that the facility is strict on infection control and require everyone to sanitize their hands when jumping between patients. He stated they get the clipboards from the rack when setting up for the next patient treatment for the 2nd and 3rd shifts. They are placed on the raised counter of the nursing station with other supplies that are awaiting the next dialysis patient. PCT-N stated they should remain at the dialysis station throughout the treatment and be cleaned and returned to the rack after the patient leaves. If they are left lying around the nursing station it is just a bad day and should be kept behind the monitor of the dialysis machine. On 9/11/24 at approximately 2:03 PM, an interview was conducted with charge nurse, RN-M, who stated the clipboards are cleaned at the end of the day. She clarified that the clipboards have orders on them to include heparin orders and the PCT’s document pre/post treatment weights and vitals. On 9/11/24 at approximately 4:30 PM, an interview was conducted with the Clinical Manager during which he stated they had been using the clipboards since he started at the facility 2 years ago and he had never provided or been trained on disinfection of the clipboards. He stated that the boards should be kept on the dialysis machine behind the monitor. He also stated once the patient leaves the clinic they should clean the clipboards and put them in the rack, stating they should never be left on the nursing station and staff should not carry them around the treatment floor. They can put them on the tray table for dialysis initiation but otherwise they should be kept on the machine. He stated he was not sure they had a policy for the clipboards. A policy was not provided by the time of survey exit. Review of the policy/procedure Infection Control Practices for Dialysis Facilities effective date 09/03/24 indicated that any item taken to a patient’s dialysis station is considered contaminated and can serve as a vehicle of transmission to other patients either directly or by contamination of the hands of personnel. Therefore, items taken to a patient’s dialysis station, including those placed on top of dialysis machines, will be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being returned to a common clean area or used for other patients. Under Cleaning and Disinfection item #2 “After each patient treatment, the environmental surfaces will be cleaned with a tuberculocidal disinfectant or a 1:100 dilution of household bleach (intermediate-level disinfection) at the dialysis stations, including the dialysis bed or chair, countertops, and external surfaces of the dialysis machine, including containers associated with the prime waste. Between uses of medical equipment (e.g., clamps, stethoscopes, blood pressure cuffs), the facility will clean and use an approved disinfectant or 1:100 dilution of household bleach. PPE (personal protection equipment) should be worn during the cleaning and disinfection of the dialysis stations.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 37965 Based on observation, interview and policy review the facility failed to ensure that expired medications were disposed of timely for 1 of 1 observations of Peritoneal dialysis (PD) training room. The findings include: On 09/10/24 at approximately 2:30 PM, an observation was made of the Home Dialysis training room supply cabinet which revealed a 30 Milliliter (ML) multi-dose vial of Heparin, that had an expiration date of August 2024. On the vial was written in back marker “open 8/19/24”. On 09/10/24 at approximately 3:11 PM, an interview was conducted with the PD manager and the Director of Clinical Operations. They were shown the vial of heparin with the date of 08/19/24. At first the PD Manager stated that multi-dose vials are good for 28 - 30 days after the vials are opened and that they were still within that window. When shown the expiration date on the vial the PD manager stated that the medication should have been discarded and not used. He went on to state that he trains patients for home dialysis in the training room and teaches them “SEAL” which is an acronym for “Strength, Expiration, Amount and Leaks”, which includes checking all medication and supplies for expiration dates prior to use. He stated that he was not sure if the heparin had been used during the training of his last PD patient but given the date on the vial it was possible. A review of the policy/procedure Medication Administration last reviewed on 09/23 revealed that Multidose vial with preservative: item #2 “May use medication from opened and properly labeled container up to 29 days after opening, but not to exceed the expiration date. Any drug with a specific allowable use time after opening, other than the typical 28 days, will be discarded as indicated in the drug literature.”

