Cc&d Services

“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: 03383 Based on document review and staff interview, it was determined that the facility failed to evaluate and update their emergency plan at least every 2 years. The facility census was 19. Findings were: A review of the facility’s EPP with the Facility Administrator (FA) on 8/14/24 at 12:50 a.m. revealed the facility failed to evaluate and update at least every 2 years. This was confirmed by the FA during EPP review.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 03383 Based on document review and staff interview, it was determined that the facility failed to develop emergency preparedness policies and procedures (P&P) that addressed provision of care and treatment at an alternate care site identified by emergency management officials under a waiver in accordance with section 1135 of the Act. The facility census was 19. Findings were: A review of the facility’s Emergency Preparedness Plan with the Facility Administrator (FA) on 8/14/24 at 12:50 a.m. revealed a lack of P&P which outlined the facility’s role in the provision of care and treatment at an alternate care site identified by emergency management officials under a waiver in accordance with section 1135 of the Act.”

“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: 03383 Based on observation and staff interviews, it was determined that the facility failed to maintain the integrity of the equipment (eight of eight stools) to ensure the safety of 19 patients who dialyzed at this facility. This failure could hinder effective cleaning and disinfection of the surfaces, thus had the potential for microbial growth. Findings include: During a tour with the Facility Administrator (FA) on 8/13/24 at 12:14 p.m., the following was observed: In the Patient Treatment Room: - There were eight stools with worn seat and rusty metal legs in the treatment area. The FA was present and confirmed these findings. During observations on 8/14/24 between 4:30 a.m. and 6:10 a.m., Patient Care Technician (PCT) CC was observed sitting on worn rusty stools during initiation of dialysis treatment for patients in Station (S) 1 and S4. After initiation was completed, the stools were placed under to footrest of dialysis chairs in S1 and S4 to prop the chairs up.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 03383 Based on observation and staff interviews, it was determined that the facility failed to ensure that two of nine patients, (P), (P#9 and P#10) observed, had their vascular access sites uncovered/visible to the staff throughout their hemodialysis treatment, to ensure patient safety. This deficient practice could provide an opportunity for accidental needle dislodgement or a line disconnection to go undetected and could result in exsanguination (severe loss of blood), to P#9 and P#10. The facility census was 19. Findings include: During observation in the Patient Treatment Room on 8/14/24 between 8:30 a.m. and 9:00 a.m., the following was revealed: - P#9 and P#10 who were seated in Station (S) 5 and S6 respectively, had their access sites completely covered with a blanket. This surveyor immediately notified RN AA on 8/14/24 at 8:35 a.m. RN AA stated patients will not comply with keeping access uncovered but was unable to find documented evidence. RN AA uncovered access site of both patients. P#9 kept access uncovered afterward; P#10 did not.”

