Flint Hills Dialysis LLC

“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: 40633 Based on review of the Emergency Preparedness Plan (EPP), agency documents, and an interview on 06/12/25, it was determined that the facility failed to develop and implement a system to track the location of on-duty staff and sheltered patients during an emergency, and to document the name and location of receiving facilities or other locations if relocation occurs. Findings Include: Review of the agency’s Emergency Preparedness Program (EPP), last reviewed by the facility in 2025, revealed that the policies and procedures did not include a system for tracking staff and patients during emergencies or documenting relocation details. During an interview on 06/12/25 between 10:00 AM and 2:00 PM, the Administrator confirmed that there were no policies or procedures in place for tracking the location of on-duty staff and sheltered patients or documenting relocations during emergencies.”

“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: 40633 Based on review of the Emergency Preparedness Plan (EPP), agency documents, and an interview on 06/12/25, it was determined that the facility failed to develop and implement policies and procedures for maintaining a system of medical documentation that preserves patient information, protects confidentiality, and secures the availability of records. Findings Include: Review of the agency’s Emergency Preparedness Program (EPP), last reviewed by the facility in 2025, failed to include policies or procedures for a system of medical documentation. During an interview on 06/12/25 between 10:00 AM and 2:00 PM, the Administrator confirmed that there were no policies or procedures addressing the requirements for preserving patient information, protecting confidentiality, and maintaining record availability.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(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:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 40633 Based on review of the Emergency Preparedness Plan (EPP), agency documents, and an interview on 06/12/25, it was determined the facility failed to develop and implement policies and procedures for the use of volunteers in an emergency and other emergency staffing strategies, including the integration of State and Federally designated health care professionals to address surge needs during an emergency, as required by §403.748(b)(6). The deficient practice includes a lack of documented procedures for utilizing volunteers effectively during emergencies. Findings Include: Review of the agency’s Emergency Preparedness Program (EPP), last reviewed by the facility in 2025, failed to include policies or procedures for the use of volunteers in emergencies and other emergency staffing strategies, including the integration of State and Federally designated health care professionals to address surge needs during an emergency. During an interview on 06/12/25 between 10:00 AM and 2:00 PM, the Administrator confirmed there were no policies or procedures for the use of volunteers and other emergency staffing strategies, including the integration of State and Federally designated health care professionals.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(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:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 40633 Based on review of the Emergency Preparedness Plan (EPP), agency documents, and interview on 06/12/25, it was determined the facility failed to develop and implement policies and procedures for the role of the facility under a waiver declared by the Secretary, as required by §403.748(b)(8). The deficient practice includes a lack of documented procedures for the provision of care and treatment at an alternate care site identified by emergency management officials during a declared waiver. Findings Include: Review of the agency’s Emergency Preparedness Program (EPP), last reviewed by the facility in 2025, failed to include policies or procedures for the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care at an alternate care site identified by emergency management officials. During an interview on 06/12/25 between 10:00 AM and 2:00 PM, the Administrator confirmed there were no policies or procedures for the role of the facility under a waiver declared by the Secretary for the provision of care at an alternate care site.”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 40633 Based on review of the Emergency Preparedness Plan (EPP), agency documents, and interview on 06/12/25, it was determined the facility failed to develop and maintain methods for sharing patient information and medical documentation with other health providers to maintain continuity of care, as required. Additionally, the facility did not have a means for releasing patient information during an evacuation or for providing information about the general condition and location of patients as permitted under 45 CFR 164.510. Findings Include: Review of the agency’s Emergency Preparedness Program (EPP), last reviewed by the facility in 2025, failed to include policies or procedures for sharing patient information and medical documentation with other health providers, releasing patient information during an evacuation, or providing information about the general condition and location of patients. During an interview on 06/12/25 between 10:00 AM and 2:00 PM, the Administrator confirmed there were no policies or procedures for methods to share patient information and medical documentation or for ensuring compliance with patient information release during an evacuation.”