“INVENTORY CONTROL CFR(s): 494.50(b)(1) 9.2 Inventory control Reprocessing supplies should be used on a first-in, first-out basis, and outdated supplies should be identified and discarded. This Standard is not met as evidenced by: 37965 Based on observation and interview the facility failed to ensure expired supplies were removed from the treatment area for 2 of 2 Peritoneal Dialysis (PD) home training rooms observed. The findings include: On 9/10/24 at approximately 4:50 PM, an observation was made of two peritoneal dialysis home training rooms. The following supplies were noted as being expired in the treatment rooms: 17 sealed packs of surgical gloves were noted with an expiration date of 2022-5 (May 2022); 12 sealed packs of CAPD disposable disconnect Y-sets with an expiration date of 2024-1-03 (January 3, 2024); 1 bottle of 70% Isopropyl Rubbing Alcohol with an expiration date of 9/23; Blood testing tubes with expiration dates which included 2024-05-14; 2024-05-02; 2024-05-02; 2 sealed packages of Flexicap disconnect cap with povidone-iodine solution with an expiration date of 2024-08-28; 1 box of vacutainer blood collection sets with an expiration date of 2023-06-30 1 insulin syringe with an expiration date of 2022-01-31 11 vials of normal saline with an expiration date of 2023-04 1 suture removal tray with an expiration date of 2022-02-14 2 wound culture collection sets with expiration dates of 2022-11-18 (photographic evidence obtained) On 9/11/24 at approximately 3:11 PM an interview was conducted with the PD Manager and the Director of Clinical Practice, during which they were asked about the expired supplies. The PD manager stated he comes to the center a couple of times a month to provide education for new PD patients. He stated he is new to this location but had been the manager for well over 10 years. He stated that it is his expectation that all expired supplies would be tossed away and not used. He stated that he has given in-services on the need to remove expired supplies immediately. He reported that he usually brings his own supplies and had not checked these rooms since he took over for the previous PD nurse. He went on to state that he trains patients for home dialysis in the training rooms and teaches them “SEAL” which is an acronym for “Strength, Expiration, Amount and Leaks”, which includes checking all medication and supplies for expiration dates prior to use.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 39943 Based on staff interviews and patient medical record and policy review, the dialysis center failed to complete a plan of care for 10 of 10 patients (#1, #2, #3, #4, #5, # 6, #7, #8, #9, and #10). Findings: On 9/12/24 at approximately 12:00 PM, while reviewing patient medical records for patients #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10, it was noted that these patients did not have a completed care plan. The care plans were requested for the records being reviewed and the Clinical Manager stated he would get them. A second request for the care plans was made at approximately 3:30 PM without success. On 9/12/24 at approximately 5:23 PM, an interview was conducted with the Clinical Manager and the Clinical Regulatory Specialist regarding the facilities QAPI program and incomplete care plans. They stated they were aware that the facility had not been adding completed care plans to the patients records. During the interview they acknowledged that the care plans were late and not current indicating they have spoken to the new Medical Director about these concerns and hope he will be able to assist with getting them updated. They continued stating the facility staff had been working to update the care plans but the previous medial director had not returned any of them after reviewing. They reported he always assured them he would get them back to them but never did and as a result they fell behind. Review of the facility policy: Plans of Care for Dialysis, dated 1/01/2017, and 8/20/2022 noted the following: A Plan of Care will be developed by the Interdisciplinary Team (IDT) for all patients admitted to the facility. The IDT members are expected to interact and share information from a comprehensive assessment to facilitate the development of the Plan of Care. Responsibility: Medical Director Home Training Nurse All Facility Personnel Dietician Director of Nursing Social Worker The Plan of Care will address the following: 1. Dose of Dialysis a. Volume Status: Volume status is measured in terms of the dialysis Patient’s “target weight” or estimated dry weight (EDW). . . b. Adequacy: Each patient should achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and peritoneal dialysis Kt/v of at least 1.7. . .The patient plan of care should always address the root causes for a treatment prescription not being met. . . But if the patient’s choice is to continue behavior such as shortened treatment time as long as the team documents educational efforts, this can be an explanation for not achieving the standard treatment time. . . . 9. Implementation: a. The patient’s plan of care will be completed by the interdisciplinary team, including the patient if the patient desires, and b. The plan of care will be signed by all team members, including the patient or the patient’s designee.”

