Oakland Dialysis Center LLC

“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: 51535 Based on facility policy, record review, and interview, the facility failed to complete a plan of care (POC) as unstable for 1 of 3 patients reviewed (Patient #1). The findings included: A review of the facility’s “Comprehensive Assessment and Plans of Care” documented: Unstable Patients must be reassessed by the IDT monthly including problems identified during assessment, measurable goals/outcomes, planned interventions, timetables/reassessment date and noted with signatures. The following are unstable criteria: 1) Significant changes in psychosocial need 2) Concurrent poor nutritional status 3) Marked deterioration in health status Patient #1 was admitted to the facility on 12/26/19. A record review revealed Patient #1 was deemed unstable 02/17/25 (deterioration in mental function) monthly; and stable 01/24/25 annual. A review of Patient #1 last Plan of Care (POC) meeting, dated 02/17/25, documented as monthly POC deeming the patient as unstable. There is no documentation of a POC that reveals measurable goals, expected outcomes and timetables. An interview was conducted with the Clinical Manager (CM) on 03/05/25 at 12:30 PM. to discuss the findings. The CM stated Patient #1 has been identified as unstable.”

“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: 36734 Based on record review and interview, the facility failed to have a patient’s signature acknowledging the plan of care was reviewed for 3 of 3 patients reviewed (Patient #1, #2, and #3). The findings included: A review of the facility’s policy titled Comprehensive Assessments and Plan of Care (not dated) documented: An interdisciplinary team (IDT) must complete a comprehensive assessment of patient needs, then develop the plan of care. The IDT consist of , at a minimum, the patient or designee, registered nurse, nephrologist, social worker, and dietician. 1. Patient #2 was admitted to the facility on 02/19/24. A review of the patient’s CA/POC (comprehensive assessment/plan of care) Report dated 05/17/24 was conducted. There was no patient signature to acknowledge Patient #2 had reviewed the plan of care. 2. Patient #3 was admitted to the facility on 03/19/20. A review of the patient’s CA/POC (comprehensive assessment/plan of care) Report dated 05/20/24 was conducted. There was no patient signature to acknowledge Patient #3 had reviewed the plan of care. 3. Patient #1 was admitted to the facility on 12/26/19. A record review revealed Patient #1 was deemed unstable 02/17/25 (deterioration in mental function). A review of Patient #1 last Plan of Care (POC) meeting, dated 02/17/25, revealed no signature of patient or patient representative to acknowledge plan of care was reviewed. . An interview was conducted with the Clinical Manager (CM) on 03/05/25 at 1:00 PM. The CM acknowledged the above.”

“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: 40153 Based on record review and interview, the facility failed to have appropriate social worker interventions for two of the six patients reviewed (Patient #2 and Patient #3). The findings included: A review of the facility’s policy, “Social Worker Manual,” dated 01/01/2019, revealed the following: the Social Worker must meet with all new patients within two weeks of admission to complete the initial admission note. Once the patient is stabilized, the social worker must meet with the patient at least quarterly and document their status in the social work progress notes. A chart review showed that Patient #2 was admitted to the facility for In-Center hemodialysis on 11/25/2020. A review of the Social Worker progress notes revealed that a note was written on 12/04/23, and the subsequent follow-up note was not written until 04/01/24. In an interview conducted on 05/14/24 at 10:40 AM with Staff C, the Social Worker stated that she follows up on all patients quarterly and as needed. When asked why the follow-up quarterly note was not written on Patient #2 in a timely manner, she said that she spoke to Patient #2 at the chairside in March 2024 but did not write a monthly note. A chart review revealed Patient #3 was readmitted to the facility on 03/07/24 for In-center hemodialysis as a new Patient. Further review showed that the Social Worker’s Initial note was completed on 05/01/24. During the interview conducted on 05/15/24 at 9:30 AM with the facility’s Administrator, she was informed of the findings, the Administrator acknowledged the findings.”