“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: 40633 Based on review of the Emergency Preparedness Plan (EPP), agency documents, and interview on 06/12/25, it was determined the facility failed to conduct the required exercises to test the emergency plan at least annually. Specifically, the facility did not perform the necessary full-scale or tabletop exercise within the past year, and there was no documentation or analysis of an exercise or actual emergency event during that period, as required. Findings Include: Review of the agency’s Emergency Preparedness Program (EPP), last reviewed by the facility in 2025, failed to include evidence of conducting and documenting a required emergency preparedness exercise within the last year. While documentation of exercises from previous years was available, no full-scale or tabletop exercise had been conducted during the most recent 12-month period. During an interview on 06/12/25 between 10:00 AM and 2:00 PM, the Administrator confirmed that no emergency preparedness exercises were conducted in the past year and that there were no documented policies or procedures ensuring annual testing and analysis of the emergency plan.”

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 50529 Based on record review and interview, the facility failed to develop a comprehensive infection control program to prevent transmission of infections among chronic hemodialysis patients that includes surveillance and monitoring for infection control in a dialysis facility. The facility failed perform regular monitoring and use of audits to ensure compliance with infection control practices. The failure to monitor adherence to infection control policies and procedures provides a risk of infection that could negatively impact the health and well-being of any patient who receives care at this facility. Findings Include: A facility policy specifically covering infection control oversight and documentation was not available per facility administrative staff. There is no policy in place to ensure that infection control policies and procedures are being monitored and implemented. During an interview on 06/12/25 at 2:24 PM, Staff B, Administrator, stated that there is no facility policy for auditing infection control adherence practices among staff or a frequency for such monitoring. A document request list was provided to the facility upon entrance and a request made for monthly infection control audits. Repeated requests for monthly infection control audits were made each day of survey but the facility failed to provide requested documents. During an interview on 06/17/25 at 8:00 AM, Staff B, Administrator, and Staff C, Clinical Manager stated that the facility does not have any infection control audits for 2025. During an interview on 06/17/25 at 8:58 AM, Staff D, Medical Director (MD), confirmed that there is no policy regarding infection control audits and that there have been no audits documented in 2025. MD reports that this is disappointing, but will be used as an opportunity for growth, re-education, and major improvements.”

“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: 50529 Based on observation, policy review, and interview, the facility failed to ensure patients washed their hands or performed hand hygiene after holding their dialysis (a medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) access site (a surgically created entry point into the bloodstream) after treatment. This deficient practice provided a mode of contamination with the potential spread of infectious pathogens (organisms that may cause disease or infection) which could negatively impact the health and well-being of any patient that receives treatment at this facility. Findings Include: Review of a policy titled, “Infection Control: Patients,” reviewed 01/2010, stated, “ ...Patients desiring to hold pressure on access needle sites are required to wear a glove on the hand applying pressure. Hand washing should be encouraged before and after holding pressure...” During observation on 06/11/25 at 10:04 AM at station #12, a patient went to scale after treatment while still wearing the glove from holding pressure on dialysis access to achieve hemostasis (the process of achieving blood clotting and stopping bleeding). Staff failed to offer hand sanitizer or reminder to wash hands prior to exiting the facility. During observation on 06/11/25 at 10:19 AM, Patient 5 requested to wear his dirty glove when leaving the treatment floor and clinic. Patient 5 was not offered hand sanitizer or reminded to wash his/her hands prior