Davita Home Dialysis of Indianapolis

“CFC-PATIENTS- RIGHTS CFR(s): 494.70 This Condition is not met as evidenced by: 44715 Based on record review and interview the dialysis den failed to ensure the patients individuality was secured related to the monitoring of critical labs, Potassium and Phosphorus (V542). The cumulative effect of these systemic problems has resulted in the agency’s inability to ensure provision of quality health care in a safe environment for the condition of participation 42 CFR 494.70, Patient Rights. Based on record review, and interview, the dialysis den, Entity #9, failed to notify the physicians of critical lab values for Potassium (normal level 3.6-5.2 mmol/L) and Phosphorus (normal level 2.5-4.5 mg/dl) for 1 of 1 clinical record reviewed with a critical result. (Patient #11) Patient #11 was admitted on 10-24-2023. On 10-31-2023 their Potassium (K+) level was 5.6. On 11-2-2023, their K+ level was 6.1 and their Phosphorus level was 7.7. The patient’s dialysis bath was 3K, 2.5 Calcium, Bicarbonate 35 and Sodium 140. Patient #11 was sent to the emergency room on 11-2-2023 with symptoms of nausea and vomiting. The physician was not notified of the critical lab values. The Clinical Services Manager indicated the electronic medical record has a critical alert prompt for a K+ level greater than 6.7. This immediate jeopardy had the potential to affect all patients of the dialysis den. An immediate jeopardy was announced on 11-20-2023 at 2:44 PM, under condition of participation at 42 CFR 494.70. The Regional Operations Manager and Regional Operations Director were present during the announcement of the immediate jeopardy. The immediate jeopardy was removed by the exit of the survey on 11-21-2023.”

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 44715 Based on observation, record review, and interview, the dialysis facility failed to ensure an interdisciplinary assessment was completed (See V501) and failed to ensure staff implemented the facility’s policy and procedures for the treatment of hypertension, by notifying the registered nurse of elevated blood pressures. (See V504). The cumulative effect of these systemic problems has resulted in the dialysis center’s inability to ensure provision of quality health care in a safe environment for the condition of participation 42 CFR 494.80 Patient Assessment.”

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 44715 Based on observation, record review, and interview the dialysis center failed to ensure the plans of care were developed for all patients (See V542), failed to notify the Physician of patients’ dry weights outside of normal parameters and failed to monitor and assess patients per policy (See V543), failed to ensure an initial plan of care was initiated within 30 calendar days of admission (See V557). The cumulative effect of these systemic problems has resulted in the dialysis center’s inability to ensure the provision of quality health care in a safe environment for the condition of participation 42 CFR 494.90 Patient Plan of Care.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(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 the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[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. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 44715 Based on record review and interview the agency failed to ensure an all hazards risk assessment was completed for 1 of 3 dialysis dens as part of the Emergency Preparedness (EP) plan. (Entity: 9) Findings include: 1. A review of the EP plan for Entity #9, included a binder titled, “Emergency Preparedness Plan”. The EP binder failed to evidence an all hazards risk assessment was completed. 2. An interview with the Regional Operations Manager, Administrator 1, indicated if it was not present, they were not going to make something up and will make the correction to the plan following the survey findings.”

“Procedures for Tracking of Staff and Patients CFR(s): §403.748(b)(2), §416.54(b)(1), §418.113(b)(6)(ii) and (v), §441.184(b)(2), §460.84(b)(2), §482.15(b)(2), §483.73(b)(2), §483.475(b)(2), §485.542(b)(2), §485.625(b)(2), §485.920(b)(1), §486.360(b)(1), §494.62(b)(1). [(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:] [(2) or (1)] A system to track the location of on-duty staff and sheltered patients in the [facility’s] care during an emergency. If on-duty staff and sheltered patients are relocated during the emergency, the [facility] must document the specific name and location of the receiving facility or other location. *[For PRTFs at §441.184(b), LTC at §483.73(b), ICF/IIDs at §483.475(b), PACE at §460.84(b):] Policies and procedures. (2) A system to track the location of on-duty staff and sheltered residents in the [PRTF’s, LTC, ICF/IID or PACE] care during and after an emergency. If on-duty staff and sheltered residents are relocated during the emergency, the [PRTF’s, LTC, ICF/IID or PACE] must document the specific name and location of the receiving facility or other location. *[For Inpatient Hospice at §418.113(b)(6):] Policies and procedures. (ii) Safe evacuation from the hospice, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s) and primary and alternate means of communication with external sources of assistance. (v) A system to track the location of hospice employees’ on-duty and sheltered patients in the hospice’s care during an emergency. If the on-duty employees or sheltered patients are relocated during the emergency, the hospice must document the specific name and location of the receiving facility or other location. *[For CMHCs at §485.920(b):] Policies and procedures. (2) Safe evacuation from the CMHC, which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For OPOs at § 486.360(b):] Policies and procedures. (2) A system of medical documentation that preserves potential and actual donor information, protects confidentiality of potential and actual donor information, and secures and maintains the availability of records. *[For ESRD at § 494.62(b):] Policies and procedures. (2) Safe evacuation from the dialysis facility, which includes staff responsibilities, and needs of the patients. This Standard is not met as evidenced by: 44715 Based on observation and interview, the agency failed to ensure patient and staff information was current in the Emergency Preparedness (EP) case for 1 of 3 dialysis dens. (Entity 9) Findings include: 1. A review of the EP portable case evidenced a patient list with a printed date of 11/2022 and no employee list was present. 2. An interview with the Manager of Clinical Services (Corporate Employee 3 ) noted the patient list was not current and there was no employee list available. The patient list was printed from the former Snappy, electronic medical record. (EMR). The agency’s EMR now used is referred to as CWOW.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 44715 Based on record review and interview, the agency failed to ensure Emergency Preparedness (EP) training was completed every two years for 1 of 3 dialysis dens. (Entity 8) Findings include: 1. A review of the EP binder located at Entity 8 evidenced no record of a table top exercise occurring in the last two years. 2. An interview with the Regional Operations Manager, Administrator 1 indicated if the documentation was not present in the binder, it did not exist at this time.”

