Davita Highland Dialysis

“Policies/Procedures for Medical Documentation CFR(s): §403.748(b)(5), §416.54(b)(4), §418.113(b)(3), §441.184(b)(5), §460.84(b)(6), §482.15(b)(5), §483.73(b)(5), §483.475(b)(5), §484.102(b)(4), §485.68(b)(3), §485.542(b)(5), §485.625(b)(5), §485.727(b)(3), §485.920(b)(4), §486.360(b)(2), §491.12(b)(3), §494.62(b)(4). [(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:] [(5) or (3),(4),(6)] A system of medical documentation that preserves patient information, protects confidentiality of patient information, and secures and maintains availability of records. *[For RNHCIs at §403.748(b) and REHs at §485.542(b):] Policies and procedures. (5) A system of care documentation that does the following: (i) Preserves patient information. (ii) Protects confidentiality of patient information. (iii) Secures and maintains the availability of records. *[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. This Standard is not met as evidenced by: 48387 Based on record review and interview, the facility failed to follow facility policy and ensure patient information was updated monthly in the Emergency Evacuation kit for 67 of 67 active patients. (Emergency Evacuation kit) Findings include: A 04/2024 policy titled “Facility Emergency Management Plan” indicates that designated staff are to review the content of the evacuation kit at least once a month. During the Flash Tour on 02-17-2025, at 10:20 AM, the Emergency Preparedness tote was located on the treatment floor, with no evidence of patient information or Emergency Evacuation Kit checklist. A review of the Emergency Preparedness binder on 02/20/2025, provided by FA 1 on 02/19/2025. The FA updated the patient information on 02/18/2025. The facility did not provide evidence that the team completed the Emergency Evacuation Kit checklist for the following months: 10/2024, 11/2024, 12/2024, and 01/2025.. During an interview on 02/17/2025, at 10:20 AM, RN 1 indicated she did not know where the Emergency Preparedness binder was, maybe in the FA office. During an interview on 02/17/2025 at 10:20 AM, FA 1 indicated the binder for Emergency Preparedness was not with the tote; she had taken it into her office to update the patient list. During an interview on 02/19/2025 at 12:30 PM, FA 1 indicated due to a large staff changeover, The team did not complete the Emergency Evacuation Kit checklist for October 2024, November 2024, December 2024, and January 2025.”

“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: 38262 Based on observation, record review, and interview, the facility failed to ensure bleach container lids were secured and failed to ensure staff used bleach wipes immediately after preparation for 2 of 3 observation days. Findings include: A revised 10/2023 “Bleach Policy” policy indicated that staff are to cover the bleach solution containers with a lid. The policy stated the bleach solution would degrade over time and become less effective if staff did not secure the lid to the bleach container. 1. During a flash tour on 02/17/2025 at 10:30 AM, the surveyor found a 1:100 bleach container with the lid off sitting on the counter in a clean area. During an interview on 02/17/2025 at 10:35 AM, PCT 1 stated the bleach solution container should have a lid on it and was unsure why it didn’t. 2. During an observation on 02/18/2025 at 10:00 AM, the surveyor found a 1:100 bleach container with the lid off sitting on the counter in a clean area. During an interview on 02/18/2025 at 10:15 AM, PCT 2 stated she was unsure why the bleach container had no lid. She said the bleach would evaporate if the lid were left off. 3. During an observation on 02/18/2025 at 10:20 AM, the surveyor found several bleach wipes sitting on the seat of a dialysis chair at station 2. The staff left the bleach wipes on the seat for 20 minutes. 4. During an interview on 02/18/2025 at 3:31 PM, RN 1 stated she did not know about the bleach lids being off the containers. She stated she did not know if the bleach solution would be affected if the lids were left off. 5. During an interview on 02/18/2025 at 4:14 PM, FA 2 stated it was not best practice for staff to leave the bleach container lids off. She stated staff should put the lids back on the bleach containers when finished with them. She stated that staff should use the bleach wipes immediately after preparing them and not let them set out.”