to exiting the facility. During observation on 06/11/25 at 10:51 AM, at station 10, Staff J, Patient Care Technician (PCT), failed to offer the patient hand sanitizer or encourage hand washing after holding sites and before leaving the clinic. During observation on 06/12/25 at 10:15 AM, at station #6, staff obtained pre-treatment vitals without encouraging or reminding the patient to wash access prior to initiation of dialysis treatment. During observation on 06/12/25 at 10:21 AM, at station #10, staff failed to offer the patient hand sanitizer or encourage hand washing after holding sites and prior to leaving the clinic. During observation on 06/12/25 at 11:19 AM, at station #10, Staff K, Certified Hemodialysis Technician (CCHT) failed to encourage a patient to wash his/her access prior to initiation of dialysis treatment. During an interview on 06/12/25 at 11:50 AM, Staff C, Interim Clinical Manager, stated that the facility’s policy for hand hygiene is to be followed to reduce the opportunity for cross contamination. The expectation was for patients to wash their hands and access sites prior to initiation of dialysis and to wash hands or use sanitizer post treatment after holding access sites as evidenced by signage in the treatment area. During an interview on 06/17/25 at 8:58 AM, Staff D, Medical Director, confirmed that the facility’s policy for hand hygiene was expected to be followed by staff to reduce the opportunity for the spread of infection. During an interview on 06/17/25 at 10:12 AM, Patient 11, stated that he/she was not aware of the need to wash access his/her access prior to going to assigned station. Patient 11 also stated that he/she did not recall education regarding hand hygiene pre and post treatment. Patient 11 did not know he/she was to wash hands or receive hand sanitizer after holding sites.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 50529 Based on document review, interview, manufacturer’s directions for use (DFU) review, and facility policy review, the facility failed to follow the preventative maintenance recommendations per manufacturer’s DFU for the Fresenius 2008T dialysis machine. Failure to follow manufacturer’s DFU had the potential to result in equipment malfunction and/or failure and negatively impact the safety and well-being of any patients who utilized the Fresenius 2008T machines for dialysis treatments. Findings Include: Review of a policy titled, “HD Machine Operational Assessment and Preventative Maintenance,” reviewed 01/2020, stated, “ ...Preventative maintenance on all HD [hemodialysis] machines will be yearly at minimum ...The preventative maintenance [PM] program is to be completed a minimum of every 4000 hours of machine operation or at least one time a year (whichever come first) ...If preventative maintenance is due on a machine that has not yet reached the 4000 hour limit and a year has lapsed since its last PM, then maintenance can be completed at any time during the calendar month it is due.” Review of the manufacturer’s DFU titled, “Fresenius 2008T Hemodialysis System Preventative Maintenance Procedures,” showed, “ ...Preventative Maintenance for the Fresenius 2008T Hemodialysis System ...Maintenance is performed in only two intervals: six (6) months, and annually or after 4000 hours of operation. The maintenance procedures have been devised to require a minimum of time while ensuring that the machine is maintained in optimum operating condition ...” Observation of the hemodialysis equipment preventative maintenance logs on 06/11/25 at 8:20 AM, revealed machine T12’s last semi-annual preventative maintenance was dated 10/2024, which made the machine 2 months overdue per manufacturer’s DFU. During an interview on 06/11/25 at 8:38 AM, Staff F, BioMed Technician, stated that the annual PM on machine T12 PM had not been completed. He stated that although the DFU is to complete 6-month PMs, the 6-month PMs aren’t necessary because it only consisted of exchanging O-rings and the cleaning and/or replacement of mesh filters. During an interview on 06/12/25 at 11:50 AM, Staff C, Interim Clinical Manager, stated that the expectation for preventative maintenance is to follow manufacturer’s DFU, which is every 6 months and annually. During an interview on 06/17/25 at 8:17 AM, Staff B, Administrator in training, stated that it is the facility’s expectation to have manufacturers’ DFU followed for the maintenance of equipment. During an interview on 06/17/25 at 8:58 AM, Staff D, Medical Director, confirmed that BioMed staff were expected to follow the manufacturer’s DFU.