Synergy Dialysis of Pembroke Pines LLC

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be [reviewed], and updated at least every 2 years. The plan must do all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [For LTC Facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 36734 Based on interview and record review, the facility failed to develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years as evidenced by the facility lack of documentation of an emergency preparedness plan. The findings included: An interview was conducted with the Facility Administrator (FA) on 06/25/25 at 12:00 PM, during a review of the facility’s emergency preparedness plan. The FA stated she did not have any documentation of an emergency preparedness plan for the facility for review. The FA acknowledged the facility should have documentation of an emergency preparedness plan in place.”

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 36734 Based on interview and record review, the facility failed to have an annual fire safety inspection, an annual Life Safety Attestation, and documentation the facility contacted the local public health and emergency management agency public official at least annually to confirm that the agency is aware of the ESRD facility’s needs in the event of an emergency and know how to contact the agencies in the event of an emergency., as evidenced by not having a current copy of an Emergency Operations Contact (EOC) letter. The findings included: A review of the facility’s Emergency Preparedness Plan was conducted with the Facility Administrator (FA) on 06/25/25 at 12:00 PM. The FA presented a Fire Safety inspection report dated 03/13/23, and a Life Safety Attestation dated 06/26/23. The FA was not able to provide an EOC letter. The FA acknowledged the provided documentation was out dated.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 36734 Based on interview and record review, the facility failed to vaccinate a susceptible patient against Hepatitis B for 1 of 6 sampled patients (Patient #2). The findings included: Record review revealed Patient #6 was admitted to the facility for home peritoneal dialysis (PD) on 01/15/25. Patient #6 consented to receive vaccination for Hepatitis B (hep B) on 01/20/25. A review of Patient #2’s laboratory values dated 01/24/25 revealed a hep B antibody <4 (< 10 susceptible). Further review of Patient #2’s record revealed the patient had not received the vaccination at the time of the survey (5 months). An interview was conducted with the Facility Administrator (FA) on 06/4/25 at 12:00 PM. The FA acknowledged the above.”