“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: 48387 Based on observation, record review, and interview, the facility failed to ensure hand hygiene was performed before drawing up intravenous (IV) medications into a syringe and before giving medication for 3 of 4 parenteral medication preparation and administration observation (RN 1, PCT 1, PCT 7) and failed to perform hand hygiene between removing gloves and collecting supplies from a clean area for 1 of 2 discontinuation of a central venous catheter (CVC) observations. (PCT 1) Findings include: 1. A revised 10/2023 “Medication Policy” policy indicated that staff must use aseptic techniques when administering medications. The policy indicated that staff should prepare medications in an aseptic environment and perform proper hand hygiene. 2. During an observation on 02/17/2025 at 1:36 PM, RN 1 applied gloves before drawing Venofer (iron medication) into a syringe. RN 1 failed to perform hand hygiene before applying gloves. RN 1 removed her gloves but did not perform hand hygiene. She reapplied gloves and injected the Venofer into Patient #9’s bloodlines. She removed her gloves but failed to perform hand hygiene before leaving the station. During an interview on 02/17/2025 at 3:31 PM, RN 1 stated she should sanitize her hands and apply gloves before drawing up medications with a syringe and before injecting medications into a patient’s bloodlines. 3. During an observation on 02/17/2025 at 2:17 PM, RN 1 failed to hand hygiene before preparing Patient # 5’s intravenous medication. 4. During an observation on 02/18/2025 at 9:20 AM, PCT 1 failed to hand hygiene between removing gloves and collecting Patient #13’s supplies from a clean area. 5. During an observation on 02/18/2025 at 10:25 AM, RN 1 applied gloves before drawing Venofer into a syringe. RN 1 failed to perform hand hygiene before applying gloves. 6. During an observation on 02/18/2025 at 11:15 AM, PCT 7 collected Heparin from the medication drawer, drew up medication into a syringe, took medication to station #6, donned gloves, and administered intravenous medication without hand hygiene. PCT 7 failed to perform hand hygiene before preparing medication and before gloving to administer medication. 7. During an interview on 02/19/2025 at 1:20 PM, the Medical Director stated staff are to perform hand hygiene and follow the facility policy. The Medical Director stated that staff need more education on infection control.”

“IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS CFR(s): 494.30(a)(1)(i) If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets. This Standard is not met as evidenced by: 38262 Based on observation, record review, and interview, the facility staff failed to keep supplies in a designated clean area for 1 of 3 observation days. Findings include: A revised 04/2023 policy titled “Infection Control for Dialysis Facilities” indicated that staff are to disinfect non-disposable items after each patient use and before removal from the treatment station. During an observation on 02/18/2025 at 10:05 AM, the surveyor found one can of Cryodose (topical numbing spray for injections), with its lid off, sitting on the ledge wall next to station 4 treatment chair. During an interview on 02/18/2025 at 10:15 AM, PCT 2 stated she wasn’t sure why the can was on the ledge. She stated that the outside of the can should be disinfected and returned to a designated drawer after use.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 38262 Based on observation, record review, and interview, the facility failed to follow applicable infection control procedures when cleaning and disinfecting contaminated surfaces and equipment for 2 of 4 observations of cleaning and disinfecting the dialysis station. (Station 2 and Station 9) Findings include: 1. A revised 04/2023 policy titled “Infection Control for Dialysis Facilities” indicated that staff should clean and disinfect all surfaces of the dialysis station, including TV, blood pressure cuffs, and countertops. Staff must disinfect non-disposable items after each patient’s use before removal from the treatment/station area. 2. During an observation on 02/17/2025 at 1:30 PM, PCT 3 disinfected station 2’s treatment chair and then laid a blood pressure cuff onto the chair seat to disinfect. PCT 3 failed to disinfect the chair again after laying the blood pressure cuff down on the chair. During an interview on 02/17/2025 at 1:33 PM, PCT 3 stated she spreads the blood pressure cuff across the chair to disinfect then flips it over to disinfect the other side. 3. During an observation on 02/17/2025 at 1:33 PM, PCT 3 disinfected station 9’s treatment chair and then laid a blood pressure cuff onto the chair seat to disinfect. PCT 3 failed to disinfect the chair seat after laying the blood pressure cuff on the seat. PCT 3 failed to disinfect the TV and countertop directly behind the treatment chair. PCT 3 brought clean supplies to the dialysis station, sitting the supplies on the wet chair. PCT 3 failed to allow the chair to air dry before laying supplies on the chair. During an interview on 02/17/2025 at 2:11 PM, PCT 3 stated disinfecting the dialysis station consisted of wiping down the chair, TV, dialysis machine, wall box, and countertop. 4. During an interview on 02/17/2025 at 3:31 PM, RN 1 stated that staff should lay the blood pressure cuff on a surface to disinfect. RN 1 stated that the staff should disinfect the chair again if the staff laid the blood pressure cuff on top of the chair to clean. RN 1 stated that staff should let the chair air dry before lying new supplies down on the chair.”

