Fmc - Nephrology - Blackthorn

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility 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. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 45607 Based on observation, record review, and interview, the dialysis facility failed to ensure all supplies in the crash cart were unexpired for 1 of 1 crash cart contents observed. Findings include: 1. Review of the Guidelines for Emergency Preparedness policy, revised 07/03/2023, indicated “ ... The following minimum emergency supplies and equipment must be on the premises at all times, clean, functional, accessible, and immediately available ... IV solutions and administration sets ...” 2. During an observation of the crash cart on 06/13/2025 at 2:52 PM, observed all IV tubing in the crash cart expired as of April 2025. 3. During an interview on 06/13/2025 at 2:52 PM, the Interim CM indicated the IV tubing in the crash cart was expired.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 45607 Based on record review and interview, the dialysis facility failed to ensure a full-scale community-based or facility-based exercise was conducted for 1 of 1 dialysis facility. Findings include: 1. Review of the Guidelines for Emergency Preparedness policy, revised 07/03/2023, indicated “ ... Annually, each facility MUST participate in a community-based disaster drill. If unable to participate, document who you contacted in the community and why the clinic was unable to participate on the Facility Specific Disaster Safety Plan form. If the EOC [Emergency Operations Center] or similar agency has not performed a community-based drill, or it was missed for a particular year, the DO [Director of Operations] should coordinate a dialysis facility area-based drill ...” 2. Review of the EP materials included tabletop exercises completed 03/20/2023 and 04/25/2025 but failed to include a full-scale community-based or facility-based exercise for 2024. 3. During an interview on 06/13/2025 at 4:22 PM, the Interim CM indicated there had not been any full-scale community-based exercises because there were none held in the county. 4. During an interview on 06/13/2025 at 6:11 PM, the Alternate Administrator indicated that while he had attended a full-scale community-based exercise in 2024, he was unable to provide documentation of the contents of the exercise and had not completed a post-exercise analysis and response.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 45607 Based on observation, record review, and interview, the dialysis facility failed to ensure the ten-percent bleach solution was correctly prepared for 1 of 1 observation of ten-percent bleach solution preparation. Findings include: 1. Review of the Mixing Bleach policy, revised 02/03/2025, indicated “ ... Pour the measured amount of water needed into a labeled opaque container. Measuring ensures proper concentration ... Slowly pour the measured amount of bleach into measured water in opaque container. Mix solution ... Test mixed solution for presence of bleach [greater than or equal to 500 parts per million] using approved test strips and document in the electronic documentation system ...” 2. During an observation of the water room opening on 06/12/2025 beginning at 5:33 AM, observed PCT 4 prepare the ten-percent bleach solution. PCT 4 put 100 milliliters of bleach into the ten-percent bleach bottle and filled with unmeasured water up to the top of the bend at the top of the bottle. No visible fill line or graduated lines were observed on the bottle. When asked if there was a line on the bottle to show how much water to add, PCT 4 indicated she did not see one. 3. On 06/13/2025 at 2:54 PM, observed the prepared ten-percent bleach solution from the treatment floor. Observed a visible black line lower than the bend at the top of the bottle. 4. During an interview on 06/12/2025 at 4:59 PM, the Interim CM indicated the procedure for mixing the ten-percent bleach solution included the PCTs have a measuring container, so they measure out for that and fill the container to the marked area. The Interim CM further indicated the ten-percent bleach solution bottle had graduated lines.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 45607 Based on observation, record review, and interview, the dialysis facility failed to ensure infection control policies and procedures were followed related to hand hygiene for 1 of 5 PCTs observed on the ICHD treatment floor. Findings include: 1. Review of the Hand Hygiene policy, revised 11/06/2023, indicated “ ... Hands Will Be ... Decontaminated using alcohol-based hand rub or by washing hands with soap and water ... Immediately after removing gloves ...” 2. During an ICHD treatment floor observation on 06/11/2025 at 2:18 PM, PCT 1 removed her gloves and failed to perform hand hygiene. At 2:22 PM PCT 1 put on new gloves and failed to first perform hand hygiene. 3. During an interview on 06/11/2025 at 3:08 PM, PCT 1 indicated hand hygiene should be performed between glove changes. 4. During an interview on 06/12/2025 at 4:59 PM, the Interim CM indicated hand hygiene should be performed before putting on gloves and after taking off gloves.”