“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: 01800 Based on treatment record reviews, policy review and interview, the dialysis facility failed to follow hemodialysis treatment orders and failed to provide documentation for not following the prescribed amount of time for the dialysis treatment, blood flow rate (BFR), dialysis flow rate (DFR), post dialysis weight/estimated dry weight (EDW), and/or implement a corrective plan when the EDW was not achieved and failed to ensure abnormal blood pressures were reported to the licensed nurse for 6 of 10 patients reviewed for dialysis prescription, (#2, #3,#7, #8 ,#9, #10). A review of the American Association of Kidney Patients (aakp.org) revealed that dry weight means the amount of body mass (weight) without extra fluid (water). If your body has too much fluid, it can lead to health risks such as high blood pressure, swelling, and other complications. The findings included: 1. Patient #10’s dialysis orders documented that that Patient #10’s hemodialysis treatments were 3 times a week for 3 hours and 45 minutes with a blood flow rate (BFR) (the rate at which blood is pushed through the dialyzer (artificial kidney) and back to the body) of 400 milliliters per minute (ml/min) and a dialysis flow rate (DFR) of 500 ml/min. Patient #10’s hemodialysis access was a tunneled catheter or central venous catheter (a soft tube that is placed under the skin into a large vein, usually in the neck). Review of the HD (hemodialysis) Treatment Flowsheet for 09/03/24 on 09/11/24 revealed that the patient’s BFR never achieved 400 ml/min during that treatment, according to physician’s orders. During Patient #10’s treatment on 09/03/24, the patient’s BFR ranged from 150 to 350 ml/min, with an average flow rate of 350 ml/min. During Patient #10’s treatment on 09/05/24, the patient’s BFR ranged from 200 to 400 ml/min, with the BFR less than 400 ml/minute for 133 minutes out of the 243 minute treatment. During an interview with Patient Care Technician (PCT)-S, on 09/11/24 at 4:40 PM, he said that he would not dialyze a patient with a BFR of 400 ml/min with a Central Vascular Catheter and he would dialyze the patient with a BFR of 350 ml/min. At 4:55 PM on 09/11/24, an interview with the dialysis center Nurse Manager revealed that the PCTs are supposed to follow the prescribed BFR order and that a patient with a tunneled hemodialysis catheter could be dialyzed with a BFR of 400 ml/min. He stated that the facility does audits daily for a sample of patients, which included checking the BFR and DFR. The facility Nurse Manager also stated that he is constantly educating staff about following the dialysis orders. Review of these audits, titled “Unit Rounds” conducted by the nurse on duty, revealed that there were no issues identified from the audit for Patient #10’s BFR on 09/03/24 and 09/05/24. According to the HD Treatment Flowsheet for 08/16/24, Patient #10 was taken off early from his dialysis treatment (he was dialyzed for one hour and 51 minutes). There was no explanation documented as to why the patient was taken off early and no documentation about the risks of not completing the treatment to the patient. The dialysis center Nurse Manager stated on 09/11/24 at 5 PM that he could not find any documentation related to Patient #10 not completing his entire dialysis treatment. 39943 2. Patient # 3’s dialysis orders read hemodialysis treatments were 3 times a week for 3 hours and 45 minutes with a blood flow rate (BFR) (the rate at which blood is pushed through the dialyzer (artificial kidney) and back to the body) of 350 milliliters per minute (ml/min) and a dialysis flow rate (DFR) of 600 ml/min. Her estimated dry weight (EDW) was 82 kilograms (kg.). The post dialysis weight (wt.) should be within 1 kg of the EDW. Review of the hemodialysis treatment flowsheets for 08/29/24, 09/03/24, and 09/07/24 revealed that patient #3 did not meet her EDW or her treatment time. On 08/29/24 Patient #3’s post dialysis wt. was 83.2 kg. and her treatment time was 2 hours and 24 minutes. On 09/03/24 her post dialysis wt. was 84 kg. and her treatment time was 2 hours and 45 minutes. On 9/07/24 her post dialysis wt. was 83.1 kg. and her treatment time was 2 hours and 18 minutes. There was no documentation indicating discussion regarding not meeting her EDW, with possible offerings of extra treatment time or an extra treatment. There was no documentation that the physician was made aware that patient #3 was not meeting her EDW, or that she was not completing her treatment time. 3. Patient #7’s dialysis orders read that hemodialysis treatments were 3 times a week for 3 hours and 30 minutes with a BFR of 300 and a DFR of 800. Patient #7’s EDW was 74 kg. Review of the hemodialysis treatment flowsheets revealed he did not meet his EDW on 8 of 9 treatments and did not meet his treatment time on 7 of 9 treatments. His BFR was incorrect for 8 of 9 treatments and his DFR was incorrect for 3 of 9 treatments. Pt. #7 did not complete the full time for his dialysis treatment for 6 of 9 treatments. The hemodialysis treatment flowsheets were reviewed for the following dates: 8/24/24-post dialysis wt. 77.7 kg. BFR 350, DFR 810-820, Treatment time 2 hours 6 minutes 8/26/24-post dialysis wt. 77. 2kg. BFR 270 x 2 hours, Treatment time 2 hours 55 minutes 8/28/24- post dialysis wt. 76 kg. BFR 200-290 DFR 780-810 8/30/24- post dialysis wt. 75.3 kg. BFR 260, Treatment time 2 hours 50 minutes 9/02/24- post dialysis wt. 75.3 kg. BFR 150-260 DFR 780-810, Treatment time 2 hours 52 minutes 9/04/24- post dialysis wt. 75.2 kg. BFR 230-300, Treatment time 2 hours 55 minutes 9/06/24- post dialysis wt. 76 kg. BFR 250, Treatment time 3 hours 09 minutes 9/09/24- post dialysis wt. 76.9 kg BFR 260, Treatment time 3 hours 19 minutes The record did not include offerings of extra time or extra treatments for the EDW not being met, there was no documentation regarding the incorrect BFR and DFR and no documentation for the physician being notified of the above or patient shortening treatment times. 