“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: 44715 Based on observation, record review and interview, the agency failed to ensure staff and patients performed hand hygiene according to policy in 1 of 3 dialysis dens, Entity 8. (Employee: Registered Nurse (RN) 6 and 4 (twice) and Patient Care Technician (PCT) 1) Findings include: 1. A revised October, 2023 agency policy titled, “Infection Control for Dialysis Facilities, 14-04-01 indicated but was not limited to, “ ... Hand Hygiene ... 1. All teammates, Physicians and Non-Physicians will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves ... d. after patient and dialysis delivery system contact ... g. before touching clean areas such as supplies, supply cart and computer keyboard/mouse.” 2. On 11/15/2023, RN 6 was observed touching the dialysis machine at Station #3 with a glove as a barrier. No hand hygiene was performed after disposing of the glove. 3. On 11/15/2023, RN 4 was observed setting up the treatment table at station # 3. RN 4 failed to set up the table by placing the tape on the table itself and not properly securing the chux covering. Removed their gloves when corrected by PCT 1 and did not perform hand hygiene. 4. On 11/15/2023, RN 4 adjusted the settings on the dialysis machine at Station #4 using the glove as a barrier and did not perform hand hygiene after disposing of the glove. 5. On 11/15/2023, PCT 1 was preparing to access the Central Venous Catheter (CVC) (a catheter inserted into a major vein) of Patient #1 at Station #1. While wearing gloves, PCT 1 reached into their scrubs to obtain a pen to document the date on the CVC occlusive dressing. PCT 1 failed to remove their gloves or perform hand hygiene prior to applying the dressing. 6. An interview with the Regional Operations Manager, Administrator 1 of the dialysis den, Entity 8 indicated staff should be practicing hand hygiene following the removal of gloves and should not be using the glove as a barrier when touching the machine.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 44354 Based on observation, record review, and interview the Dialysis Facility Den failed to ensure individuals entering the Den treatment area wore personal protective equipment in 2 of 3 dialysis dens observed. (Entity 7 and 8). Findings Include: 1. A policy titled “Davita Skilled Nursing Dialysis (DSD) Services Policies & Procedures “ received from Regional Operations Manager 3 on 11/21/23 at 1:55 PM, contained but was not limited to “PPE (i.e., gown, gloves, eye protection, face shield) ... Appropriate PPE will be worn whenever there is potential for contact with body fluids, hazardous chemicals ... example, patient care areas ... Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physicians (NPP) and visitors when in treatment den/bedside area.” 2. On 11/22/23 at 7:25 AM , Certified Nursing Assistant (CNA) 6 from Entity 7, a skilled nursing facility (SNF), entered the dialysis treatment area to bring a patient to the treatment chair next to a patient having their dialysis treatment initiated. The CNA assisted dialysis staff with transferring the patient from a wheelchair to the treatment chair. The CNA failed to don protective clothing including a mask, shield, and gown while in the treatment area during dialysis. 3. On 11/22/23 at 11:25 AM CNA 6, from Entity 7, entered the dialysis treatment area without a mask, gown, or shield to assist in returning a patient to the SNF. 44232 4. A review of a sign on the entrance door of the treatment area of the dialysis den, at Entity 8, the skilled nursing facility, on 11-21-2023 at 6:40 AM, stated, “Private Treatment Area. PPE (Personal Protective Equipment), Gown, Mask, Goggles, Face Shield, Gloves.” 5. On 11-21-2023 at 7:05 AM, while observing the dialysis floor, Skilled Nursing Facility staff member 10, with Entity 8, wheeled Patient #18 in their recliner from the Skilled Nursing Facility hallway into the dialysis unit, Station #1, and was without mask and gown. 6. On 11-21-2023 at 11:00 AM, observed the CNA for Entity 8, Person 11, enter the treatment area. Person 11 assisted Patient #18 in their recliner from Station #1, into the skilled nursing facility hallway. Person #7 failed to be instructed or offered a mask, or gown prior to entering the treatment area by the Registered Nurse (RN) 14, or the Patient Care Technician (PCT) 1. 7. During an interview on 11-21-2023 at 11:35 AM, the Unit Manager of Entity 8, Person 1, confirmed the skilled nursing facility staff were to wear masks and gowns when transferring the patients of Entity 8 into the dialysis den.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to properly manage the handling of expired supplies in 1 of 3 dialysis dens. (Entity 8) Findings Include: 1. A revised April 2023 agency policy, titled, “Skilled Nursing Facility (SNF): Home Hemodialysis (HHD) Infection Control For Dialysis Facilities” was provided by the Regional Operational Manager, Admin 3, on 11-21-2023 at 1:53 PM. The policy indicated but was not limited to, “ ... Supplies will be stored in a manner that maintains their integrity ... “ 2. A review of a facility document signed and dated 11-06-2023, titled “Monthly Infection Control Audit (All modalities)” was provided by the Registered Nurse (RN) 14, on 11-21-2023 at 1:00 PM. The audit indicated in the section subtitled, “Supply Management” all lab supplies for patient use were not expired was checked yes. 3. On 11-21-2023 at 6:45 AM, observed on the top shelf of the cabinet in the lab area all 24 BS culture vials had expired 10-13-2023. 