“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: 45607 Based on record review and interview, the medical director failed to ensure the dialysis facility’s policies and procedures related to patient assessment and monitoring and determination of blood pressure for 5 of 5 patient records reviewed (Patient #9, 10, 11, 12, 13); hypertension for 3 of 5 patient records reviewed; and blood flow rate for 3 of 5 patient records reviewed (Patient #10, 11, 13). Findings include: 1. Review of the Medical Director Compliance Guidelines policy, revised 01/01/2007, indicated “ ... The Medical Director of the facility is designated in writing to be responsible for the execution of patient care policies ...” 2. Review of the Patient Assessment and Monitoring policy, revised 05/01/2023, indicated “ ... During Treatment ... Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations ... Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes or per state regulations ... Report to the nurse ... Systolic blood pressures greater than 180 mm/Hg [millimeters of mercury] ... Diastolic blood pressure greater than 100 mm/Hg ... Blood Pressure less than or equal to 100 mm/Hg systolic ... Check machine settings and measurements ... Check prescribed blood flow is being achieved or document in medical record if unable to meet prescribed blood flow ... Document any findings and interventions in the medical record ...” 3. Review of the Hypertension policy, dated 09/07/2021, indicated “ ... Staff will recognize, report, and immediately address systolic blood pressures greater than 180 mm/Hg [millimeters of mercury] and/or diastolic blood pressures greater than 100 mm/Hg ...” 4. Review of the Determination of Blood Pressure policy, revised 02/07/2022, indicated “ ... Incenter patients ... Obtain blood pressure readings pre- and post-dialysis sitting and standing (if applicable) and every 30 minutes or more during hemodialysis treatments as indicated ...” 5. Review of Patient #9’s treatment sheets dated 05/24/2025 to 06/10/2025 included the following: 05/27/2025 Blood pressure, pulse rate, and access checks were conducted at 1:03 PM with follow-up blood pressure, pulse rate, and access checks at 2:02 PM (59 minutes later). Staff failed to conduct blood pressure, pulse rate, and access checks every 30 minutes during ICHD treatment. 05/29/2025 Blood pressure, pulse rate, and access checks were conducted at 12:31 PM with follow-up blood pressure, pulse rate, and access checks at 1:31 PM (one hour later). Staff failed to conduct blood pressure, pulse rate, and access checks every 30 minutes during ICHD treatment. 05/31/2025 Blood pressure and pulse rate checks were conducted at 12:04 PM with follow-up blood pressure and pulse rate checks at 1:08 PM (one hour and four minutes later). An access check was conducted at 12:05 PM with a follow-up access check at 1:08 PM (one hour and three minutes later). Staff failed to conduct blood pressure, pulse rate, and access checks every 30 minutes during ICHD treatment. 06/05/2025 Blood pressure, pulse rate, and access checks were conducted at 1:05 PM with follow-up blood pressure, pulse rate, and access checks at 2:03 PM (58 minutes later). Staff failed to conduct blood pressure, pulse rate, and access checks every 30 minutes during ICHD treatment. 06/10/2025 A pre-treatment sitting blood pressure of 211/99 was recorded by PCT 3. The record failed to evidence the RN was notified of the systolic blood pressure greater than 180. During an interview on 06/13/2025 at 3:20 PM, PCT 6 indicated blood pressure, pulse, and access checks should be performed at the beginning of treatment, every 30 minutes, and at the end of treatment. During an interview on 06/13/2025 at 3:14 PM, PCT 5 indicated blood pressures over 180 systolic should be reported to the nurse. 6. Review of Patient #10’s treatment sheets dated 05/24/2025 to 06/10/2025 included the following: 05/24/2025 Blood pressure and pulse rate checks were conducted at 10:03 AM with follow-up blood pressure and pulse rate checks at 11:02 AM (59 minutes later). Staff failed to conduct blood pressure and pulse rate checks every 30 minutes during ICHD treatment. Patient #10’s prescribed blood flow rate was 500. The treatment was started at 8:25 AM with the first machine settings check recorded at 8:27 AM with a blood flow rate of 400, and Patient #10 ran at 400 until 11:02 AM when it was lowered to 350. The Patient then ran at a blood flow rate of 350 until the end of the treatment. The treatment run sheet failed to evidence the reason the blood flow rate was not set as prescribed by the physician. Patient #10 had an order to receive Midodrine (a medication used to treat low blood pressure) 5 milligrams by mouth as needed for systolic blood pressures below 100. At 11:02 AM, Patient #10 had a blood pressure of 86/45, and had a blood pressure of 90/32 at 11:32 AM. The treatment record failed to evidence Patient #10 received Midodrine after a blood pressure less than 100 systolic. 