4. Patient #8’s dialysis orders read hemodialysis treatments were 3 times a week for 3 hours and 45 minutes. His EDW was 98 kg. Review of the hemodialysis treatment flowsheets for 08/14/24 and 09/09/24 indicated that pt. #8 did not meet his EDW. On 08/14/24 and 09/09/24 patient # 8’s post dialysis wt. was 99. 1kg. There was no documentation indicating a discussion regarding not meeting his EDW and no documentation indicating the physician was informed. On 09/11/24 at 4:55 PM the nurse manager stated the staff are supposed to follow the physician orders for the dialysis treatments. He stated the staff are reminded frequently that the orders need to be followed as written. 37965 5. A review of the medical record for patient #9 revealed she was admitted to the clinic on 5/24/24 and received in-center dialysis three times weekly. She had a standing order dated 05/24/24 for Clonidine 0.1 mg one time PRN (as needed) for systolic >180. A review of her treatment records revealed that on 09/4/24 dialysis was initiated at 1106 (11:06 AM) and at 1348 (1:48 PM) her blood pressure was noted to be 187/86, at 1417 (2:17 PM) 183/84, and upon termination of the treatment at 1448 (2:48 PM) 182/84 she had a post treatment standing blood pressure of 182/84. There is no indication the Registered nurse was notified of the elevation of blood pressure. A review of the treatment record for 09/06/24 revealed that dialysis was initiated at 1113 (11:13 AM) and terminated at 1450 (2:50 PM) with a BP of 182/77 and a post treatment standing blood pressure of 180/82, there was no indication the nurse was notified of the elevated blood pressure. A Plan of Care for this patient was not received prior to the survey exit on 09/12/24. On 09/11/24 at approximately 3:37 PM, an interview was conducted with Charge Nurse, RN-R, who was shown the elevated blood pressures for patient #9. He stated that the patients have a standing order for Clonidine and this should have been administered however there was no documentation that the PCT ever informed him of the concern. He offered that if he is not told he cannot do anything about it. Review of the policy/procedure Hypertension with an effective date of 03/01/23 reveals “Patients are hypertensive if their post-dialysis diastolic blood pressure is >90 mmHG (millimeters of mercury) and >160 systolic when the patient is believed to be at their dry weight. Notify the physician if the blood pressure is significantly high for that patient and chart in EMR (electronic medical record). Review of the policy/procedure “Physician Standing Orders Procedure” last revised 12/2022 states that “Standing Orders/non-routine orders are provided for facility personnel to provide patient care and ensure that certain orders are met routinely for all patients.” “It is the responsibility of the nurse/Director of Nursing to ensure that treatments are performed as prescribed; initiate and administer therapies for complications that occur during the dialysis treatment, and administer routine medications as ordered. 6. A review of the medical record for patient #2 revealed he was admitted to the dialysis center on 10/11/21 for home dialysis with an order for an EDW of 81 kg (kilograms). Further review of his record revealed that between 7/01/24 and 9/10/24 the patient received treatments 72 times and was over the EDW for every treatment. There is no indication that the physician was ever notified of the patient not meeting the EDW or efforts to adjust the EDW to fit the needs of the patient. Dates when the patient was over his EDW included: 7/1/23 EDW 83.7 kg 7/2/24 83.4 kg 7/3/24 82.9 kg 7/4/24 83.1 kg 7/5/24 83 kg 7/6/24 83 kg 7/7/24 82.7 kg 7/8/24 83.4 kg 7/9/24 84.6 kg 7/10/24 83.8 kg 7/11/24 83.8 kg 7/12/24 84.4 kg 7/13/24 84.3 kg 7/14/24 84 kg 7/15/24 84.5 kg 7/16/24 83.7 kg 7/17/24 84 kg 7/18/24 84. 2 kg 7/19/24 84.6 kg 7/20/24 84. 2kg 7/21/24 83.7 kg 7/22/24 837 kg 7/23/24 83.6 kg 7/24/24 83.6 kg 7/25/24 84. 2 kg 7/26/24 83.9 kg 7/27/24 84.6 kg 7/28/24 84.6 kg 7/29/24 84.6 kg 7/30/24 84.4 kg 7/31/24 84.3 kg 8/1/24 85 kg 8/2/24 83.7 kg 8/3/24 83.9 kg 8/4/24 83. 1kg 8/5/24 83.3 kg 8/6/24 84.4 kg 8/7/24 84. 1kg 8/8/24 84.7 kg 8/9/24 84.3 kg 8/10/24 83.2 kg 8/11/24 84.2 kg 8/12/24 84.9 kg 8/13/24 85.3 kg 8/14/24 85.7 kg 8/15/24 85.6 kg 8/16/24 85.2 kg 8/17/24 85.1 kg 8/18/24 85.2 kg 8/19/24 85.6 kg 8/20/24 84.9 kg 8/21/24 85 kg 8/22/24 84.7 kg 8/23/24 85.2 kg 8/24/24 85.3 kg 8/25/24 85.6 kg 8/26/24 85.3 kg 8/27/24 86 kg 8/28/24 84.7 kg 8/29/24 85.2 kg 8/30/24 84.9 kg 8/31/24 85.4 kg 9/1/24 83.9 kg 9/2/24 84.9 kg 9/3/24 84.6 kg 9/4/24 84.5 kg 9/5/24 85 kg 9/6/24 85.3 kg 9/7/24 86 kg 9/8/24 86.2 kg 9/9/24 85.6 kg 9/10/24 85.6 kg A review of the most recent nursing visit not dated 09/05/24 revealed, the patient’s EDW remained 81 kg “The patient presented for his scheduled monthly clinic visit and lab work. Venipuncture was performed on the left lower arm (RLA), without complications. Upon assessment there were no signs of infection or edema at the site. The patient reported no issues with his current treatments, which were thoroughly reviewed during the visit.” There is no indication from the note that the patient not meeting EDW was reviewed or discussed. The patient’s plan of care was not provided by the end of the survey on 09/12/24. On 09/12/24 at approximately 8:17 AM, a telephone interview was conducted with the Peritoneal