“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: 03383 Based on a review of medical records and staff interviews, it was determined that the facility failed to ensure that the Interdisciplinary Team (IDT) updated the patient’s plans of care to reflect a change in dry weight for five of five patients (P) (P#1, P#2, P#3, P#4, and P#5) who consistently presented at or below EDW (estimated dry weight) or consistently left below dry weight. Removal of too much fluid or going below the patient’s target weight may cause low blood pressure, muscle cramping, and clotting of the vascular access. This deficient practice could negatively affect the health and safety of P#1, P#2, P#3, P#4, P#5, and the other 14 patients who were receiving dialysis treatment at this facility. Findings include: P#1: Pt #1’s dialysis prescription: Tx (Treatment) time: 4:30 hours (4 hours and 30 minutes), EDW: 100 kg (kilogram), BFR (Blood Flow Rate): 450, DFR (Dialysate Flow Rate): 800. - On 7/31/24: P#1’s EDW was 100 kg. P#1’s pre dialysis weight was 101.7 kg. Post weight 97.5 kg. On 8/2/24: - P#1’s EDW was 100 kg. P#1’s pre dialysis weight was 98.7 kg. Post weight 95 kg. On 8/5/24: - P#1’s EDW was 100 kg. P#1’s pre dialysis weight was 99.7 kg. Post weight 95.8 kg. On 8/7/24: - P#1’s EDW was 100 kg. P#1’s pre dialysis weight was 97.2 kg. Post weight 92.9 kg. On 8/9/24: - P#1’s EDW was 100 kg. P#1’s pre dialysis weight was 96.5 kg. Post weight 91.2 kg. On 8/12/24: - P#1’s EDW was 100 kg. P#1’s pre dialysis weight was 95.2 kg. Post weight 90.5 kg. P#1 was admitted to the facility on 5/13/24 and did not yet have a care plan developed by the IDT P#2: Pt #2’s dialysis prescription: Tx time: 3:30 hours (3 hours and 30 minutes), EDW: 73 kg, BFR: 400, DFR: 800. On 7/22/24: - P#2’s EDW was 73 kg. P#2’s pre dialysis weight was 73.4 kg. Post weight 72.2 kg. On 7/24/24: - P#2’s EDW was 73 kg. P#2’s pre dialysis weight was 73.5 kg. Post weight 72 kg. On 7/26/24: - P#2’s EDW was 73 kg. P#2’s pre dialysis weight was 72 kg. Post weight 71.6 kg. On 7/29/24: - P#2’s EDW was 73 kg. P#2’s pre dialysis weight was 72.2 kg. Post weight 70.2 kg. On 8/9/24: - P#2’s EDW was 73 kg. P#2’s pre dialysis weight was 75.5 kg. Post weight 72 kg. On 8/12/24: - P#2’s EDW was 73 kg. P#2’s pre dialysis weight was 74.8 kg. Post weight 72.7 kg. P#3: Pt #3’s dialysis prescription: Tx time: 3:15 hours (3 hours and 15 minutes), EDW: 75 kg, BFR: 400, DFR: 400. On 7/26/24: - P#3’s EDW was 75 kg. P#3’s pre dialysis weight was 74.6 kg. Post weight 72 kg. On 7/24/24: - P#3’s EDW was 75 kg. P#3’s pre dialysis weight was 74.6 kg. Post weight 72 kg. On 7/29/24: - P#3’s EDW was 73 kg. P#3’s pre dialysis weight was 72.7 kg. Post weight 72.5 kg. On 7/31/24: - P#3’s EDW was 75 kg. P#3’s pre dialysis weight was 72.7 kg. Post weight 72.5 kg. On 8/2/24: - P#3’s EDW was 75 kg. P#3’s pre dialysis weight was 74.3 kg. Post weight 72.5 kg. On 8/5/24: - P#3’s EDW was 75 kg. P#3’s pre dialysis weight was 72.2 kg. Post weight 71.4 kg. On 8/7/24: - P#3’s EDW was 75 kg. P#3’s pre dialysis weight was 72.9 kg. Post weight 71.9 kg. On 8/9/24: - P#3’s EDW was 75 kg. P#3’s pre dialysis weight was 72.3 kg. Post weight 71.5 kg. On 8/12/24: - P#3’s EDW was 75 kg. P#3’s pre dialysis weight was 72.8 kg. Post weight 71.6 kg. P#4: Pt #4’s dialysis prescription: Tx time: 3:30 hours, EDW: 87 kg, BFR: 400, DFR: 700. On 7/10/24: - P#4’s EDW was 87 kg. P#4’s pre dialysis weight was 89.1 kg. Post weight 83.1 kg. On 7/12/24: - P#4’s EDW was 87 kg. P#4’s pre dialysis weight was 87 kg. Post weight 84.6 kg. On 7/15/24: - P#4’s EDW was 87 kg. P#4’s pre dialysis weight was 90 kg. Post weight 85.3 kg. On 7/19/24: - P#4’s EDW was 87 kg. P#4’s pre dialysis weight was 89.4 kg. Post weight 84 kg. On 8/7/24: - P#4’s EDW was 87 kg. P#4’s pre dialysis weight was 89.4 kg. Post weight 86.4 kg. On 8/9/24: - P#4’s EDW was 87 kg. P#4’s pre dialysis weight was 87.5 kg. Post weight 84.6 kg. P#4’s CIPA/POC dated 7/26/24 showed EDW was not updated or adjusted to reflect current dry weigh. P#5: Pt #5’s dialysis prescription: Tx time: 3:30 hours, EDW: 65 kg, BFR: 350, DFR: 800. On 7/24/24: - P#5’s EDW was 65 kg. P#5’s pre dialysis weight was 68.1 kg. Post weight 64.2 kg. On 7/29/24: - P#5’s EDW was 65 kg. P#5’s pre dialysis weight was 66.8 kg. Post weight 68.4 kg. On 7/31/24: - P#5’s EDW was 65 kg. P#5’s