06/05/2025 Patient #10’s prescribed blood flow rate was 500. The treatment was started at 8:04 AM with the first machine settings check recorded at 8:07 AM with a blood flow rate of 400, and Patient #10 ran at 400 until 10:02 AM when it was lowered to 350. The Patient then ran at a blood flow rate of 350 until the end of the treatment. The treatment run sheet failed to evidence the reason the blood flow rate was not set as prescribed by the physician. Patient #10 had an order to receive Midodrine 5 milligrams by mouth as needed for systolic blood pressures below 100. At 9:37 AM, Patient #10 had a blood pressure of 96/47, 85/66 at 10:02 AM, 98/60 at 10:34 AM, 82/43 at 11:06 AM, 86/53 at 11:31 AM, and 82/42 at 12:01 PM. The treatment record failed to evidence Patient #10 received Midodrine after a blood pressure less than 100 systolic. Patient #10’s prescribed blood flow rate was 500. The treatment on 6/10/2025 was started at 8:46 AM with the first machine settings check recorded at 9:01 AM with a blood flow rate of 450, and Patient #10 ran at 450 until 12:04 PM when it was lowered to 400. The Patient then ran at a blood flow rate of 400 until the end of the treatment. The treatment run sheet failed to evidence the reason the blood flow rate was not set as prescribed by the physician. Patient #10 had a blood pressure of 93/33 at 11:04 AM and 95/52 at 11:05 AM recorded by PCT. The treatment record failed to evidence the RN was notified of the systolic blood pressures less than 100. During an interview on 06/13/2025 at 3:14 PM, PCT 5 indicated blood pressures under 100 systolic should be reported to the nurse. During an interview on 06/13/2025 at 3:20 PM, PCT 6 indicated patients should be started at a blood flow rate of 50 and gradually increased until the prescribed blood flow rate is reached. PCT 6 further indicated Patient #10 was a catheter patient who usually can’t run at 500 due to venous pressure. PCT 6 indicated he was told to inform the RN when the blood flow rate could not be run as prescribed but did not document that because he assumed the RNs would document it. During an interview on 06/13/2025 at 2:57 PM, RN 1 indicated treatments should begin with the prescribed blood flow rate and indicated the reason for lowering it should be documented on the treatment run sheet. 7. Review of Patient #11’s treatment sheets dated 05/26/2025 to 06/11/2025 included the following: 05/26/2025 The treatment record indicated Patient #11 had a pre-treatment standing blood pressure recorded but failed to include a post-treatment standing blood pressure. The treatment record failed to indicate a reason the post-treatment standing blood pressure could not be assessed. 06/09/2025 Blood pressure, pulse rate, and access checks were conducted at 11:35 AM with follow-up blood pressure, pulse rate, and access checks at 12:34 PM (59 minutes later). The next follow-up blood pressure, pulse rates, and access checks were conducted at 1:31PM (57 minutes later). Staff failed to conduct blood pressure, pulse rate, and access checks every 30 minutes during ICHD treatment. Patient #11 had a prescribed blood flow rate of 500. Treatment began at 9:49 AM with the first blood flow rate recording of 410 at 10:02 AM. Patient #11 ran at a blood flow rate of 410 for the entire treatment. The treatment run sheet failed to evidence the reason the blood flow rate was not set as prescribed by the physician. 06/11/2025 Patient #11 had an RN assessment at 10:12 AM which indicated the Patient was ambulatory with a steady gait. The treatment record failed to include a pre-treatment standing blood pressure nor a reason the standing blood pressure could not be assessed. During an interview on 06/13/2025 at 3:08 PM, PCT 4 indicated standing blood pressure checks should be performed before and after treatment. PCT 4 indicated she did not know why Patient #11 did not have a pre-treatment standing blood pressure on 06/11/2025 and indicated the Patient sometimes refuses. PCT 4 indicated the reason for not performing a standing blood pressure is documented on the treatment sheet in the notes section. During an interview on 06/13/2025 at 3:06 PM, PCT 2 indicated blood pressures, pulse rates, and accesses should be checked every 30 minutes during ICHD. During an interview on 06/13/2025 at 3:39 PM, the Interim CM indicated she did not see a reason why Patient #11 was not started and run at the prescribed blood flow rate on 06/09/2025. 