“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: 48387 Based on observation, record review, and interview, the nursing staff failed to dispose of expired medication in 1 of 1 nursing medication drawers. Findings include: 1. A 10/2023 revised policy titled “MEDICATION POLICY” indicates staff should not use expired medication. Disposal of expired medication on the last day of the month if the medication has an expiration date of month and year. 2. During the Flash Tour on 02-17-2025 at 10:20 AM, The medication at the nurse’s station was found to have two expired medications: Clonidine Hydrochloride (used for high blood pressure) with an open date of 10/13/2023 and an expiration date of 12/2024 and Nitroglycerin (used for chest pain) with an expiration date of 09/2024. 3. During an interview on 02/17/2025 at 10:20 AM, RN 1 indicated that the nurses are responsible for looking through the medication drawer for expired medications. 4. During an interview on 02/17/2025 at 11:30 AM, the FA indicated the clinical coordinator, RN 1, is responsible for discarding expired medications.”

“ENVIRONMENT-SCHEMATIC DIAGRAMS/LABELS CFR(s): 494.40(a) 8 Environment: schematic diagrams/labels Water systems should include schematic diagrams that identify components, valves, sample ports, and flow direction. Additionally, piping should be labeled to indicate the contents of the pipe and direction of flow. If water system manufacturers have not done so, users should label major water system components in a manner that not only identifies a device but also describes its function, how performance is verified, and what actions to take in the event performance is not within an acceptable range. This Standard is not met as evidenced by: 48387 Based on observation, record review, and interview, the facility failed to have complete schematics of the water system and all pipes labeled with the direction of flow in 1 of 1 water treatment rooms. Findings include: 1. A 10/2021 revised policy titled “Water Treatment Systems Minimum Component Requirement” indicated that all water systems will include a posted schematic diagram that identifies components and flow of directions. All Piping will be labeled to indicate the contents in the pipe and the direction of flow 2. A document provided by FA of the schematic diagram failed to evidence the direction of water flow from the point of entrance into the building to where hot water and cold water combines and the water heater. 3. During an observation of the water treatment on 02/17/2025 at 9:55 AM, no arrows identified the direction of water flow on water pipes from the water pipe entering the building to where the cold and hot water combine. A schematics diagram located on the wall in the water treatment room did not identify the water heater and where water enters the building. 4. During an interview with Bio 1 and Bio 2 on 02/17/2025 at 1:30 PM, Bio 2 indicated that pipes should have arrows showing the flow direction from where water enters the building, continuing through the water system. Bio 1 indicated he had not realized there were no arrows on water lines before hot and cold water combined. 5. During an interview on 02/19/2025 at 11:40 AM, FA 1 provided a schematic diagram of the water treatment room. She indicated that Bio 2 indicated that the installers of the water treatment system had placed the schematics on the walk, but no other schematics were available.”