Dialysis (PD) Manager who stated that patient #2 has never met his EDW, and he was unsure if it had been reported to the physician. He reported that he had just taken over the patient when the former PD nurse left the ESRD a few months ago, who conducted the last nursing visit for this patient. This could be reasonable for this patient but “I have not seen him”. He stated that the Quality Assurance (QA) expectation is that patients can be within 5% of their EDW and their weight can fluctuate more than that. A review of the Policy/Procedure: Evaluation of Dry Weight with an issued/revised date of 04/29/15 and 03/01/22 revealed, “A patient’s dry weight may fluctuate from the ordered dry weight (DW) at any time. The patient assessment prior to dialysis may indicate a need to challenge the current ordered DW. The clinical staff may need one or more dialysis treatments for challenging the DW to determine the current DW. Anytime the patient’s signs and symptoms during a challenge are not clear, the clinical staff may consult the doctor if other co-morbid are affecting the outcome”. “Conservative challenges are preferred for a max of 0.3 to 0.5 kg challenge above or below dry weight.’ “Any deviation from the ordered dry weight or challenge of the ordered dry weight for the day, based on the nurse’s assessment of the patient, will be documented in the patient’s medical record treatment sheet. Once new dry weight value is determined a new dry weight order should be obtained from physician/physician extender.””

“POC-TRANSPLANT STATUS PLAN OR WHY NOT CFR(s): 494.90(a)(7)(ii) When the patient is a transplant referral candidate, the interdisciplinary team must develop plans for pursuing transplantation. The patient’s plan of care must include documentation of the- (A) Plan for transplantation, if the patient accepts the transplantation referral; (B) Patient’s decision, if the patient is a transplantation referral candidate but declines the transplantation referral; or (C) Reason(s) for the patient’s nonreferral as a transplantation candidate as documented in accordance with §494.80(a)(10). This Standard is not met as evidenced by: 37965 Based on record review and interview the facility failed to maintain a record of the transplant criteria for all transplant centers they refer patients to and failed to ensure timely referrals to transplant centers for patients who expressed interest in transplants (#2, #3,#5,and #10). The findings include: A review of the Dialysis Facility Report for Fiscal Year 2025 for the End Stage Renal Disease clinic revealed that for 2020-2023 the Standardized 1st transplantation Ratio (STR) of observed to expected number of patients transplanted for this facility is 0.70, which is 30% lower than expected for this facility. For the transplant waitlist the report states “The 2023 age-adjusted percent waitlisted at this facility is 7/7%, which is 8/3% lower than the national adjusted percentage. “At this facility, the 2020-2022 Standardized Waitlist Ratio (SWR) is 0.57, which is 43% fewer patients on the waitlist and living donor transplants than expected for this facility. A review of the Transplant Status Report provided by the Social Worker for the dates 11/13/23 to 9/30/24 revealed that of the 81 patients listed on the report 64 (79%) of them had been assessed on 09/05/24 as being “Not a candidate for transplant evaluation”. Also, on 09/05/24 two of the patients were noted as “Inactive on transplant list”, one was noted as “not accepted” by transplant center, eight had been referred for evaluation and two had referrals sent. No assessments were noted as completed prior to 09/05/24. On 09/12/24 at approximately 9:58 AM, an interview was conducted with the Social Worker. She offered that transplantation is discussed with the patients on admission, 90 days after admission, and annually thereafter. She stated it is a fluid discussion with family and patients throughout their treatment during which they often change their minds and either want to discuss or want information. She reported that there is not a set process on referrals and that she has been sending off referrals this week, “since you guys (meaning the surveyors) have been here”. At this time, she was asked why so many patients were identified as not being a candidate for transplant on the transplant report. She stated that the report does not offer many options when it comes to identifying who is a candidate and who does not want a transplant because there is not an option for “not interested” or “Don’t’ want”. The report is skewed because of the options she has to pick from. There is also not an option to say they have changed their minds and want more information for a specific program. She reported that she refers patients to all the transplant centers in the state of Florida and they each have their own criteria. She stated that she does not have the criteria for all the centers, clarifying that she does not keep them because they change all the time. She stated she only refers patients if they request to be referred but that all patients are offered a transplant referral on admission but if they change their minds the reports does not allow her to change it. She did not offer an explanation as to why the only date on the 10 months report she provided had all patients being assessed on 09/05/24. On 09/12/24 at approximately 5:11 PM, an interview was conducted with the Medical Director who reported that he had just taken over this role. He stated that he was aware of the low transplant rate and had a goal of increasing that