pre dialysis weight was 64.5 kg. Post weight 62.2 kg. On 8/2/24: - P#5’s EDW was 65 kg. P#5’s pre dialysis weight was 62.7 kg. Post weight 63 kg. On 8/5/24: - P#5’s EDW was 65 kg. P#5’s pre dialysis weight was 63.7 kg. Post weight 60.8 kg. During an interview on 8/14/24 at approximately 3:40 p.m., this surveyor informed the Facility Administrator (FA) about the above concerns that no changes were made to reflect current EDW on the patient’s care plan or treatment order to reflect that EDW has been reviewed and readjusted by the IDT/physician. The FA confirmed that CIPA/POC was not updated to address the EDW of P#1, P#2, P#3, P#4, and P#5.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 03383 Based on a review of medical records and staff interviews it was determined that the facility failed to ensure the interdisciplinary team (IDT) developed and implemented an initial plan of care for one of one patient (P) (P#1) sampled for new admission, within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. Findings include: P#1 was admitted to the facility on 5/13/24. During an interview on 8/14/24 at 3:30 p.m., the Facility Administrator revealed that the CIPA/POC (Comprehensive Interdisciplinart Patient Assessment/Plan of Care) has not been completed by the physician, social worker, and the dietitian; the RN was the only member of the IDT who has completed the CIPA/POC.”

“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: 03383 Based on a review of the facility’s Fiscal Year 2024 Quarterly Dialysis Facility Report (FY2024 QDFR), (DFR: A report prepared by the Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients), a review of facility records, and staff interview, it was determined that the Quality Assessment and Performance Improvement (QAPI) Committee failed to track, trend, analyze, and develop plans of action to improve and sustain the facility’s Anemia Management, Nutrition, Mineral Metabolism and Bone Disorder, Fluid Management, and Vascular Access Management, for six of six months (February 2024 - July 2024) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of all 19 in-center hemodialysis (ICHD) patients who were receiving dialysis services at this facility. Findings include: A review of the FY2024 QDFR, (third quarter 2023), revealed that the facility was above the United States (US) threshold in: 1. Nutrition [Albumin < (less than) 4.0] - this facility was 74.0 %, whereas, US was 50.5% 2. Mineral Metabolism and Bone Disorder - [Phosphorus greater than (>) 7.0] - this facility was 29.5 %, whereas, US was 15.6 %. 3. Anemia - (Hemoglobin <10.0) - facility was 41.2 %, whereas, US was 23.4 %. 4. Vascular Access - (Long-Term Catheter Rate) - facility was 18.9 %, whereas, US was 17.2 %. In Comparison, a review of the facility’s last six months of QAPI meeting minutes from December patients using a Central Venous Catheter (CVC) =/> 90 days ranged between 25 % (lowest in May) and 42.86 % (highest in July). 5. Fluid Management - UFR (ultrafiltration rate - fluid removal) >13 mL/kg/hr was 11.6%, whereas, US was 7.7%. Additionally, the facility’s QAPI meeting minutes from (December 2023 - June 2024) revealed no documentary evidence that the interdisciplinary team (IDT) conducted a comprehensive review of the above outcomes with appropriate action plans, root cause analysis, and follow-up evaluations to ensure and sustain improvement. The Facility Administrator (FA) stated on 8/14/24 at approximately 12:15 p.m., that the IDT will work toward improvement of these outcomes. The FA revealed that for anemia, the lab was monitoring Hgb 9-11 rather than Hgb <10 for QAPI; for bone/mineral management, the laboratory was monitoring phosphorus (PO4) of 3.5-5.5 rather than PO4 > 4; and the IDT was not currently monitoring UFR for QAPI.