“MD RESP-MED DIR QUAL/ACCOUNTABLE TO GOV BODY CFR(s): 494.150 The dialysis facility must have a medical director who meets the qualifications of §494.140(a) to be responsible for the delivery of patient care and outcomes in the facility. The medical director is accountable to the governing body for the quality of medical care provided to patients. This Standard is not met as evidenced by: 40153 Based on record review and interview, the facility failed to have a Medical Director who is accountable to the governing body for the quality of medical care provided to patients for 2 of 6 patients’ records reviewed (Patient #2 and Patient #6). The findings included: A review of the Medial Director Job Description signed on 01/26/2019 revealed the following: the Medical Director is directly responsible for delivering patient care and outcomes in the facility. Assuring adequate monitoring of the patient and the dialysis process, which includes but is not limited to staffing ratios, assessment of patients, reporting of changes in the patient ’ s condition, and documentation. It further showed that the Medical Director works with and supports the clinic manager in ensuring compliance with the facility ’ s policy and procedures. 1. A record review for Patient #2 revealed that she was admitted to the facility for In-Center Hemodialysis on 11/25/20. Patient #2 was deemed unstable in April of 2024 due to hospitalization and severe weight loss of 5% or more in one month. A nutritional progress note dated 05/04/24 revealed that Patient #2 had an 8.9% weight loss in 30 days and poor appetite and intake. Further review showed that the Clinical Dietitian contacted the medical director, who was also Patient #2 ’ s Nephrologist, to request an order for an appetite stimulant. In an interview conducted on 05/13/24 at 11:20 AM, Patient #2 stated that she had lost a significant amount of weight and said that she was waiting for the appetite stimulant order from her doctor, which was not yet ordered. A follow-up progress note dated 05/01/24 that was written by Patient #2 ’ s Nephrologist revealed that Patient #2 was doing well. However, Patient #2 was deemed unstable the month before, with a severe weight loss of 8.9% of her body weight. An interview conducted on 05/14/24 at 11:00 AM with Staff D, Registered Dietitian, stated that she verbally spoke to Patient #2 ’ s Nephrologist last week regarding the appetite stimulant. As of yesterday, it was not ordered. In an interview conducted on 05/15/24 at 12:14 PM with Staff D, she stated that she spoke to the Nephrologist yesterday regarding the appetite stimulant for Patient #2, which had not been ordered. The facility ’ s Administrator attempted to call the Medical Director multiple times during the survey on 05/14/24 and 05/15/24, but no call or response was noted from the Medical Director. In an interview conducted on 05/15/24 at 12:00 PM with the facility’s Manager of Clinical and Regulatory Services, she was told of the findings. 47207 2. Patient #6 was admitted to the facility 11/30/2023 a medical record review completed 5/15/2024 showed multiple MD notes stating that the patient was seen, patient resting denies complaints, same prescription, anemia management continues. On 5/09/2024 a note was written by the Nurse Practioner saying that the patient was seen and examined during treatment, patient doing well, no shortness of breath, no complaint at this time. There was no mention of the patient having several readings of high blood pressure (BP) for example 193/95 at 853 on the date 5/09/2024 the note states that the patient was resting and had no complaints. The timestamp for the Nurse Practioner note was 236 PM the patient left the facility at 853 AM, no indication of the note being written late. On 4/25/2024 at 831 a note had been written by the physician writing blood pressure reviewed patient resting comfortably the treatment record showed the following blood pressure (BP) readings 169/87, 172/92, 209/100, 181/99, 159/89, 198/102, 177/112 at 801 the BP was 168/115 at 831. On 3/14/2024 a comprehensive review was completed by the MD lab were reviewed at this time the hemoglobin was 11.0 the MD notes indicated to stay maintain the treatment as it is. On 4/18/24 a comprehensive review of labs was completed by the physician, hemoglobin was now 9.4, phosphate level 8.3 again the note says the patient is doing well and no change in treatment, on 5/09/2024 the physician completed a comprehensive review of the patient’s treatment, labs reviewed hemoglobin 9.7 phosphate level 8.3. The notes from the MD indicated the patient was doing well, no complaints, no change in treatment. There was no addressing the change in hemoglobin levels mentioned in the notes, a review of the medication prescriptions showed no change in the patient’s anemia management. There was no mention of the phosphate levels being addressed or any preventative measures being made by the physician or nurse practitioner. On 3/14/2024 there was a recommendation made by the Registered Dietician for Zemplar 13 mg and Velphoro to help the patient with his increased phosphate levels. An email from the dietician dated 4/17/2024 1019 AM states that the dietician had reached out to the insurance company and the pharmacy required an electronic prescription to be sent. The email goes on to state that the patient had been waiting for this prescription since 3/09/2024. The prescription was finally seen in the patient dialysis medications list on 5/14/2024. In an interview with the District Clinical Manager, Staff #2 and (Clinical Manager, Staff 1) on 5/15/2024 at 230 PM agreed that the MD and Nurse Practitioner were not addressing these issues in a timely manner.”