rate to 30%. He stated that he felt the low referral rate was the result of physicians not doing an adequate job referring patients or education misconceptions. This was discussed at the August Quality Assurance Performance Improvement meeting. On 09/12/24 at approximately 5:23 PM, an interview was conducted with the Clinic Manager, and the Clinical Regulatory Specialist, during which they were asked about the low transplant referral rate for the clinic. They reported that the pervious Medical Director sent them a text, about a year ago, which stated they there were not to offer his patients transplants. All patients who have received transplants have been patients of other physicians in the area and that the majority of the patients in the clinic are patients of the previous Medical Director. They are hoping that the education that will be provided by the new Medical Director will help with increasing the referral rate. All patients who request information on transplant will be referred to the Social Worker for transplant information. A record review was conducted for patient #3 which revealed a first dialysis date of 11/02/23. The Social Worker Assessment dated 03/27/24 revealed the patient “was educated on kidney transplantation, the selection criteria for each center, and their right to apply to the transplant center of choice. The patient was also informed of the right not to apply for transplant due to suitability.” A record review was conducted for patient #5 which revealed that on 08/13/24 the patient indicated they were interested in transplantation. On 09/03/24 the Social Worker noted that she provided the patient with the transplant center’s online application. With a note that the “SW (Social Worker) provided pt (patient) with (transplant center) application flyer”. A review of the transplant report revealed the patient was referred for the evaluation to the transplant center on 09/05/24. On 09/12/24 at approximately 11:00 AM, the Director of Clinical Operations provided a copy of the flyer provided by the social worker to patient #5. She stated this was what the social worker provided to the patient as a referral for evaluation. She verified the criteria for transplant was not listed on the flyer, that there was not additional documentation of education provided to the patient and that she found this to be insufficient. She stated that the patient should not be listed on the transplant report as being referred for evaluation and has only been given the flyer, nothing more. A review of the medical record for patient #2 revealed the patient expressed interest in transplant to the Social Worker on 12/17/21 during his initial social work assessment. The Psychosocial Narrative notes include “Pt remains interested in transplant and has application for transplant health and completing his testing.” A Social Worker Assessment dated as “incomplete 12/17/22” revealed the patient was alert and oriented, worked full time as a driver and was independent with all activities of daily living. The notes state the patient “was educated on how much does a kidney transplant cost this month. Patient needs to complete additional testing to continue with the transplant process.” The patient was not referred for a transplant until 02/20/23 without any further documentation in the record as to why the referral was delayed. The social worker was not available for additional interviews nor was a plan of care provided for this patient by the time of survey exit. Review of the policy and procedure Transplant Referral/Work-Up, issued/revised dates of 5/00, 2/05, 4/07, 11/11, 4/13, 2/22, revealed that “The Social Worker will document the patient’s interested in transplant status on the Psychosocial Assessment. The RN (Registered Nurse) will address transplant status on the Comprehensive Assessment and Care Plan (CA/CP) to be completed within 30 days of admission, again 75-90 days after the initial CA/CP and annually for stable patients.” The policy goes on to state “Transplant Liaison Nurse and/or Social Worker” will review the “Comprehensive Assessment/care plan for patient interest in transplant”; determine which transplant facility(s) the patient is interested in and follow up with work-up procedure for the designated transplant facility. Under “Documentation of Transplant Status” it states, “Comments on transplant status should be documented by the Social Worker on a monthly basis.” And “Request for periodic updates from transplant facility may be necessary in order to follow patient’s progress through the referral and transplant listing process.” 01800 Patient #10 was admitted to the dialysis center on 12/23/23 to receive hemodialysis treatments. According to Patient #10’s past medical history, he had a previous kidney transplant that failed. Review of the admission Social Work Assessment dated 01/12/24, revealed documentation that the “Patient would consider a kidney transplant if needed, February 21 Patient received transplant.” This assessment included an Initial Assessment Summary that documented, “SW (Social Worker) met with recently admitted patient. Patient is new to [facility], patient has been a kidney transplant recipient in the past. Patient’s transplanted kidney is not functioning properly, patient recently began treatment again. Patient has been informed that his kidneys will not regain function . . . Patient reports that he would be interested in receiving another kidney transplant if he would be a candidate . . . Patient was educated on kidney transplantation, the selection criteria for each center, and