8. Review of Patient #12’s treatment sheets dated 05/23/2025 to 06/09/2025 included the following: 05/30/2025 An RN assessment was conducted at 12:30 PM in which Patient #12 was described as ambulatory with a steady gait. The treatment record failed to include a pre-treatment standing blood pressure nor a reason the standing blood pressure could not be assessed. PCT 5 recorded a blood pressure of 126/104 at 3:08 PM for Patient #12. The treatment record failed to evidence PCT 5 informed the RN of the diastolic blood pressure greater than 100. 06/06/2025 Blood pressure, pulse rate, and access checks were conducted at 1:33 PM with follow-up blood pressure, pulse rate, and access checks at 2:30 PM (57 minutes later). Staff failed to conduct blood pressure and pulse rate checks every 30 minutes during ICHD treatment. 06/09/2025 An RN assessment was conducted at 12:30 PM in which Patient #12 was described as ambulatory with a steady gait. The treatment record failed to include a pre-treatment standing blood pressure nor a reason the standing blood pressure could not be assessed. During an interview on 06/13/2025, PCT 5 indicated she did not know what the parameters were for reporting diastolic blood pressures to the RN. PCT 5 also indicated she documents RN notification by checking the box that says, “RN notified” and sometimes also puts in a note. PCT 5 also indicated she wasn’t sure why she didn’t get Patient #12’s pre-treatment standing blood pressures on 05/30/2025 and 06/09/2025 because she usually gets it unless the patient is already in the chair. 9. Review of Patient #13’s treatment sheets dated 05/26/2025 to 06/11/2025 included the following: 05/26/2025 RN assessments were conducted at 10:47 AM and 2:10 PM in which Patient #13 was described as ambulatory with a steady gait. The treatment record failed to include a pre-treatment or post-treatment standing blood pressure nor a reason the standing blood pressures could not be assessed. 05/28/2025 RN assessments were conducted at 10:37 AM and 2:03 PM in which Patient #13 was described as ambulatory with a steady gait. The treatment record failed to include a pre-treatment or post-treatment standing blood pressure nor a reason the standing blood pressures could not be assessed. 05/30/2025 RN assessments were conducted at 8:05 AM and 11:57 AM in which Patient #13 was described as ambulatory with a steady gait. The treatment record failed to include a pre-treatment or post-treatment standing blood pressure nor a reason the standing blood pressures could not be assessed. Patient #13 had a prescribed blood flow rate of 500. Treatment began at 8:18 AM with a blood flow rate of 400. Patient #13 ran at a blood flow rate of 400 for the entire treatment. The treatment run sheet failed to evidence the reason the blood flow rate was not set as prescribed by the physician. During an interview on 06/13/2023 at 3:14 PM, PCT 5 indicated standing blood pressure checks should be performed before and after ICHD treatment. PCT 5 indicated Patient #13 refused standing blood pressure checks on 05/28/2025, but there was no choice for “patient refuses” in the system. PCT 5 indicated she could add a note in. During an interview on 06/13/2025 at 2:57 PM, RN 1 indicated Patient #13 has refused standing blood pressure checks. RN 1 further indicated it should probably be documented when the patient refuses standing blood pressure checks. RN 1 also indicated treatments should be started at the patient’s prescribed blood flow rate, and the reason should be documented somewhere if the blood flow rate was lowered. RN 1 indicated she did not see a reason documented by the PCT or herself why Patient #13 was not started at the prescribed blood flow rate. 10. During an interview on 06/13/2025 at 3:39 PM, the Interim CM indicated blood pressure, pulse rate, and access checks are to be performed every 30 minutes during treatment and that blood pressures over 180 systolic should be reported to the nurse. The Interim CM indicated that information should be documented somewhere on the treatment run sheet. The Interim CM indicated she would have to check the policy regarding the parameters for reporting diastolic blood pressures to the RN. The Interim CM also indicated patient treatment should be started at the prescribed blood flow rate whenever possible and further indicated changes from the prescribed blood flow rate should be noted in the treatment record. 11. During an interview on 06/13/2025 at 4:43 PM, the Medical Director indicated he is responsible for everything that happens in the facility and that policies are followed.”