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. 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 as 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 This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to document care of a central venous catheter (CVC), and failed to follow standards of practice as evidenced by administering Heparin (blood thinning medication) without a physician order for 1 of 6 sampled patients (Patient #2). The findings included: Record review revealed Patient #2 was admitted to the facility for home peritoneal dialysis (PD) on 01/15/25. A review of Patient #2’s Initial Nursing Assessment dated 01/23/24 documented the patient had a central venous catheter (CVC). Further review of Patient #2’s record did not reveal any documentation of Patient #2’s CVC in the monthly Nursing Visit notes. A review of Patient #2’s physician orders lacked an order for a CVC, including care and heparin administration. A phone interview was conducted with the PD nurse on 06/24/25 at 1:00 PM. The PD nurse confirmed Patient #2 still had a CVC. The PD nurse stated she had been providing CVC care, though not documented. The PD nurse further stated she had been administering Heparin to the catheter. The PD nurse confirmed there was no order for Patient #2 to receive Heparin. An interview was conducted with the Facility Administrator (FA) on 06/24/25 at 1:15 PM. The FA acknowledged the above.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 51535 Based on administrative record review and staff interview, the facility failed to consistently follow the established policy and procedures regarding the total chlorine test procedure for 2 of 4 machines reviewed. This is evidenced by the staff failure to perform the total chlorine testing within 4 hours of the previous test; and the facility failed to have evidence of chlorine testing for 2 of 2 sampled at home hemodialysis patients (Patient #1 and #6) The findings included: The facility policy Water-Total Chlorine Analysis published 01/01/2017 documented, “Total Chlorine testing shall be performed prior to the start of dialysis each day and every 4 hours thereafter. Total Chlorine test results shall be documented on the Water Start Up and Total Chlorine Test Log. 1) Review of the facility’s Weekly Total Chlorine Test Log revealed that the facility staff failed to provide evidence that the total chlorine testing was performed every four hours as follows: for 8 hours and 25 minutes on May 10, 2025, between 03:20 AM and 11:45 AM. In May, the facility staff documented on the log 05/10/25 at 3:20 AM. However, there is no documentation of the total chlorine test being performed again until 05/10/25 at 11:45 AM (8 hours and 25 minutes later.) There is no documentation that the staff performed the total chlorine testing within four hours and monitored per policy. Further record review revealed that the facility staff failed to provide evidence that the total chlorine testing was performed every 4 hours on June 20, 2025, during the hours of the facility operation of 08:00 AM and 5:00 PM. Further record review revealed the RO DAILY WATERLOG (in center) notes product pressure should be <10 (no numerical values noted on log) June 1, 2025 - June 7, 2025. The administrative records do not provide a specified location of 2 of 2 water system or an explanation for the deviation from the total chlorine testing of every four hours of the water system. The Documentation provided to the surveyor was loose leaf papers and without organization. An interview was conducted on 06/25/25 at approximately 11:25 AM with the Biomedical Technician (Biomed Tech). The surveyor reviewed with Biomed Tech the documentation on the Total Chlorine Log and RO Daily Waterlog. He confirmed that there is no documentation of chlorine testing every four hours on the weekly total chlorine test log and no numerical values on the RO Waterlog. 36734 2. Patient #1 was admitted to the facility as a home hemodialysis (HHD) patient on 09/13/24. Patient #6 was admitted to the facility for HHD on 10/17/22. An interview was conducted with the biomed tech on 06/25/25 at 10:00 AM. The biomed tech stated he did not have any records for chlorine testing for Patient #1 or Patient #6, as the tests were done in the patient’s home by the patient care technicians (PCT). The biomed stated there were 24 patients receiving home hemodialysis (HHD), and he does not know where they keep the records for chlorine testing. An interview was conducted with the Facility Administrator (FA) on 06/25/25 at 12:00 PM. The FA stated she was not aware of the above. The FA acknowledged there was no oversight for chlorine testing for HHD patients.”