their right to apply to the transplant center of choice. Patient was also informed of the right not to apply for transplant due to suitability. Social worker will continue to follow up, provide supportive services and assist as needed. . .” Review of the Social Worker’s monthly documentation, for 01/16/24; 02/08/24; 03/07/24; 04/04/24; 05/31/24; 06/27/24; 07/01/24; and 07/16/24; indicated the question about the patient being interested in transplant, under the Psychosocial Assessment section was marked “no” and there was no documentation about the status of the patient’s referral for kidney transplant. The Social Worker’s monthly documentation on 08/20/24 indicated the answer “yes” for the question about the patient being interested in transplant, under the Psychosocial Assessment section and there was a narrative note stating “Patient provided SW with transplant applications for Cleveland Clinic; Miami Institute clinic, and UF Shands. Social worker will continue to follow up, provide supportive services and assist as needed. The Social Worker’s monthly documentation on 09/05/24 indicated the answer “yes” for the question about the patient being interested in transplant, under the Psychosocial Assessment section and there was a narrative note stating “Patient returned transplant applications for UF Shands, Cleveland, and Miami. SW collected patient’s insurance card, social security care, and driver’s license. SW faxed them to each clinic . . . “ Review of the Transplant Reports for Jackson Memorial Hospital; Cleveland Clinic, and UF Shands Hospital, the SW made a referral for Patient #10 on 09/05/24, eight months after the patient’s initial assessment indicating that he was interested in receiving another kidney transplant. Additionally, there was no plan of care developed to address the patient’s goal to apply for a kidney transplant. On 09/12/24 at 2:24 PM, an interview was conducted with the facility Director of Operations, representing the facility SW. The Director of Operations was asked why the SW’s monthly notes indicated that the answer for the question about the patient being interested in transplant, was answered “no” instead of “yes” when the patient showed interest in a kidney transplant on the SW’s admission assessment. The Director of Operations stated that this was an error in documentation, and that it should be answered “yes” if the patient expressed that he wanted to have a transplant. She stated that once a patient states they want a transplant, the SW gives the application to the patient to fill out and then the applications go back to the dialysis center to attach to the medical information. After that is complete, the SW will fax the information transplant center. The Director of Operations stated that they have a new Medical Director since 09/01/24 and the former Medical Director did not want to refer any of his patients for a transplant or do peritoneal dialysis (a treatment for kidney failure in which waste products from the blood are removed using a cleansing fluid in the abdomen). The Director of Operations was informed that the SW’s monthly notes did not include any documentation about any follow up for the patient’s referral for transplant. She said that it should be documented - “if it isn’t documented, it’s not done.” The Director of Operations was asked to provide a facility policy on transplant referral. She said she would look for it and that the policy was old. The facility Transplant Referral Work up Policy, Issued/Revised Dates: 5/00, 2/05, 4/07, 11/11, 4/13, 2/22, included the following: Initial Introduction 1. The patient will be introduced to the transplant modality on their initial visit with the Social Worker as well as by the RN within 30 days of admission. 2. The Social Worker will document the patient’s interest in transplant on the Psychosocial Assessment. The RN will address transplant status on the Comprehensive Assessment and Care Plan (CA/CP) to be completed within 30 days of admission, again 75 - 90 days after the initial CA/CP and annually for stable patients. Transplant Liaison Nurse and/or Social Worker. 1. Review the Comprehensive Assessment/Care Plan for patient interest in transplant. 2. Determine which transplant facility(s) the patient is interested in, which may be defined by payer, and seek referral as necessary. 3. Follow the work-up procedure for the designated transplant facility. Process for Referral 1. Have patient sign Central Florida Kidney Center (CFKC) AUTHORIZATION TO OBTAIN/RELEASE INFORMATION form if he/she has not already done so. 2. Give patient Transplant packet from the designated transplant facility. The patient needs to be instructed to fill out the form(s) completely. All incomplete packets will be returned to CFKC. 3. After the patient has completed the packet, the nurse will add copies of: -Insurance cards -History and Physical -Office notes/progress notes -Recent lab and X-ray reports -Current medication list -**For patients >50 yrs, diabetic or cardiac history - the transplant facility may require a Nuclear stress test and WRITTEN cardiac clearance must accompany the transplant application. Follow the work-up procedure for the designated transplant facility. 4. Send completed packet to the designated transplant facility. Documentation of Transplant Status 5. Comments on transplant status should be documented by the Social Worker on a monthly basis. 6. Requests for periodic updates from transplant facility may be necessary in order to follow patient’s progress through the referral and transplant listing process.”