4. During an interview on 11-21-2023 at 6:49 AM, RN 14 confirmed the vials had expired and they used the vials to obtain cultures. RN 14 further indicated they should have been checked.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 44774 Based on observation and interview the agency failed to maintain the proper care and treatment of the Central Venous Catheter (CVC) for patients as noted in 2 of 3 dialysis dens. (Entity 8 and 9) Findings include: 1. A revised October 2023, agency policy titled ‘POLICY: 14-05-02A CENTRAL VENOUS CATHETER (CVC) CARE’ page 2 of 12 stated, “ ... Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnecting during treatment for any reason.” Page 6 stated, “ ... 16. Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue, for example blood. Hold the limbs until the antiseptic has dried.” 2. On 11-21-2023 at 7:13 AM, PCT 1 was initiating treatment for Patient #18 at Station #1 at Entity 8 via the patient’s Central Venous Catheter (or CVC, a vessel inserted into a vein below the collar bone). During initiation, PCT 1 held the red port in hand and scrubbed the hub with a twisting motion for 17 seconds, then immediately connected a syringe. 3. On 11-21-2023 at 8:00 AM, Registered Nurse (RN) 14 was initiating treatment for Patient # 19 at Station #2 at Entity 8 via the patient’s Central Venous Catheter (or CVC, a vessel inserted into a vein below the collar bone). During initiation, RN 14 held the red port in hand and scrubbed the hub with a twisting motion for 12 seconds, then immediately connected a syringe. 4. On 11-21-23 at 12:33 PM, when queried as to how long hubs should be scrubbed during a CVC initiation, RN 14 indicated this should be thirty (30) seconds long and indicated usually provided fifteen (15) turns during scrubbing, estimated this equaled thirty (30) seconds, and utilized this practice when not able to view the clock. 44715 5. On 11-16-2023 at 11:55 AM, PCT 2 at Entity 9 was observed initiating the CVC of Patient #12. PCT 2 removed the old dressing to clean the insertion site. The patient’s clothing was not secured allowing the insertion site to come into contact with the clothing. 6. On 11-16-2023 at 12:17 PM, PCT 2 at Entity 9 was observed initiating the CVC of Patient #34. PCT 2 removed the old dressing to clean the insertion site. The chux barrier applied under the CVC ports came into contact with the CVC insertion site.”

“RO-CHEMICAL ANALYSIS-FREQUENCY CFR(s): 494.40(a) 6.2.7 Reverse osmosis: Chemical analysis: frequency Chemical analysis for the contaminants listed in 4.1.1 (Table 1) should be done when the RO system is installed, when membranes are replaced, and at not less than annual intervals thereafter to ensure that the limits specified in 4.1.1 are met (see Table 1). Chemical analyses should be done when seasonal variations in source water suggest worsening quality or when rejection rates fall below 90 %. This Standard is not met as evidenced by: 44715 Based on record review and interview the agency failed to follow their policy related to elevated endotoxin results for 1 of 3 dialysis dens (Entity 8) when above normal levels were reported. Findings include: 1. A revised October 2017 agency policy titled, “Water Treatment System Monitoring, 12-14-05” was provided by the Regional Operations Manager, (Administrator 1). The policy indicated but was not limited to, “ ... 15. Endotoxin (LAL) testing on reverse osmosis (dialysis quality) water and dialysate will be performed at least monthly ... “ 2. On 11-15-2023, An agency document titled, “CHL Machine Culture and Endotoxin report” was provided by Biomed 1. The report for all results for dates 04-01-2023 to 10-31-2023 evidenced the following:. A. On 07-13-2023, reverse osmosis (RO) machine 7-1386700 had an H2O Endo level of <.20. B. On 07-13-2023, reverse osmosis (RO) machine 7-1386708 had an H2O Endo level of <.20. C. On 08-14-2023, reverse osmosis (RO) machine 1-1386156 had an H2O Endo level of <.20. D. On 10-20-2023, reverse osmosis (RO) machine 4-1386269 had an H2O Endo level of <.20. 3. On 11-17-2023, the Group Biomed, Employee 2 was queried about the elevated results. Employee 2 indicated anything greater than .12 is an actionable level and the results should have been repeated.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 44232 Based on observation, record review, and interview, the facility failed to provide a safe and comfortable environment for 1 of 3 dialysis dens. (Entity 8) Findings Include: 1. An agency policy with a revision date April 2023, titled, “Skilled Nursing Facility (SNF): Home Hemodialysis (HHD) Infection Control For Dialysis Facilities” was provided by the Regional Operational Manager, Admin 3, on 11-21-2023 at 1:53 PM. The policy indicated but was not limited to, “ ... Sinks should be easily accessible and readily available in the treatment den/bedside area and in other appropriate areas such as the medication area ... a. Sinks must be plumbed with both hot and cold water ... “ 2. On 11-21-2023 at 6:51 AM, observed dirt and debris under the sink in the medication area. 3. On 11-21-2023 at 4:18 PM, observed the hot water required over 4 minutes to get warm at the sink in the medication area.”

