Sanford Health Dialysis Hospers

“QAPI-INDICATOR-NUTRITIONAL STATUS CFR(s): 494.110(a)(2)(ii) The program must include, but not be limited to, the following: (ii) Nutritional status. This Standard is not met as evidenced by: 51639 Based on review of facility policy, CMS (Centers for Medicare and Medicaid Services) resources, facility documents, and staff interviews, the facility failed to develop a QAPI (Quality Assurance and Performance Improvement) indicator for analysis of nutritional data with development of an action plan, if indicated, using the albumin goal as specified on the CMS MAT (Measures Assessment Tool). The End Stage Renal Disease (ESRD) facility reported a census of 18 in center hemodialysis patients at the time of the survey. Findings include: 1) The “Dialysis Enterprise Strategic Quality Strategic Quality Plan” facility policy dated 2025 revealed, in part, that albumin is indicator of mortality in dialysis. The goal was that albumin =/> (equal to or greater than) lower limit of age based lower limits. The document’s reference listed for albumin was the MKN (Midwest Kidney Network [MKN is the regional ESRD network for the states of Michigan, Minnesota, North Dakota, South Dakota, and Wisconsin]) best practice recommendations. The document did not refer to albumin levels related to BCG ([Bromcresol Green]/ BCP[Bromcresol Purple] which are dyes used in colorimetric assays to measure albumin in blood). 2) The CMS Measures Assessment Tool (MAT), version 2.5, revealed the lab level for albumin is equal to or greater than 4.0 g/dL (grams per deciliter) BCG preferred. The MAT’s reference is KDOQI Nutrition 2000 (Kidney Disease Outcomes Quality Initiative, a program by the National Kidney Foundation that develops evidence-based clinical practice guidelines to improve the quality of care for people with kidney disease). The CMS MAT indicates albumin levels in ESRD are to be equal to or greater than 4.0g/dL with the BCG method. The CMS MAT does not mention albumin levels as adjusted for age utilizing the BCG method. 3) Review of the facility document titled, “2025 Outpatient HD QAPI,” showed a nutrition goal for the facility at >80% of dialysis patients will have an albumin >3.5 g/dL. 4) In a concurrent medical record review, staff interview, and facility document review on 12/9/25 at 3:25 PM, with the Clinical Care Leader and the Director, Patient #1’s medical record revealed a trend of decreasing albumin levels with no documentation of interventions to improve the albumen level. The Clinical Care Leader reported that no interventions were necessary for Patient #1 as the levels were within normal limits with levels of 3.9 g/dL on 10/1/25, 3.8 g/dL on 11/5/25, and 3.5 g/dL on 12/3/25. The Director reported that an albumin level of 3.5g/dL was considered within the lower limits of normal. 5) During an interview on 12/9/25 at 1:46 PM, the Registered Dietician (RD) indicated albumin levels below 3.2 g/dL were considered low and levels 3.2 g/dL or higher were considered meeting the goal, depending on the patient’s age group. 6) In an interview on 12/10/25 at 2:47 PM, the RD reported that an acceptable albumin level was 4 g/dL, but that the EMR (electronic medical record) displays what the acceptable albumin range is for the patients based on their age. 7) Information related to the facility’s method of albumin testing (BCG or BCP) was not provided by the facility staff prior to the survey exit conference.”