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 03383 Based on a review of medical records, staff interview, and a review of policy, it was determined that the medical director failed to ensure that two of three patients (P) (P#2, P#5) sampled who experienced high blood pressure (BP) readings, received medical care and supervision appropriate to patients’ dialysis needs. Persistently high BP could cause heart disease and stroke. This deficient practice had the potential to negatively affect the health and safety of P#2 and P#5. The facility census was 19. Findings include: A review of treatment records revealed the following: P#2: On 7/26/24: - The initiation of P#2’s dialysis treatment began at 5:29 a.m. and BP was 187/122 mmHg (millimeters of mercury). BP reading was 199/126 mmHg at 6:00 a.m.; 212/112 mmHg at 6:30 a.m.; 190/116 mmHg at 7:00 a.m.; 179/95 mmHg at 7:30 a.m.; 197/117 mmHg at 8:00 a.m. P#2 complained of shortness of breath and oxygen (O2) was administered; BP was 210/112 mmHg at 8:30 a.m., and 189/105 mmHg at 9:00 a.m., at the end of treatment. - There was a lack of documented evidence that the registered nurse (RN) notified the physician about P#2’s high BP readings before, during and after dialysis treatment on 7/26/24 or followed protocol or policy for BP outside parameters. On 8/12/24: - The initiation of P#2’s dialysis treatment began at 5:36 a.m. with a BP reading of 190/117 mmHg. Notes showed BP was elevated, patient requested O2 due to pain and breathing struggles and the RN was aware.; BP reading at 6:00 a.m. was 199/126 mmHg. The flowsheet showed “gave Meds (medicines) for BP” however, did not show what medications were given for BP. P#2’s BP reading was 212/112 mmHg at 6:30 a.m.; 190/119 mmHg at 7:00 a.m. and the flowsheet showed BP remained elevated.; 176/111 mmHg at 7:30 a.m.; 187/117 mmHg at 8:00 a.m. and UF (ultrafiltration - fluid removal) off due to cramping; 187/107 mmHg at 8:30 a.m., and 190/119 mmHg at 9:06 a.m., at the end of treatment. - There was a lack of documentary evidence that the nurse notified the physician of P#4’s high BP readings. There was a lack of interventions done for the elevated BP readings during dialysis treatment after the patient’s home dialysis medication was taken at 10:51 a.m. and BP continued to be elevated and exceeded parameters per standing order for hypertension (elevated BP). P#5: On 7/24/24: - The initiation of P#5’s dialysis treatment began at 5:27 a.m. and BP was 215/108 mmHg. The flowsheet showed that P#5 did not take BP meds. BP reading was 204/111 mmHg at 6:00 a.m.; 202/110 mmHg at 6:30 a.m.; 193/108 mmHg at 7:00 a.m.; 188/105 mmHg at 7:30 a.m.; 159/96 mmHg at 8:00 a.m.; 137/106 mmHg at 8:30 a.m., and 139/101 mmHg at 9:01 a.m., at the end of treatment. - There was a lack of documentary evidence that the nurse notified the physician about P#5’s high BP readings outside parameters from 5:27 a.m. to 7:30 a.m. - There was a lack of interventions done for the elevated BP readings during dialysis treatment. A review of undated policy titled, “Use of Clonidine in Chronic Hemodialysis Patients” showed the following: Hypertension: May administer Clonidine by mouth 0.1 mg (milligram) as directed by physician, may repeat x2 (maximum 3 dose). A review of undated policy titled, “Clinical Parameters for Physician Notification” showed the following: The Dialysis Nursing Staff will notify the physician of the following: B/P diastolic (bottom number) > (greater than) 110 or systolic (top number) >190 or < (lower than) 80. The patient will be assessed, and physician notified of changes. Across the continuum of care. The patient’s condition, relevant information, and interventions will be documented in the progress notes. The nurse and physician will document follow-up assessment in the progress notes, to include resolution of symptoms or stabilization of patient. The Facility Administrator was informed of the above findings on 8/14/24 at 3:30 p.m.”