Fmc - Spring Valley

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 50688 Based on record review, document review and interview, it was determined for 5 of 7 (Pt #1, Pt #2, Pt #4, Pt #5, Pt #6) patients, the Facility failed to ensure all patients were trained on Emergency Preparedness Procedures per policy. 1. The following patient records for in-center hemodialysis were reviewed throughout the survey on 1/6/2025, 1/7/2025, and 1/9/2025. The records lacked consistent documentation of quarterly patient education of emergency preparedness, including access care, emergency take off (emergency disconnection procedure) and disaster planning: a) Pt #1, Start of Care (SOC): 8/14/2024 - Emergency preparedness education completed 12/24/2025, with no prior emergency preparedness education documented in patient record. b) Pt #2, SOC: 11/20/2020 - Emergency preparedness education completed 12/17/2025, with no prior emergency preparedness education being documented in patient record since 9/30/2024. c) Pt #4, SOC: 6-3-2025 - Emergency preparedness education completed 12/16/2025, with no prior emergency preparedness education documented in patient record. d) Pt #5, SOC: 9/7/2023 - Emergency preparedness education completed 12/16/2025, with no prior emergency preparedness education being documented in patient record since 9/3/2024. e) Pt #6, SOC: 10/20/2023 - Emergency preparedness education documentation noted in patient record as being completed on 9/4/2024 and 9/27/2023, with no additional quarterly documentation in patient record. 2. The policy titled “Patient Education (Published 02/06/2023)” was reviewed on 1/9/2026 at approximately 10:15 AM. The policy noted “...Fire/Emergency Evacuation and take off procedures...Time frame: within the 1st month for new patients and quarterly for existing patients...” 3. The policy titled “Guidelines for Emergency Preparedness” (Published 09/02/2025) was reviewed on 1/7/2025 at approximately 11:00 AM. The policy noted “QAI Documentation ...Quarterly, all FKC patients must receive fire drill and emergency evacuation training. Training must be documented in QAI and on the fire drill attendance form...Patient Education...Facility staff must educate patients on: Evacuation procedures....Emergency Disconnection Procedures...Emergency Preparedness ...It is important for staff to engage patients in disaster drills and emergency procedures. Consideration should be given to patients with physical or cognitive impairments to ensure they are aware of the emergency drills conducted at the clinic (disconnect drills, fire alarm, disaster drills, etc.) and include them in the drills as much as possible.” 4. The document titled “QAPI Meeting Agenda - ICHD, December 16, 2025”, reviewed on 1/7/2025, at approximately states, “ ...Current Active Action Plan(s) Update ...CM (Clinical Manager) will also be opening an action plan for quarterly patient education.” 5. The document titled “Action Plan”, dated 12/17/2025, states “Clinic currently behind on quarterly patient education. Internal Audit completed and action plan discussed with MD at QAI ...Goal to bring patient education current by next QAI meeting ...CM discussed with PCT 3 (Patient Care Technician 3) and plan going forward is for PCT 3 assist all PCT’s in patient education and report weekly to CM the progress. The action plan addressed bringing patient education current, but did not include a projected date for completion or address a plan for compliance with quarterly patient education on emergency preparedness going forward. 6. The document titled “Clinical Services Policy and Procedure Updates Crosswalk, September 2, 2025” was reviewed on 1/9/2025” at approximately 9:55 AM, which notes updates from the previous version of the policy “Guidelines for Emergency Preparedness.” No changes to patient education requirements were noted. 7. An interview was conducted on 1/6/2025 at approximately 2:00 PM, with the Clinical Manager from a different, associated location (E#5), who was on-site to assist with the survey, and the Director of Operations (E #3). During discussion regarding documentation of emergency preparedness education to patients, E #5 stated “There are some missing. They’re not all there.” E #3 noted this as a topic during the 12/16/2025 QAPI meeting, noting that an action plan is now in place regarding quarterly patient education. 8. An interview was conducted on 1/7/2025 at approximately 2:55 PM, with the Clinical Manager (E #4). E #4 noted the previous Clinical Manager created the Action Plan and Director of Operations, additionally noting she is new to the Clinical Manager role. During discussion regarding documentation of weekly progress of patient education of emergency preparedness since the action plan creation date of 12/17/2025, E #4 stated “I don’t think there is. I’ll look, but I don’t think so.” During a follow-up interview on 1/9/2025, with E #4, E #4 verified there was no documentation of weekly progress of the action plan. During discussion of the verbiage “fire drill attendance form”, used in the policy “Guidelines for Emergency Preparedness”, E #4 stated the form titled “Incenter HD Patient Participation in Emergency and Disaster Preparedness Form,” is the same as the fire drill attendance form noted in the policy. During discussion regarding previous versions of the policies “Patient Education” and “Guidelines for Emergency Preparedness”, requested for review of any possible changes in patient education requirements for emergency preparedness, E #4 noted they do not have access to previous versions, as policies are now electronic, and previous versions are removed once the newest version is uploaded. 9. A follow-up interview was conducted on 1/9/2025 at approximately 11:35 AM, with the Director of Operations (E #3). During this time, E #3 provided documentation of the completion of patient education for emergency preparedness. During discussion of the inconsistency of completion of patient education for emergency preparedness, it was noted that documentation of education for several of the patient records reviewed had gaps of a year or more between education, or having not been previously completed at all. E #3 agreed the action plan did not contain an element to ensure compliance with patient education per policy, going forward.”