“BACT CONTROL-DISINFECT 1X/MO/DWELL CFR(s): 494.40(a) 7 Strategies for bacterial control 7.1 General: disinfect monthly/disinfection dwell Routine low-level disinfection of the pipes should be performed to control bacterial contamination of the distribution system. The frequency of disinfection will vary with the design of the system and the extent to which biofilm has already formed in existing systems, but disinfection must be performed at least monthly. A mechanism should be incorporated in the distribution system to ensure that disinfectant does not drain from pipes during the disinfection period. This Standard is not met as evidenced by: 51535 Based on administrative record review and staff interview, the facility failed to consistently follow the established policy and procedures regarding Machine Disinfection for 1 of 2 months reviewed. This is evidenced by the staff failure to ensure that Machine #121 Room #3 disinfection was completed daily and documented on the disinfection log; and the facility failed to documentation for 2 of 2 sampled patient’s home hemodialysis machine daily disinfection (Patient #1 and #6). The findings included: The facility policy Bacteriology of Water and Dialysate, effective 01/01/2017, documented, Incidences of pyrogenic reactions have been directly related to the number of bacteria in the dialysate.” Review of the facility’s Machine Ready for use Log “MACHINES MUST BE DISINFECTED WITHIN 48 HOURS. MACHINE DISINFECTION CYCLE THAT EXCEEDS 48 HOURS MUST BE BLEACH DISINFECTED PRIOR TO USE.” - Logbook/sheet for June 2025 revealed that the facility disinfection of the Machine #121 Room #3 delivery system was not performed on: June 11, 2025 - June 15, 2025 June 25, 2025 - June 30, 2025 There is no evidence of documentation the staff disinfected dialysis machine #121 on the dates mentioned above. The documentation provided to the surveyor was loosed leaf paper without organization. There is no explanation for not disinfecting machine #121 in Room #3. An interview was conducted on 06/25/25 at approximately 11:30 AM with the Biomedical Technician (Biomed Tech). The surveyor reviewed the documentation in logbook/sheet with the technician, and he confirmed the disinfection of Machine #121 in Room 3 was not completed. 36734 2. Patient #1 was admitted to the facility as a home hemodialysis patient on 09/13/24. Patient #6 was admitted to the facility for HHD on 10/17/22. An interview was conducted with the biomed tech on 06/25/25 at 10:00 AM. The biomed tech stated he did not have any records for daily machine disinfection for Patient #1 or Patient #6, as the process was done in the patient’s home by the patient care technicians (PCT). The biomed stated there were 24 patients receiving home hemodialysis (HHD), and he does not know where they keep there records for daily machine disinfection. An interview was conducted with the Facility Administrator (FA) on 06/25/25 at 12:00 PM. The FA stated she was not aware of the above. The FA acknowledged there was no oversight for daily machine disinfection for HHD patients.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 51535 Based on observation, administrative record review, and staff interview, the facility failed to follow the established policy and procedures for verifying the dialysate conductivity. This is evidenced by the staff failure to verify the dialysate conductivity with an independent device. The findings included: The facility policy Bacteriology of Water and Dialysate, effective 01/01/2017, documented, Prior to each patient treatment, staff shall verify the dialysate conductivity and pH of each machine with an independent device.” An observation revealed 2 Myron Meters in the laboratory area on 06/23/25 at 10:00 AM to 4:00 PM. During observation, surveyor did not observe any staff member using an independent source to collect dialysate to perform independent conductivity testing on the dialysis machine in between dialysis patients. The Myron Meters remained in the laboratory area during the time of observations. An interview was conducted on 06/24/25 at approximately 10:15 AM with Patient Care Technician (PCT). The surveyor asked PCT about the policy for checking conductivity. The PCT reports “I complete the conductivity testing at the start of the shift once per day.” Surveyor inquired about independent testing on 06/23/25, She acknowledged that she did not complete independent conductivity testing between patients on 06/23/25 stating “I was doing what Biomed informed me to do. Today, I am using the Myron Meter to complete the conductivity test. I spoke with Biomed, and I was informed that the conductivity testing must be completed prior to the start of the next patient.””

“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: 51535 Based on observation, patient interview, and staff interview, the facility failed to ensure emergency equipment was maintained and operated in accordance with the manufacturer’s recommendations, as evidenced by the failure of staff to ensure the emergency call light is functioning in the Rest Room and 4 of 4 patient care rooms. The findings included: 1) An observation conducted on 06/23/25 at 11:05 AM revealed a non-functioning emergency call light located in the Rest Room area. The call light string is wrapped around the handicapped rail. 2) An observation conducted on 06/23/25 at 11:15 AM revealed a non-functioning call light located in the patient care rooms #1, # 2, #3, and #4. The call light is visible and assessable to the patient. When the patient presses the emergency call light to summons for help, the staff does not receive an alert. An interview conducted on 06/23/25 at 11:17 AM with patient in Room #3 states “when I need help, I’ll knock on the window to summons for help. They usually respond right away.” An interview with PCT conducted on 06/23/25 at 11:17 AM, she confirmed the emergency call light located in the Rest Room in inoperable. She states, “the call light does not work, its battery operated. I will notify Biomed.””

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 36734 Based on observation and interview, the facility failed to display a Dialysis Performance Certificate. The findings included: An observation of the dialysis lobby was conducted on 06/23/25 at 11:00 AM. The facility did not have a Dialysis Performance Certificate on display to be seen and read by patients. An interview was conducted with the Facility Administrator (FA) on 06/25/25 at 1:00 PM. The FA acknowledged the above.”