“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: 48387 Based on record review and interview, the nursing staff failed to verify the patient’s prescription and/or perform pretreatment assessment within one hour of starting treatment, affecting 7 of 7 records reviewed. (Patient #2, #3, #4, #5, #6, #10, #11) Findings include: 1. A 04/2024 revised policy titled “PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING, AND NURSING ASSESSMENT” indicated that licensed nurses should confirm patients’ prescriptions and perform a nursing assessment on patients within one hour of treatment initiation. 2. A review of Patient #2’s record failed to evidence timely assessments for the following dates: A Treatment Detail Report dated 01/27/2025 indicated Patient #2 started treatment at 2:48 PM. RN 1 documented a pretreatment assessment time of 4:16 PM. The RN failed to perform a pretreatment assessment within one hour of starting treatment. A Treatment Detail Report dated 02/14/2025 indicated Patient #2 started treatment at 2:57 PM. RN 1 documented a pretreatment assessment time of 4:28 PM. The RN failed to perform a pretreatment assessment within one hour of starting treatment. A Treatment Detail Report dated 02/17/2025 indicated Patient #2 started treatment at 3:01 PM. RN 1 documented a prescription verification time of 5:31 PM and a pretreatment assessment time of 5:34 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. During an interview on 02/17/2025 at 3:31 PM, RN 1 stated she should perform prescription verification and pretreatment assessments within one hour of initiating the treatment. 3. A review of Patient #3’s record failed to evidence timely assessments for the following dates: A Treatment Detail report dated 01/27/2025 indicated a treatment start time of 5:19 AM; RN 1 documented a pretreatment assessment time of 6:39 AM. The RN failed to perform a pretreatment assessment within one hour of starting treatment. 4. A review of Patient #4’s record failed to evidence timely assessments for the following dates: A Treatment Detail report dated 02/03/2025 indicated a treatment start time of 11:45 AM; RN 1 documented a prescription verification of 12:57 PM and a pretreatment assessment time of 1:52 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. A Treatment Detail report dated 02/05/2025 indicated a treatment start time of 2:25 PM; RN 1 documented a pretreatment assessment time of 4:39 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. A Treatment Detail report dated 02/10/2025 indicated a treatment start time of 2:59 PM; RN 1 documented a pretreatment assessment time of 4:42 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. A Treatment Detail report dated 02/14/2025 indicated a treatment start time of 2:32 PM; RN 1 documented a prescription verification of 3:54 PM and a pretreatment assessment time of 4:30 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. A Treatment Detail report dated 02/17/2025 indicated a treatment start time of 1:19 PM; RN 1 documented a prescription verification of 2:30 PM and a pretreatment assessment time of 2:41 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. 5. A review of Patient #5’s record failed to evidence timely assessments for the following dates: A Treatment Detail Report dated 02/05/2025 indicated Patient #5 started treatment at 2:29 PM. RN 1 documented a pretreatment assessment time of 4:29 PM. The RN failed to perform a pretreatment assessment within one hour of starting treatment. A Treatment Detail Report dated 02/07/2025 indicated Patient #5 started treatment at 2:29 PM. RN 2 documented a prescription verification time of 3:51 PM and a pretreatment assessment time of 3:52 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. A Treatment Detail Report dated 02/10/2025 indicated Patient #5 started treatment at 1:52 PM. RN 1 documented a prescription verification time of 3:12 PM and a pretreatment assessment time of 4:43 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. A Treatment Detail Report dated 02/12/2025 indicated Patient #5 started treatment at 2:31 PM. RN 1 documented a prescription verification time of 3:55 PM and a pretreatment assessment time of 4:32 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. 6. A review of Patient #6’s record failed to evidence timely assessments for the following dates: A Treatment Detail report dated 02/03/2025 indicated a treatment start time of 5:19 AM; RN 1 documented a prescription verification of 8:54 AM. The RN failed to perform a prescription verification within one hour of starting treatment. A Treatment Detail report dated 02/06/2025 indicated a treatment start time of 4:17 AM; RN 1 documented a prescription verification of 5:29 AM and a pretreatment assessment time of 5:30 AM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. 7. A review of Patient #10’s record failed to evidence timely assessments for the following dates: A Treatment Detail Report dated 02/04/2025 indicated Patient #10 started treatment at 10:46 AM. RN 1 documented a prescription verification time of 11:51 AM and a pretreatment assessment time of 12:32 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. A Treatment Detail Report dated 02/06/2025 indicated Patient #10 started treatment at 10:03 AM. RN 2 documented a prescription verification time of 11:24 AM and a pretreatment assessment time of 11:24 AM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. A Treatment Detail Report dated 02/15/2025 indicated Patient #10 started treatment at 10:19 AM. RN 1 documented a prescription verification time of 11:41 AM and a pretreatment assessment time of 12:13 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. 