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 50529 Based on record review, policy review, and interview, the facility failed to ensure staff provided assessment and/or monitoring of patients during treatment for 5 (Patient 3, 4, 5, 6, and 7) out of 6 sampled patients. This deficient practice poses a risk for a change in patient condition to go unrecognized and unaddressed that could negatively impact the health and well-being of any patient who receives treatments at this facility. Findings Include: Review of a policy titled, “Standing Orders,” revised 04/2021, stated, “ ...Interdialytic Treatment and Complication ...Blood pressure and machine checks every 30 minutes and PRN [as needed] ... Documentation on BP [blood pressure] checks will include patient activity, notification of RN [Registered Nurse] if necessary ...Document all events in proper sequence as it occurred in the patient’s EMR [electronic medical record] ...” A facility policy specifically covering patient monitoring and/or treatment flowsheet documentation was not available per facility administrative staff. There is no policy in place to ensure that pre and post treatment vitals are completed, and vitals are obtained during intra-treatment to ensure patient safety and monitoring while patients are undergoing dialysis treatment. During an interview on 06/12/25 at 2:24 PM, Staff C, Interim Clinical Manager, stated that there were no policies that covered patient monitoring and/or treatment flowsheet documentation. All available facility policies were provided to surveyor without any evidence of policies that supported the above-mentioned topics. During an interview on 06/17/25 at 2:06 PM, Staff B, Administrator, confirmed there were not policies to address patient monitoring and/or flowsheet documentation. Patient 3 Patient 3’s treatment flowsheet, dated 05/21/25, revealed that patient monitoring was not documented for 59 minutes, from 7:34 AM until 8:35 AM. Patient 3’s treatment flowsheet, dated 05/23/25, revealed that patient monitoring was not documented for 60 minutes, from 6:04 AM until 7:04 AM. Patient 3’s treatment flowsheet, dated 05/28/25, revealed that patient monitoring was not documented for 60 minutes, from 8:05 AM until 9:05AM. Patient 4 Patient 4’s treatment flowsheet, dated 05/19/25, revealed that Patient 4 arrived for treatment and was discharged ambulatory with the assistance of a walker, but also revealed that staff failed to obtain a pre-treatment or post treatment standing blood pressure. Patient 4’s treatment flowsheet, dated 05/21/25, revealed that Patient 4 arrived at treatment and was discharged ambulatory with the assistance of a walker, but also revealed that staff failed to obtain a pre-treatment or post treatment standing blood pressure. Patient 4’s treatment flowsheet, dated 05/26/25, revealed that patient monitoring was not documented for 60 minutes, from 12:01 PM until 1:01 PM. Patient 4’s treatment flowsheet, dated 05/28/25, revealed that patient monitoring was not documented for 90 minutes, from 11:00 AM until 12:30 PM and for 61 minutes, from 1:00 PM until 2:01 PM. Patient 4’s treatment flowsheet, dated 06/02/25, revealed that Patient 4 arrived at treatment and was discharged ambulatory with the assistance of a walker, but also revealed that staff failed to obtain a pre-treatment or post treatment standing blood pressure. Patient 4’s treatment flowsheet, dated 06/04/25, revealed that Patient 4 arrived at treatment and was discharged ambulatory with the assistance of a walker, but also revealed that staff failed to obtain a pre-treatment or post treatment standing blood pressure. Patient 4’s treatment flowsheet, dated 06/06/25, revealed that patient monitoring was not documented for 41 minutes, from 10:27 AM until 11:11 AM and for 60 minutes, from 12:30 PM until 1:30 PM. Patient 4’s treatment flowsheet, dated 06/06/25, revealed that Patient 4 arrived at treatment and was discharged ambulatory with the assistance of a walker, but also revealed that staff failed to obtain a pre-treatment or post treatment standing blood pressure. Patient 4’s treatment flowsheet, dated 06/09/25, revealed that Patient 4 arrived at treatment ambulatory with the assistance of a walker, but also revealed that staff failed to obtain a pre-treatment or post treatment standing blood pressure. Patient 5 Patient 5’s treatment flowsheet, dated 05/19/25, revealed that Patient 5 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain a post treatment standing blood pressure. Patient 5’s treatment flowsheet, dated 05/21/25, revealed that Patient 5 