“PR-PRIVACY & CONFIDENTIALITY-RECORDS CFR(s): 494.70(a)(4) The patient has the right to- (4) Privacy and confidentiality in personal medical records; This Standard is not met as evidenced by: 44232 Based on observation, and interview, the facility failed to ensure the clinical records at the dialysis den, Entity 8, a skilled nursing facility, were secured and maintained in a manner to ensure the privacy of personal health information (PHI) for all patients discharged in 16 boxes year dated 2022, and 17 active patients. (Patients: #1, 5, 14, 15, 16, 17, 18, 19, 24, 25, 26, 27, 28, 29, 30, 31, and 32) Findings Include: 1. On 11-21-2023 at 6:15 AM, the Patient Care Technician (PCT) 1, led the survey team across the hall from the dialysis den, at Entity 8, a skilled nursing facility, to an unlocked office room for set up. The office contained a closet door with a sign titled, “Medical Records.” The door to the medical records contained a key which was unlocked. The closet contained a rack with the dialysis den’s active patients’ records. 2. On 11-21-2023 at 8:10 AM, noted 16 boxes stacked around the office room, dated 2022 discharge records. The door to the office was unlocked. During an interview on 11-21-2023 at 8:45 AM, the Regional Operational Manager in training, Admin 1, and the Manager of Clinical Services, Admin 2, confirmed office door should be closed and locked.”

“PR-RECEIVE SERVICES OUTLINED IN POC CFR(s): 494.70(a)(12) The patient has the right to- (12) Receive the necessary services outlined in the patient plan of care described in §494.90; This Standard is not met as evidenced by: 44716 Based on record review and interview, the facility failed to obtain medical doctor orders and update the plan of care for delivery of intravenous antibiotic in 1 of 33 patients. (Patient #33) Findings include: An agency’s policy titled ‘MEDICATION POLICY 1-06-01’ dated October 2023 revealed, “ ... 9. Medications are administered as prescribed and then documented in the patient’s medical record. No medications are given without an order from the physician ... “ On 11/21/2023 at 2:30 PM, review of the facility’s QAPI (quality assurance performance improvement) program evidenced IV ATB (intravenous antibiotic) administration for Patient #33 initiating on 03/03/2023. On 11/21/2023 at 4:07 PM, Administrator 4 indicated the facility will run IV ATB’s for Entity 8 as a favor and would get physician orders to run the ATB for the patient. On 11/21/2023 at 4:30 PM, Person 2 from Entity 8 provided Patient #33’s order for IV ATB Vancomycin (to treat and prevent various bacterial infections caused by gram-positive bacteria) 1,000 mg to be given after dialysis, dated 3/3/2023 with a start date of 3/3/2023, discontinue on 3/10/2023 for Sepsis (is the clinical name for blood poisoning by bacteria. It is the body’s most extreme response to an infection. Sepsis that progresses to septic shock has a death rate as high as 50%, depending on the type of organism involved. Sepsis is a medical emergency and needs urgent medical treatment). On 11/22/2023 at 8 AM, a review of Patient #33 Clinical Record failed to evidence medical doctor notification. orders or changes to the plan of care to administer IV ATB.”