8. A review of Patient #11’s record failed to evidence timely assessments for the following dates: A Treatment Detail report dated 02/17/2025 indicated a treatment start time of 3:53 PM; RN 1 documented a pretreatment assessment time of 5:38 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. A Treatment Detail report dated 02/10/2025 indicated a treatment start time of 3:05 PM; RN 1 documented a pretreatment assessment time of 4:40 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. A Treatment Detail report dated 01/31/2025 indicated a treatment start time of 3:28 PM; RN 1 documented a pretreatment assessment time of 4:38 PM. The RN failed to perform a prescription verification and pretreatment assessment within one hour of starting treatment. V113 no hand hygiene with medications. 9. During an interview on 02/17/2025 at 2:40 PM, RN 1 indicated that all patients are to have a nurse’s assessment and that their prescriptions must be verified within the first hour after treatment starts. 10. During an interview on 02/18/2025 at 11:05 AM, PCT 1 indicated the nurse should check the prescription order within 30 minutes; at that time, the nurse will do the pre-assessment, too. 11. During an interview on 2/18/2025 at 12:55 PM, FA 2 indicated a nursing assessment, and the prescription verification should be done on all patients within the first hour after treatment begins.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 48387 Based on record review and interview, the facility failed to obtain the patient’s early termination of treatment documentation in 5 of 7 charts reviewed (Patient #3, #4, #6, #10, #11) Findings include: 1. A 04/2024 revised policy titled “Prescribed Treatment Time Not Met” indicates shortened/early termination of dialysis treatment, including all reasons prescribed dialysis time not met by 30 or more minutes. A completed Early Termination of Treatment against Medical Advice will be in the patient’s health record. 2. The clinical record for Patient #3 was reviewed and evidenced by the following: A Treatment Detail report dated 02/08/2025 indicated a prescribed treatment time of 4 hours 0 minutes and a treatment duration of 1 hour 02 minutes. The facility failed to complete 2 hours 58 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. During an interview with FA 1 and FA2 on 02/19/2025 at 9:26 AM, FA 2 confirmed the patient left early on 02/08/2025 3. The clinical record for Patient #4 was reviewed and evidenced by the following: A Treatment Detail report dated 01/31/2025 indicated a prescribed treatment time of 3 hours 30 minutes and a treatment duration of 2 hours 52 minutes. The facility failed to complete 38 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. 4. The clinical record for Patient #6 was reviewed and evidenced by the following: A Treatment Detail report dated 02/03/2025 indicated a prescribed treatment time of 3 hours 30 minutes and a treatment duration of 1 hour 10 minutes. The facility failed to complete 2 hours 20 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. A Treatment Detail report dated 02/18/2025 indicated a prescribed treatment time of 3 hours 30 minutes and a treatment duration of 1 hour 58 minutes. The facility failed to complete 1 hour 32 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. 5. The clinical record for Patient #10 was reviewed and evidenced by the following: A Treatment Detail report dated 02/13/2025 indicated a prescribed treatment time of 3 hours 30 minutes and a treatment duration of 2 hours 06 minutes. The facility failed to complete 1 hour 24 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. A Treatment Detail report dated 02/11/2025 indicated a prescribed treatment time of 3 hours 30 minutes and a treatment duration of 2 hours 10 minutes. The facility failed to complete 1 hour 20 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. A Treatment Detail report dated 02/08/2025 indicated a prescribed treatment time of 3 hours 30 minutes and a treatment duration of 2 hours 68 minutes. The facility failed to complete 62 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. A Treatment Detail report dated 01/31/2025 indicated a prescribed treatment time of 3 hours 30 minutes and a treatment duration of 2 hours 72 minutes. The facility failed to complete 58 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. 6. The clinical record for Patient #11 was reviewed and evidenced by the following: A Treatment Detail report dated 02/06/2025 indicated a prescribed treatment time of 3 hours 15 minutes and a treatment duration of 1 hour 57 minutes. The facility failed to complete 1 hour 18 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. A Treatment Detail report dated 02/14/2025 indicated a prescribed treatment time of 3 hours 15 minutes and a treatment duration of 1 hour 46 minutes. The facility failed to complete 1 hour 29 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. A Treatment Detail report dated 02/17/2025 indicated a prescribed treatment time of 3 hours 15 minutes and a treatment duration of 2 hours 21 minutes. The facility failed to complete 54 minutes of the prescribed treatment time. The agency failed to obtain an early termination of treatment documentation. 7. During an interview on 02/17/2025 at 3:30 PM, RN 1 indicated the facility has a lot of patients who leave before the end of treatment. All patients who leave early from treatment should sign an Against Medical Advise (AMA) document, and the nurse on shift must also sign it. RN 1 indicated the AMA document should be in the patient’s chart. 8. During an interview with FA 1 and FA 2 on 02/19/2025 at 9:26 AM, FA 2 reviewed the records of Patients # 4, #6, and #11; she indicated all patients who leave early are required to sign an AMA form. 9. During an interview on 02/19/2025 at 11:35 AM, FA 1 indicated she had provided all requested AMAs for selected patients, no other AMA’s were available.”