“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: 36734 Based on record review and interview, the facility failed to complete an initial comprehensive assessment and plan of care for 1 of 6 patients reviewed (Patient #2). The findings included: Patient #2 was admitted to the facility for peritoneal dialysis (PD) on 01/15/25. Record review revealed an initial comprehensive assessment dated 06/09/25 (4 months late). Further review of the assessment revealed the physician assessment was not completed. An interview was conducted with the Facility Administrator (FA) on 06/24/25 at 1:00 PM. The FA acknowledged the above.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to conduct a follow up comprehensive reassessment for 1 of 6 sampled patients (Patient #1). The findings included: Patient #1 was admitted to the facility for home hemodialysis (HHD) on 09/13/24. Record review revealed an initial comprehensive assessment dated 10/14/24. Further record review did not reveal a follow up comprehensive reassessment was conducted for Patient #1 (due 01/25). An interview was conducted with the Facility Administrator (FA) on 06/24/25 at 2:00 PM. The FA acknowledged the above.”

“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: 36734 Based on record review and interview, the facility failed to conduct an annual comprehensive assessment and plan of care for 1 of 6 sampled patients (Patient #6). The findings included: Patient #6 was admitted to the facility on 10/17/22 for home hemodialysis (HHD). Record review revealed an annual assessment and care plan dated 10/19/23. Further record review revealed there was no annual assessment and care plan conducted in 2024 for Patient #6. An interview was conducted with the Facility Administrator (FA) on 06/25/25 at 10:00 AM. The FA acknowledged the above.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 51535 Based on clinical record review and staff interview, the clinical staff failed to check prescribed dialysate flow rate (DFR) is being achieved, or reason documented in the medical record if unable to meet prescribed DFR for 1 of 6 patients reviewed. The findings included: The clinical record review conducted on 06/24/25 revealed patient #3 has physician orders dated 06/20/25 for Dialysate Flow Rate (DFR) 800. Treatment Records dated 06/23/25 indicate the patient did not receive the prescribed DFR of 800. He received 600 for 3 hours 30 minutes of 3 hours 30 minutes of treatment. The treatment records do not provide an explanation for the deviation from the dialysis prescription. An interview conducted on 06/24/25 at 10:38 AM with the Charge Nurse (CN), he acknowledged that the staff were not following the correct dialysis prescription.”

“POC-EFFECTIVE NUTRITIONAL STATUS CFR(s): 494.90(a)(2) The interdisciplinary team must provide the necessary care and counseling services to achieve and sustain an effective nutritional status. A patient’s albumin level and body weight must be measured at least monthly. Additional evidence-based professionally-accepted clinical nutrition indicators may be monitored, as appropriate. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to address a nutritional deficit for 1 of 6 patients reviewed (Patient #2). The findings included: Patient #2 was admitted to the facility on 01/15/25 for peritoneal dialysis (PD). Record review of a Dietician Monthly/Quarterly Review dated 03/04/25 that documented Patient #2 had an albumin level (indicative of nutritional status) of 1.8 (normal is >4). The note documented a request for Intra Parental Nutrition (intravenous supplements). The note further documented that pharmacy representative was aware of the referral and awaiting insurance information to process request. Further record review of Patient #2’s record did not reveal any documentation of the status of the requested Intra Parental Nutrition (IPN) or any additional supplements at the time of the survey. An interview was conducted with the Facility Administrator on 06/24/25 at 3:00 PM. The FA acknowledged the above.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to have monthly physician progress notes for 3 of 6 sampled patients (Patient #1, #2, and #6). The findings included: 1. Patient #1 was admitted to the facility on 09/13/24 for home hemodialysis (HHD). Record review revealed a lack of physician progress notes for the requested last 6 months. 2. Patient #2 was admitted to the facility for peritoneal dialysis (PD) on 01/15/25. Record review revealed no physician progress notes since admission 3. Patient #6 was admitted to the facility on 10/17/22. Record review revealed a lack of physician progress notes for the requested last 6 months. An interview was conducted with the Facility Administrator (FA) on 06/24/25 at 3:00 PM. The FA stated home patients do not come into the facility. They are seen in the physician’s office. Office visit documentation was to be scanned and uploaded into patient’s electronic medical records. The FA acknowledged the above. The FA stated she would send a request for the physician notes to be faxed to the clinic.”