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 44715 Based on record review and interview, the facility failed to ensure the interdisciplinary team members (IDT)completed comprehensive interdisciplinary assessments for 4 of 10 clinical records reviewed at Entity 9, a dialysis den. (Patient #6, 8, 10, 12) Findings include: 1. A revised July 2023 agency policy titled, SNF:Hemodialysis Patient Assessment and Plan of Care was provided by the Regional Operations Manager, Administrator 1. The policy indicated but was not limited to “ ... Assessment: 1. The facility’s interdisciplinary team (IDT) consists of , at a minimum, the patient or the patient’s personal representative, a registered nurse (RN), a physician or Non-Physician Practitioner, ... a social worker, and a dietitian. 2. For patients residing in the skilled nursing facility (SNF), the IDT will also include a representative of the SNF to very that an adequate coordination of care is accomplished ... 6. A comprehensive assessment will be conducted on all new patients within 30 calendar days ... “ 2. A clinical record review of Patient #6, admitted on 9-07-2023, evidenced an incomplete comprehensive assessment. A Medical Social Worker (MSW) Progress note dated 10-05-2023 indicated, “The Comprehensive Assessment, completed by MSW 3, has fulfilled the need for a MSW progress note for this period.” There was no comprehensive assessment provided and the progress note was blank. There was no documentation provided indicating the SNF leadership teams were involved with the IDT. There was a Registered Dietitian completed monthly progress note dated 9-26-2023. 3. A clinical record review of Patient #8, admitted on 4-22-2023, evidenced an incomplete comprehensive assessment. There was no comprehensive assessment provided by the RN. There was no documentation provided indicating the SNF leadership teams were involved with the IDT. There was a Registered Dietitian completed monthly progress note dated 9-26-2023. 4. A clinical record review of Patient #10, admitted on 9-07-2023, evidenced an incomplete comprehensive assessment. There was no comprehensive assessment provided by the RN. There was no documentation provided indicating the SNF leadership teams were involved with the IDT. There was a Registered Dietitian completed monthly progress note dated 9-26-2023 and 10-09-2023. 5. A clinical record review of Patient #12, admitted on 1-28-2023, evidenced no available comprehensive assessment. There was no comprehensive assessment provided by the RN, MSW or RD. There was no documentation provided indicating the SNF leadership teams were involved with the IDT. 6. On 11-20-2023, the Registered Dietician (RD) of the Skilled Nursing Facility for Entity 9, Other Employee #12, was queried about their role in IDT. They replied, “I do not participate.” When queried about their communication with Entity 9’s RD, the employee indicated they occasionally receive lab results and it is not consistent. 7. On 11-20-2023, the Regional Operation Manager, Corporate Administrator 1, indicated there were no comprehensive documents available for the patients if they were not present and no documentation regarding the SNF leadership/RD communication with IDT. Administrator 1 indicated it was the charge nurses responsibility to gather the information and ensure it was located in the clinical record. The charge RN responsible is no longer with the agency as of 11-17-2023.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 44715 Based on record review, and interview the dialysis facility failed to ensure patient pre, during, post and intradialytic blood pressures were being assessed and managed in 9 of 10 clinical records reviewed in 1 of 3 dialysis dens, (Entity 9). (Patient #2, 3, 7, 8, 9, 10, 11, 12 and 13) Findings include: 1. A revised October, 2023 agency policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” was provided by the Regional Operations Manager, Employee 1. The policy indicated but was not limited to, “ Abnormal Findings: Unless other abnormal parameters are established ... the following are considered abnormal findings and should be reported to the licensed nursed and documented in the patients record ... Fluid Status: ... Post-treatment: If patients is above or below 1kg from the target weight. Blood pressure: Pre dialysis Systolic greater than 180mmHg (mercury) or less than 90 mm HG. Diastolic greater than or equal to 100 mmhg. Blood Pressure- Intradialytic: Difference of 20 mmHG increase of decrease from patient’s last intradialytic treatment BP reading ...” 2. A clinical record review of Patient #2, admitted on 10-06-2022, evidenced a series of agency documents titled, “Treatment Details Report” on 11-02-2023 at 2:04 PM the patient’s blood pressure (BP) was 134/109. At 2:34 PM, the patient’s BP was reported as 104/67 both taken by Patient Care Technician (PCT) 6. The drop in BP was not reported to the Registered Nurse. The prescribed Midodrine was not given to the patient for the drop in the BP. The patient concluded their treatment at 2:58 PM and was returned to their room. 3. A clinical record review of Patient #3, admitted on 10-31-2022, evidenced a series of agency documents titled, “Treatment Details Report” on 10-25-2023 at 10:30 AM the patient’s BP was 131/80. Prior to the treatment ending at 10:39 AM, the BP was 156/88. There is no documentation the RN was notified by PCT 2. On 10-27-2023 the patient’s BP was documented by PCT 2 at 8:30 AM as 218/113, at 9:00 AM, the patient’s BP was documented as 165/102. At 10:00 AM, the patient’s BP was 133/82 and at 10:30 AM, the BP was 168/107. The treatment ended t 11:06 AM. There is no documentation the RN was notified of changes in BP. On 11/03/2023, at 8:30 AM the patient’s BP was documented by PCT 2 as 161/89 and at 9:00 AM, the BP was 130/74. There was no documentation the RN was notified. 