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain post treatment standing blood pressure. Patient 5’s treatment flowsheet, dated 05/23/25, revealed that Patient 5 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain a pre-treatment or post treatment standing blood pressure. Patient 5’s treatment flowsheet, dated 05/26/25, revealed that Patient 5 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain a pre-treatment or post treatment standing blood pressure. Patient 5’s treatment flowsheet, dated 05/28/25, revealed that Patient 5 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain a pre-treatment or post treatment standing blood pressure. Patient 5’s treatment flowsheet, dated 05/30/25, revealed that Patient 5 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain a post treatment standing blood pressure. Patient 5’s treatment flowsheet, dated 06/02/25, revealed that Patient 5 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain a pre-treatment standing blood pressure. Patient 5’s treatment flowsheet, dated 06/06/25, revealed that Patient 5 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain a post treatment standing blood pressure. Patient 5’s treatment flowsheet, dated 06/09/25, revealed that Patient 5 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain a pre-treatment or post treatment standing blood pressure. Patient 6 Patient 6’s treatment flowsheet, dated 05/21/25, revealed that Patient 6 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain a post treatment standing blood pressure. Patient 6’s treatment flowsheet, dated 05/23/25, revealed that Patient 6 arrived at treatment and was discharged ambulatory, but also revealed that staff failed to obtain a post treatment standing blood pressure. Patient 6’s treatment flowsheet, dated 05/23/25, revealed that patient monitoring was not documented for 60 minutes, from 8:31 AM until 9:31 AM and for 50 minutes, from 9:31 AM until 10:21 AM. Patient 7 Patient 7’s treatment flowsheet, dated 05/19/25, revealed that Patient 7 arrived at treatment and was discharged ambulatory with the assistance of a cane, but also revealed that staff failed to obtain a pretreatment standing blood pressure. Patient 7’s treatment flowsheet, dated 05/23/25, revealed that Patient 7 arrived at treatment and was discharged ambulatory with the assistance of a cane, but also revealed that staff failed to obtain a pretreatment and post treatment standing blood pressure. Patient 7’s treatment flowsheet, dated 05/26/25, revealed that Patient 7 arrived at treatment and was discharged ambulatory with the assistance of a cane, but also revealed that staff failed to obtain a pretreatment and post treatment standing blood pressure. Patient 7’s treatment flowsheet, dated 05/30/25, revealed that Patient 7 arrived at treatment and was discharged ambulatory with the assistance of a cane, but also revealed that staff failed to obtain a post treatment standing blood pressure. Patient 7’s treatment flowsheet, dated 06/02/25, revealed that Patient 7 arrived at treatment and was discharged ambulatory with the assistance of a cane, but also revealed that staff failed to obtain a post treatment standing blood pressure. Patient 7’s treatment flowsheet, dated 06/06/25, revealed that Patient 7 arrived at treatment and was discharged ambulatory with the assistance of a cane, but also revealed that staff failed to obtain a pretreatment standing blood pressure. During an interview on 06/12/25 at 7:36 AM, Staff K, Certified Clinical Hemodialysis Technician (CCHT), stated that staff is expected to obtain pre and post treatment standing blood pressures if the patient walks in. The only time they are not required to is if the patient refuses. During treatment, vital signs are to be input every 30 minutes unless ordered otherwise. During an interview on 06/12/25 at 11:50AM, Staff C, Interim Clinical Manager, stated pre and post standing blood pressures are required if the patient is walking out of the clinic. It is the expectation that staff obtain both pre and post treatment standing blood pressures in addition to every 30 minutes while on treatment to ensure patients safety while ambulating from the clinic. During an interview on 06/17/25 at 8:58 AM, Staff D, Medical Director, stated staff should be obtaining all necessary data for pre, intra, and post treatment assessments for best patient care and safety.