“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: 36734 Based on record review and interview, the facility failed to retrieve and review peritoneal dialysis (PD) flowsheets for 1 of 6 sampled patients (Patient #2); and failed to have PD orders. The findings included: Patient #2 was admitted to the facility for peritoneal dialysis (PD) on 01/15/25. Record review revealed a lack of evidence that the self-monitoring data from Patient #2 as reviewed. Further record review revealed there were no orders for PD. An interview was conducted with the Facility Administrator (FA) on 06/24/25 at 3:00 PM. The FA stated monthly data was to be printed and signed that the data was reviewed. The FA acknowledged the above.”

“H-COORDINATION OF CARE BY MEMBER OF IDT CFR(s): 494.100(c)(1)(ii) Services include, but are not limited to, the following: (ii) Coordination of the home patient’s care by a member of the dialysis facility’s interdisciplinary team. This Standard is not met as evidenced by: 36734 Based on record review and interview, the facility failed to have a nurse assessment pre and post treatment and failed to administer medications while providing home hemodialysis for 1 of 6 sampled patients (Patient #6). The findings included: Record review revealed Patient #6 was admitted to the facility for home hemodialysis (HHD) on 10/17/22. A review of the last 7 HD treatment flowsheets dated from 06/02/25-06/16/25 lacked a nurse’s assessment pre treatment and post treatment. Further record review revealed ordered medications Heparin (blood thinner)every Monday, Wednesday and Friday, Micera (for anemia) bi-weekly, and Venofer (iron) every Monday, Wednesday, and Friday was not administered. An interview was conducted with the Facility Administrator (FA) on 06/25 25 at 12:00 PM. The FA acknowledged the above.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 36734 Based on interview and record review, the facility failed to have personnel files for 3 of 3 patient care technicians (PCT) reviewed out of 14 PCTs providing home hemodialysis. The findings included: A side by side review of a Facility Personnel File Worksheet and a HHD schedule was conducted on 06/25/25 at 12:00 PM. Three PCT names that were responsible for a total of 7 patient’s care were missing form the Personnel File Worksheet. An interview was conducted with the Facility Administrator (FA) on 06/25/25 at 1:00 PM. The FA stated she did not have any information on the missing staff personnel files, including hire date, license/certification, cardiopulmonary resuscitation expiration dates, tuberculosis evaluation date, hepatitis vaccination status, competencies, emergency procedures and infection control training, and water,dialysate, machine training.”

“GOV-RN, MSW, & RD AVAIL TO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs; This Standard is not met as evidenced by: 51535 Based on administrative record, clinical record reviews and interviews, the facility failed to ensure that a member of the interdisciplinary team (Social Worker) was available to meet the patient’s clinical needs for 2 of the 6 patients reviewed (patient #3 and #6). The findings included: The facility Renal Social Worker description, revised 01/01/2017, documented, “Assist in transplant evaluation and work-up. Assist in home training evaluation, work up, and follow up. Maintains records to provide social service statistics for reports and authorized research. Prepares appropriate correspondence to agencies, treatment facilities, doctors, patients, etc.” 1. A review of clinical records revealed the following Social Worker note dated 04/05/2025; Further records review revealed there is are no other Social Worker notes for 2025. An interview with FA on 06/24/25 at 2:45 PM, she acknowledges facility social worker has no additional notes from January 2025 to June 2025. 36734 2. Record review revealed Patient #6 was admitted to the facility on 10/17/22. A review of the last 6 months revealed no social worker notes for Patient #6. An interview was conducted with the Facility Administrator (FA) on 06/25/25 at 12:00 PM. The FA acknowledged the above.”