4. A clinical record review of Patient #7, admitted on 1/20/2020, evidenced a series of agency documents titled, “Treatment Details Report” on 10-21-2023 at 9:08 AM, the patient’s BP was documented by PCT 4 as 126/53, and at 9:33 AM as 96/45. On 10-25-2023 at 1:39 PM, PCT 2 documented the patient’s BP as 134/85 and at 2:00 PM as 160/70. On 10/28/2023 at 9:00 AM PCT 2 documented the patient’s BP as 157/62 and at 9:30 AM as 125/64, at 11:00 AM as 160/73 and at 11:30 as 126/65 at 12:00 PM as 153/65 and at 12:30 PM as 193/66. There was no documentation the patient was treated for the fluctuations in BP or the RN being notified. 5. A clinical record review of Patient #8, admitted on 4/22/2023, evidenced a series of agency documents titled, “Treatment Details Report”. On 10-16-2023, PCT 2 reported the patient’s BP at 2:30 PM as 142/70, at 3:00 PM as 175/75, there was no BP documented at 3:30 PM, at 4:00 PM as 178/81. There was no documentation the RN was notified of the changes in BP. 6. A clinical record review of Patient #9, admitted on 2-14-2023, evidenced a series of agency documents titled, “Treatment Details Report” on 10-18-2023 PCT 4 documented the patient’s BP at 1:58 PM as 199/86, at 2:31 PM as 176/75, at 3:00 PM as 173/76 and at 3:22 PM as 192/75. The patient terminated their treatment 2 hours early and this issue was documented in their plan of care as a barrier to their treatment. On 10-23-2023 at 1:09 PM, PCT 4 documented the patient’s BP as 176/72, at 1:22 PM as 153/68. The patient ended their treatment 2 hours early. On 11-02-2023, PCT 4 documented the patient’s BP as 223/90 at 7:49 AM, at 8:05 AM as 212/89, at 8:35 AM as 207/85, at 9:05 AM as 206/77 and at 9:11 AM as 200/87. There was no documentation the RN was notified of the elevated BP or treatment given. 7. A clinical record review of Patient #10, admitted on 9-7-2023, evidenced a series of agency documents titled, “Treatment Details Report”. On 10-19-2023, PCT 4 documented the patient’s BP at 7:29 AM as 170/77 and at 8:09 AM as 127/75. On 10-21-2023, the RN documented the patient’s BP as 161/79 at the start of treatment. At 8:40 AM, PCT 4 documented the BP as 137/70. On 10-24-2023, PCT documented the patient’s BP as 160/74 at 7:52 AM and at 8:00 AM as 137/69. On 10-26-2023, PCT 2 documented the patient’s BP as 162/85 at 11:00 AM and at 11:30 AM as 126/73. On 10-28-2023 at 8:33 AM, RN 1 documented the patient’s BP as 145/61 and at 9:00 AM, PCT 2 documented the BP as 121/61, at 9:30 as 127/75, at 10:00 AM as 100/57, at 10:30 as 63/39, at 11:00 as 109/53. On 10-31-2023, PCT 2 documented the patient’s BP as 115/58 and at 12:00 as 78/60. On 11-02-2023, PCT 4 documented the patient’s BP at 8:02 AM as 110/55, at 8:37 AM as 137/71 and at 9:00 AM as 86/33. The patient concluded their treatment at 10:38 AM with a BP of 77/34. There is no documentation the RN or Physician was notified or the patient was treated for fluctuations in blood pressures. 8. A clinical record review of Patient #11, admitted on 10-24-2023, evidenced a series of agency documents titled, “Treatment Details Report”. On 10-26-2023 at 10:30 AM PCT 2 documented the patient’s BP as 147/65 and at 11:00 AM as 119/508. On 10-31-2023, PCT 2 documented the patient’s BP at 8:13 AM as 160/77, no BP is documented at 8:30 AM. At 9:00 AM, the BP is documented by PCT 2 a 126/62. On 11-02-2023 at 7:34 AM, PCT 6 documented the BP as 129/68 and at 8:00 AM as 149/62. There was no documentation the RN was notified of fluctuations in blood pressures. 9. A clinical record review of Patient #12, admitted on 1-28-2023, evidenced a series of agency documents titled, “Treatment Details Report”. On 10-23-2023 at 11:30 AM, PCT 4 documented the patient’s BP as 86/59 and at 11:40 as 103/61. On 11-09-2023, PCT 3 documented the BP at 6:00 PM as 180/84, at 7:17 PM as 149/91, at 6:30 PM as 152/77, at 7:17 PM as 135/96, at 8:00 PM as 130/75 and at 8:03 as 107/78. On 11-14-2023, PCT 1 documented the BP as 128/80 and at 1:30 PM as 101/67 and 2:00 PM as 78/57. The patient ended their treatment at 3:30 PM with PCT 1 documenting the BP as 83/55. On 11-16-2023, PCT 2 documented the patient’s BP at 12:30 PM as 133/80, at 1:00 PM as 107/74, at 2:26 PM as 144/79, at 2:30 PM as 125/75, at 3:00 PM as 107/69, at 3:30 PM as 96/62, at 4:00 PM as 83/59, at 4:30 PM as 108/61, at 5:00 PM as 82/57 and at 5:30 PM as 125/61. There was no documentation the RN was notified of the fluctuations in blood pressure. 