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 50529 Based on policy review, record review, and interview, the facility failed to follow the individualized dialysis prescription as prescribed by the medical provider for 4 of 6 (Patient 4, 5, 6, and 7) sampled patients. This deficient practice has the potential to negatively impact the effectiveness of dialysis treatment for any patient who receives treatment at this facility. Findings Include: Review of a policy titled, “Standing Orders,” revised 04/2021, stated, “ ...The blood flow rate (BFR) may be adjusted (individualized) up or down based on the patient’s arterial/venous pressures ...Maximum BFR is 550mL/min. Goal is to provide optimum blood cleansing safely ...The dialysate flow rate (DFR) will be set at 1.5x the BFR (autoflow) unless otherwise prescribed by provider. The Fresenius 2008T will adjust DFR up to the nearest 100th ...Documentation on BP [blood pressure] checks will include patient activity, notification of RN if necessary ...Document all events in proper sequence as it occurred in the patient’s EMR [electronic medical record] ...” Patient 4 Patient 4’s treatment sheet, dated 05/19/25, revealed a prescribed blood flow rate (BFR) of 500mL/min. Patient 4’s BFR was documented as 450mL/min for the entirety of the treatment without any documented rationale why prescribed BFR was not achieved. Patient 4’s treatment sheet, dated 05/21/25, revealed a prescribed BFR of 500mL/min. Patient 4’s BFR was documented as 350mL/min for the entirety of the treatment without any documented rationale why prescribed BFR was not achieved. Patient 4’s treatment sheet, dated 05/26/25, revealed a prescribed BFR of 500mL/min. Patient 4’s BFR was documented as 400mL/min for the entirety of the treatment without any documented rationale why prescribed BFR was not achieved. Patient 4’s treatment sheet, dated 05/28/25, revealed a prescribed BFR of 500mL/min. Patient 4’s BFR was documented as 450mL/min for the entirety of the treatment without any documented rationale why prescribed BFR was not achieved. Patient 4’s treatment sheet, dated 06/02/25, revealed a prescribed BFR of 500mL/min. Patient 4’s BFR was documented as 480mL/min for 31 minutes from 1:00 PM until 1:31 PM, documented as 425mL/min for the remainder of the treatment without any documented rationale why prescribed BFR was not achieved. Patient 4’s treatment sheet, dated 06/06/25, revealed a prescribed BFR of 500mL/min. Patient 4’s BFR was documented as 400mL/min for 153 minutes from 11:45 AM until 2:18 PM without any documented rationale why prescribed BFR was not achieved. Patient 5 Patient 5’s treatment sheet, dated 05/19/25, revealed a prescribed BFR of 450mL/min. Patient 5’s BFR was documented as 480mL/min for 150 minutes of the prescribed treatment time without any documented rationale why prescribed BFR was not achieved. Patient 5’s treatment sheet, dated 05/21/25, revealed a prescribed BFR of 450mL/min. Patient 5’s BFR was documented as 400mL/min at 6:32 AM and 550mL/min at 8:47 AM without any documented rationale why prescribed BFR was not achieved. Patient 5’s treatment sheet, dated 05/28/25, revealed a prescribed BFR of 500mL/min. Patient 5’s BFR was documented as 420mL/min and 400mL/min without any documented rationale why prescribed BFR was not achieved. Patient 5’s treatment sheet, dated 05/30/25, revealed a prescribed BFR of 500mL/min. Patient 5’s BFR was documented as 400mL/min for 116 minutes from 8:02 AM until 9:58 AM without any documented rationale why prescribed BFR was not achieved. Patient 6 Patient 6’s treatment sheet, dated 05/19/25, revealed a prescribed BFR of 500mL/min. Patient 6’s BFR was documented as 475mL/min for 59 minutes from 9:09 AM until 10:08 AM without any documented rationale why prescribed BFR was not achieved. Patient 6’s treatment sheet, dated 05/23/25, revealed a prescribed BFR of 500mL/min. Patient 6’s BFR was documented as 490mL/min for the entire treatment without any documented rationale why prescribed BFR was not achieved. Patient 7 Patient 7’s treatment sheet, dated 05/23/25, revealed a prescribed BFR of 450mL/min. Patient 7’s BFR was documented as 350mL/min for 90 minutes from 5:01 PM until 6:31 PM without any documented rationale why prescribed BFR was not achieved. Patient 7’s treatment sheet, dated 05/26/25, revealed a prescribed BFR of 450mL/min. Patient 7’s BFR was documented as 350mL/min for the entire treatment without any documented rationale why prescribed BFR was not achieved. Patient 7’s treatment sheet, dated 06/02/25, revealed a prescribed BFR of 450mL/min. Patient 7’s BFR was documented as 400ml/min for 34 minutes from 5:00 PM until 5:34 PM and 325mL/min for 60 minutes from 5:34 PM until 6:34 PM without any documented rationale why prescribed BFR was not achieved.”