“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: 37965 Based on interviews and record reviews the facility failed to maintain an effective Quality Assurance Performance Improvement program by failing to address identified concerns with transplant referrals and plan of care initiation, implantation and updating. The findings include: A review was conducted of the Quality Assurance Performance Improvement (QAPI) Meeting Minutes for the months of April, May, June, July and August 2024. Each month had a Patient Census/Activity Report that included the number of patients transplanted and a Social Worker Report that included number of patients referred for transplant: Number of patients being worked up for transplant and the number of patients on transplant waiting list, which included a clinical measure with a goal of >10%. The review revealed the facility had failed to meet their >10% goal for all months reviewed. The results were as follows: April 18, 2024, Census at start of month was 88. Number of patients transplanted 1; Number of patients referred for transplant: 1; Number of patients being worked up for transplant: 0; Number of patients on transplant waiting list 2 (>10% Goal not met). The social worker action plan noted as “ongoing” includes “Continue to educate and refer patients for transplant work up. Track patient’s who are on transplant list ensure that monthly labs are drawn and sent to transplant center”. No further action plans were available. May 23, 2024, Census at start of month was 82. Number of patients transplanted 0; Number of patients referred for transplant: 0; Number of patients being worked up for transplant: 0; Number of patients on transplant waiting list 3 (>10% Goal not met). The social worker action plan noted as “ongoing” includes “Continue to educate and refer patients for transplant work up. Track patients who are on transplant list ensure that monthly labs are drawn and sent to transplant center”. No further action plans were available. June 27, 2024, Census at start of month 82. Number of patients transplanted 0; Number of patients referred for transplant: 0; Number of patients being worked up for transplant: 0; Number of patients on transplant waiting list 3 (>10% Goal not met). The social worker action plan noted as “ongoing” includes “Continue to educate and refer patients for transplant work up. Track patients who are on transplant list ensure that monthly labs are drawn and sent to transplant center”. No further action plans were available. July 25, 2024, Census at start of month 90. Number of patients transplanted 0; Number of patients referred for transplant: 1; Number of patients being worked up for transplant: 0; Number of patients on transplant waiting list 1 (>10% Goal not met). The social worker action plan noted as “ongoing” includes “Continue to educate and refer patients for transplant work up. Track patients who are on transplant list ensure that monthly labs are drawn and sent to transplant center”. No further action plans were available. August 20, 2024, Census at start of month 90. Number of patients transplanted 2; Number of patients referred for transplant: 1; Number of patients being worked up for transplant: 1; Number of patients on transplant waiting list 0 (>10% Goal not met). The social worker action plan noted as “ongoing” includes “Continue to educate and refer patients for transplant work up. Track patients who are on transplant list ensure that monthly labs are drawn and sent to transplant center”. No further action plans were available. A review of the Dialysis Facility Report for Fiscal Year 2025 for the End Stage Renal Disease clinic revealed that for 2020-2023 the Standardized 1st transplantation Ratio (STR) of observed to expected number of patients transplanted for this facility is 0.70, which is 30% lower than expected for this facility. For transplant waitlist the report states “The 2023 age-adjusted percent waitlisted at this facility is 7/7%, which is 8/3% lower than the national adjusted percentage. “At this facility, the 2020-2022 Standardized Waitlist Ratio (SWR) is 0.57, which is 43% fewer patients on the waitlist and living donor transplants than expected for this facility. On 9/12/24 at approximately 5:11 PM, an interview was conducted with the Medical Director who reported that he had just taken over this role. He stated that he was aware of the low transplant rate and had a goal of increasing that rate to 30%. He stated that he felt the low referral rate was the result of physicians not doing an adequate job referring patients or education misconceptions. This was discussed at the August Quality Assurance Performance Improvement meeting. On 9/12/24 at approximately 5:23 PM, an interview was conducted with the Clinical Manager and the Clinical Regulatory Specialist regarding the facilities QAPI program. They stated they were aware that the facility had not been meeting their goal of >10% of patients on the transplant waiting list. They reported that the pervious Medical Director sent them a text, about a year ago, which stated they there were not to offer his patients transplants. All patients who have received transplants have been patients of other physicians in the area and that the majority of the patients in the clinic patients of the previous Medical Director. They are hoping that the education that will be provided by the new Medical Director will help with increasing the referral rate. All patients who request information on transplant will be referred to the Social Worker for transplant information. The reported because of the Medical Directors refusal to allow the clinic to refer patients they had not made attempts to meet the goal. During the interview they acknowledged that the care plans were late and not current. They have spoken to the new Medical Director about these concerns and hope he will be able to assist with getting them updated. They stated the facility staff had been working to update the care plans but the previous medial director had not returned any of them after reviewing. They reported he always assured them he would get them back to them but never did and as a result they fell behind. They had not included the development of or accuracy of the care plans as part of the QAPI meeting and had not developed a plan of correction. They felt their hands were tied. A review of the policy/procedure Quality Assessment Performance Improvement, issued/revised 8/2019 revealed that “The purpose of the Facility committee is to utilize a local multidisciplinary team that provides a dynamic and systematic process to assess, identify, analyze, correct, and monitor real or potential problems and/or trends existing within the facility itself. The Facility will compare their specific data to network or national data to assess, identify, analyze, correct and monitor real or potential problems and/or trends. Under the Program Components item D. Problem resolution: The QAPI Program shall facilitate and ensure an appropriate plan for actions including solution identification and implementation, and problem tracking and reassessment. Under Program Evaluation item C. Recommendations for corrective actions must include timelines for implementation, monitoring strategies, and outcomes measures.”