10. A clinical record review of Patient #13, admitted on 10-20-2023, evidenced a series of agency documents titled, “Treatment Details Report”. On 10-20-2023, PCT 2 documented the patient’s BP at 7:40 AM as 145/66, at 8:00 AM as 104/43, at 8:30 AM as 163/81, at 9:00 AM as 159/62, at 9:30 AM as 134/47, at 10:00 AM as 109/68, 11:00 AM as 144/99. On 10-25-2023, PCT 2 documented the BP at 7:38 AM as 186/65 and at 8:00 AM as 147/55, at 11:00 AM as 146/56, at 11:30 AM as 109/75 and at 11:41 AM as 191/71. On 10-27-2023, PCT 4 documented the patient’s BP at 7:46 AM as 121/83 and at 8:00 AM as 165/77. On 10-30-2023. PCT 2 documented the BP at 7:18 AM as 137/53 and at 7:30 AM as 163/70, at 10:00 AM as 149/58 and at 10:20 AM as 119/40. On 11-02-2023 at 9:52 AM, PCT 6 documented the patient’s BP at 9:53 AM as 126/96 and at 10:02 AM as 172/88. There was no documentation the RN was notified of the fluctuation in blood pressure. 11. On 11-17-2023, the Manager of Clinical Services, Corporate 3 reviewed the same documentation within the electronic medical record. When queried about the lack of reporting to address the trending blood pressure issues, Corporate 3 indicated there is education needing to be done.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 44715 Based on record review and interview, the interdisciplinary team (IDT) failed to ensure it developed a plan of care (POC) for 3 of 10 clinical records reviewed at dialysis den, Entity 9. (Patient #6, #7, #10 ). The findings include: 1. A revised July 2023 agency policy titled, SNF:Hemodialysis Patient Assessment and Plan of Care was provided by the Regional Operations Manager, Administrator 1. The policy indicated but was not limited to “ ... Assessment: 1. The facility’s interdisciplinary team (IDT) consists of , at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or Non-Physisician Practitioner, ... a social worker, and a dietitian. 2. For patients residing in the skilled nursing facility (SNF), the IDT will also include a representative of the SNF to very that an adequate coordination of care is accomplished ... 6. A comprehensive assessment will be conducted on all new patients within 30 calendar days ... “ 2. On 11-15-2023, the clinical record for Patient #6, admitted on 09-07-2023, failed to evidence a Plan of Care (POC) had been established. 3. On 11-17-2023, the clinical record for Patient #7, admitted on 01-20-2020, failed to evidence a POC had been established. 4. On 11-17-2023, the clinical record review for Patient #10, admitted on 09-07-2023 failed to evidence a POC had been established. 5. On 11-20-2023, the Regional Operations Manager, Administrator 1, confirmed the Plan of Cares could not be provided for the patients.”

“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: 44232 Based on record review and interview, the agency failed to ensure post treatment data was reported to the licensed nurse or the patient’s provider in 2 of 3 dialysis dens. (Entity 8 and 9) Findings include: 1. A revised October, 2023 agency policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” was provided by the Regional Operations Manager, Employee 1. The policy indicated but was not limited to, “ Abnormal Findings: Unless other abnormal parameters are established ... the following are considered abnormal findings and should be reported to the licensed nursed and documented in the patients record ... Fluid Status: ... Post-treatment: If patients is above or below 1 kg from the target weight. Blood pressure: Pre dialysis Systolic greater than 180mmHg (mercury) or less than 90 mm HG. Diastolic greater than or equal to 100 mmhg. Blood Pressure- Intradialytic: Difference of 20 mmHG increase of decrease from patient’s last intradialytic treatment BP reading ... “ 2. The clinical record of Patient #5 of Entity 8, a dialysis den, was reviewed on 11-21-2023 with a total of 10 dialysis treatment records reviewed for the period of 11-01-2023 through 11-20-2023. The treatment records indicated the patient’s estimated dry weight (EDW, goal weight for the patient to be at the end of dialysis treatment) was 75.9 (kilograms) kg. The treatment records for 7 of 10 treatments where the patient completed the entire treatment indicated the patient’s weight at the end of dialysis was higher than the goal weight, with ending weights documented as: 87.3 kg on 11-01-2023 (11.4 kg from EDW, a gain of 25.08 lbs) 85.6 kg on 11-08-2023 (9.7 kg from EDW, a gain of 21.39 lbs) 82.3 kg on 11-10-2023 (6.4 kg from EDW, a gain of 14.11 lbs) 88.2 kg on 11-13-2023 (12.3 kg from EDW, a gain of 27.12 lbs) 89.9 kg on 11-15-2023 (14 kg from EDW, a gain of 30.87 lbs) 89.4 kg on 11-17-2023 (13.5 kg from EDW, a gain of 29.76 lbs) 91.2 kg on 11-20-2023 (15.3 kg from EDW, a gain of 22.73 lbs) The facility failed to notify the licensed nurse or physician of the patient not meeting fluid management. The record contained facility documents titled, “Patient Notes” dated 08-21-2023 through 11-21-2023. The patient note signed and dated 11-01-2023 at 12:30 PM, indicated that Patient #5’s physician was notified of pre-treatment weight 15.5 kg over their dry weight. The patient notes failed to evidence any notification to the physician regarding Patient #5’s EDW not being met. During an interview on 11-21-2023 at 10:40 AM, the Registered Nurse (RN) 14, indicated concerns regarding the patient’s conditions or treatments were to be sent to the physician via secure message. 3. During an interview on 11-21-2023 at 4:11 PM, the Regional Operational Manager, Admin 3, when queried regarding Patient #5’s weights not meeting EDW by 6 to 15 kg, indicated it is at the nurse’s discretion when to notify the physician.”