“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: 50529 Based on policy review, record review, and interview, the facility failed to ensure treatment records reflected patient attaining target weight (weight prescribed or ordered by nephrologist) at the end of each treatment, documented acknowledgement of why target weight was not attained, and type of intervention provided to address fluid status for 3 of 6 sampled patients (Patient 1, 3, & 7). This deficient practice places any patient receiving services at risk of poor clinical outcomes, injury, harm, and/or increased mortality. Findings Include: Review of a policy titled, “Standing Orders,” revised 04/2021, stated, “ ...Adjusting Dry Weight: RN may increase or decrease dry weight by no more than 0.5kg per treatment after assessing for signs and symptoms of fluid volume status without doctor notification and documentation of assessment ...Crit-line will be utilized on all new patients to establish EDW, after hospitalization, per physician order and monthly as scheduled ...” A facility policy specifically addressing the assessment and monitoring of patient target weight to avoid complications resulting from fluid overload or hypovolemia (not enough fluid in the vascular system, was not available per facility administrative staff. There is no policy in place to ensure that patients are attaining their physician prescribed target weights, physician notification of not attaining target weight, and/or interventions put in place to achieve target weight. Patient 1 Patient 1’s treatment flowsheet dated 06/12/25, revealed a prescribed target weight of 74 kg. Patient’s pre-weight was 80.4 kg, and post-weight was 76.6 kg. Patient 1 was discharged 2.6 kg over his/her target weight. There is no evidenced documentation of adjustments to target weight after assessment, physician notification or Crit-line utilization. Patient 1’s treatment flowsheet dated 06/14/25, revealed a prescribed target weight of 74 kg. Patient 1’s pre-weight was 81.5 kg, and post-weight was 78.4 kg. Patient 1 was discharged 4.4 kg over his/her target weight. There is no evidenced documentation of adjustments to target weight after assessment, physician notification or Crit-line utilization. Patient 3 Patient 3’s treatment flowsheet dated 06/09/25, revealed a prescribed target weight of 59.2 kg. Patient 3’s pre-weight was 62.2 kg, and post-weight was 60.4 kg. Patient 3 was discharged 1.2kg over his/her target weight. There is no evidenced documentation of adjustments to target weight after assessment, physician notification or Crit-line utilization. Patient 7 Patient 7’s treatment flowsheet dated 05/30/25, revealed a prescribed target weight of 64.5 kg. Patient 7’s pre-weight was 68.7 kg, and post-weight was 66.7 kg. Patient 7 was discharged 2.2 kg over his/her target weight. There is no evidenced documentation of adjustments to target weight after assessment, physician notification or Crit-line utilization. Patient 7’s treatment flowsheet dated 06/02/25, revealed a prescribed target weight of 64.5 kg. Patient 7’s pre-weight was 67.9 kg, and post-weight was 66.3 kg. Patient 7 was discharged 1.6 kg over his/her target weight. There is no evidenced documentation of adjustments to target weight after assessment, physician notification or Crit-line utilization. Patient 7’s treatment flowsheet dated 06/06/25, revealed a prescribed target weight of 64.5 kg. Patient 7’s pre-weight was 68.6 kg, and post-weight was 65.7 kg. Patient 7 was discharged 1.2 kg over his/her target weight. There is no evidenced documentation of adjustments to target weight after assessment, physician notification or Crit-line utilization. Patient 7’s treatment flowsheet dated 06/09/25, revealed a prescribed target weight of 64.5 kg. Patient 7’s pre-weight was 69.2 kg, and post-weight was 67.2 kg. Patient 7 was discharged 2.7 kg over his/her target weight. There is no evidenced documentation of adjustments to target weight after assessment, physician notification or Crit-line utilization. During an interview on 06/12/25 at 7:36 AM, Staff K, Certified Clinical Hemodialysis Technician (CCHT), stated that techs don’t typically notify the nurse of a patient leaving clinic over their target weight unless requested by patient or seems to have other issues. During an interview on 06/12/25 at 11:50 AM, Staff C, Interim Clinical Manager, stated that there is not a policy in place regarding patients not attaining their prescribed target weight, but there should not be any concerns because patients are seen by a provider at least once a week. During an interview on 06/17/25 at 8:58 AM, Staff D, Medical Director (MD), confirms that there is no written policy regarding patients attaining prescribed target weight and that nurses do not need to notify the MD due to nurse practitioners rounding weekly. Weights and other issues are addressed with the nurse practitioner and they pay close attention to why there are changes in weight with each patient individually.”