“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: 44715 Based on record review and interview, the agency failed to ensure initial patient assessments were completed according to policy prior to receiving an initial dialysis treatment for 3 of 4 newly admitted patients in Entity 9. (Patient #10, #11 and #13) Findings include: 1. A revised October, 2023 agency policy titled, “New Patient Pre-Treatment Evaluation” was provided by the Regional Operations Manager, Administrator 1. The policy indicated but was not limited to, “ ... 1. A registered nurse (RN) by federal regulation will perform an initial pre treatment evaluation of all patients prior to the initiation of their first treatment at the facility ... “ 2. A clinical record review of Patient #10, admitted on 9-07-2023, evidenced an initial dialysis treatment time of 7:52 AM. The RN initial dialysis evaluation was completed at 10:01 AM. 3. A clinical record review of Patient #11, admitted on 10-24-2023, evidenced an initial dialysis treatment time of 11:16 AM. The RN initial dialysis evaluation was completed at 1:47 PM. 4. A clinical record review of Patient #13, admitted on 10-20-2023, evidenced an initial dialysis treatment time of 7:40 AM. The RN initial dialysis evaluation was completed on 10-20-2023. There is no documented time on the agency document titled, “Initial Patient Nursing Assessment”. 5. On 11-17-2023, the Manager of Clinical Services, Corporate 3, reviewed the documentation in the electronic medical record and could not provide further documentation indicating the assessments were completed according to policy.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 44716 Based on record review and interview the facility failed to ensure the Quality Assessment and Performance Improvement (QAPI) program addressed, tracked, and potentially identified trends in medical injuries/errors in 1 of 3 dialysis dens. (Entity 9) Findings include: An agency policy titled ‘SNF: HHD CONTINUOUS QUALITY IMPROVEMENT PROGRAM 14-01-09’ dated October 2020 revealed, “ ... 7. The facility will measure, analyze, track quality indicators or other aspects of performance. The program must include, but not be limited to ... Review of trends of adverse patient occurrences including falls and blood loss ... “ On 11/20/2023 at 12:05 PM upon review of the facility’s QAPI program and during an interview with the corporate regional operations manager, they indicated the facility does not currently have logs for facility’s errors/occurrences.”

“QAPI-INDICATOR-PT SATIS & GRIEVANCES CFR(s): 494.110(a)(2)(viii) The program must include, but not be limited to, the following: (viii) Patient satisfaction and grievances. This Standard is not met as evidenced by: 44716 Based on record review and interview the facility failed to ensure patient satisfaction surveys were provided to patients receiving dialysis in 1 of 3 dialysis dens. (Entity 9) Findings include: An agency policy titled. ‘SNF: HHD CONTINUOUS QUALITY IMPROVEMENT PROGRAM 14-01-09’ dated October 2020 revealed, “ ... 7. The facility will measure, analyze, and track quality indicators ... The program must include, but not be limited to ... Patient Satisfaction and Grievances ... “ On 11/17/2023 at 12:08 PM, a review of the facility’s QAPI (Quality Assurance Performance Improvement) program failed to evidence Patient Satisfaction Surveys. On 11/17/2023 at 12:09 PM, Corporate Employee 1 was unable to provide evidence of patient satisfaction surveys. On 11/17/2023 at 12:10 PM, Corporate Employee 3 indicated patient satisfaction surveys were no longer a requirement.”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 44716 Based on record review and interview, the facility failed to ensure the facility was tracking all infections in their QAPI (quality assurance performance indicators) program in 1 of 3 dialysis dens. (Entity 9) Findings include: An agency policy titled. ‘SNF: HHD CONTINUOUS QUALITY IMPROVEMENT PROGRAM 14-01-09, dated October 2020 revealed, “ ... 7. The facility will measure, analyze, and track quality indicators ... The program must include, but not be limited to ... Infection Control, including Incidence of infections. On 11/21/2023 at 2:43 PM, the QAPI program failed to evidence infection tracking for the period of January 2023 through October 2023. On 11/21//2023 at 2:45 PM, Administrator 4 was interviewed and indicated the den had no infections for the period of January 2023 through October 2023. On 11/21/2023, further review of QAPI evidenced IV ATB (intravenous antibiotic) treatment began for Patient #33 on 03/03/2023. On 11/21/2023 at 4:07 PM, Administrator 4 indicated the facility will run IV ATB’s for Entity 8 as a favor, not necessarily an infection their facility would be following, like a blood infection. On 11/21/2023 at 4:30 PM, Person 2 from Entity 8 provided Patient #33’s order for IV ATB Vancomycin (medication to treat and prevent various bacterial infections caused by gram-positive bacteria) 1,000 mg to be given after dialysis, dated 3/3/2023--3/10/2023 for Sepsis (a systemic infection).”

“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: 44716 Based on record review and interview the facility failed to follow their own Tuberculosis (TB) infection control policy in 2 of 3 employee record reviews. (MSW 1 and Corporate Employee 1) Findings include: An agency policy dated April 2020 titled, ‘Tuberculosis monitoring and Follow-Up Policy: 4-06-05’ revealed, “ ... Baseline new hire requirements ... 1. TB-Risk Assessment and Symptom Evaluation Questionnaire. ... 3. Testing options ... Negative Chest x-ray ... Documentation of a negative two step TST [one method of determining whether a person is infected with Mycobacterium tuberculosis] ... “ A review of the employee record for Master of Social Work (MSW) 1 received TB testing upon hire March 2021, but failed to evidence TB testing annually and failed to evidence a “TB risk assessment. A review of employee record Corporate Employee 1 with a hire date of July 2019 failed to evidence TB testing had occurred upon hire or annually and failed to evidence a TB risk assessment..”