Fresenius Medical Care- Wichita East

“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: 43397 Based on document review, policy review, and interview, the facility failed to ensure that it had developed and maintained an emergency preparedness patient orientation program for 5 of 5 sampled patients (Patient 1, 2, 3, 4, and 5). The patient orientation program must be reflective of the facility’s risk assessment to determine if it is reflective of the risks and hazards identified within the facility’s program. The failure of the facility to ensure it has a patient emergency preparedness orientation program has the potential to leave patients ill-prepared for emergent situations and could negatively impact the health and well-being of the 51 patients who received dialysis treatments at the facility. Findings Include: Review of a policy titled, “Guidelines for Emergency Preparedness,” dated 07/03/23, showed, “The facility must develop a communication plan for all patients ...This plan includes the following ...Provide each patient with hard copies of the following information: Name, address and phone number of the dialysis facility; Name and phone number of their nephrologist; Any organizational emergency contact information such as the Patient Emergency Number; Materials that include information regarding emergencies, such as; Emergency Kit Checklist; Emergency Food and Water Supply; Emergency Meal Plan; Care Transitions Report ...Facility staff must educate patients on: Evacuation procedures; Emergency Disconnection Procedures; Emergency Meal Plan; Facility Contact Information; Shelter Information; Transportation Information; Emergency Preparedness ...” Review of the medical record for Patient 1, 2, 3, 4, and 5 failed to show documented evidence that patients received and attested to documentation on emergency preparedness materials and/or education for emergency preparedness and procedures. During an interview on 12/17/24 at 1:15 PM, Staff B, Director of Operations acknowledged that the facility failed to obtain documented attestation that patients had received the required Emergency Preparedness Orientation, materials, and/or education for emergency preparedness and procedures.”

“PR-INFORMED OF PT CARE POLICIES CFR(s): 494.70(a)(8) The patient has the right to- (8) Be informed of facility policies regarding patient care, including, but not limited to, isolation of patients; This Standard is not met as evidenced by: 43397 Based on medical record review, policy review, and interview, the facility failed to ensure 5 of 5 sampled patients (Patient 1,2,3,4 and 5) was informed of facility policy/procedure for discontinuation of dialysis and evacuation in case of emergency procedures. The failure of the facility to provide policy/procedures for disconnection and evacuation during an emergency has the potential to negatively impact the health and well-being of the 51 patients who received dialysis treatments at the facility. Findings Include: Review of a policy titled, “Guidelines for Emergency Preparedness,” dated 07/03/23, showed, “ ...Facility staff must educate patients on: Evacuation procedures; Emergency Disconnection Procedures; Emergency Meal Plan; Facility Contact Information; Shelter Information; Transportation Information; Emergency Preparedness ...” Review of the medical records for Patients 1, 2, 3, 4, and 5 failed to show documented evidence that any patient was provided with information of the facility’s emergency preparedness policies or procedures that could be verified by patient signature of receipt and understanding. Upon request, the facility was unable to provide documentation signed by the patient acknowledging receipt of same. During an interview on 12/17/24 at 10:00 AM, Staff A, Clinical Manager acknowledged that the patients’ medical records failed to contain documented evidence that the facility provided patients with facility policy/procedure on evacuation procedures, emergency disconnection, emergency meal plan, facility contact information, shelter information, transportation information, and emergency preparedness as required per facility policy.”

“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: 43397 Based on interview, record review, and facility policy review, the facility failed to follow the individualized dialysis prescription as prescribed by the medical provider for 2 of 5 sampled patients (Patient 1 and 3). Failure to follow the medical providers’ dialysis prescription had the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the 51 in-center patients who received dialysis treatments at the facility. Findings Include: Review of a policy titled, “Early Termination or Arriving Late for Treatment,” dated 11/07/22, showed, “Treatment duration and frequency is prescribed by a patient’s physician and the facility expects that all patients will adhere to their prescribed treatment time and schedule. Serious health related consequences may result from missed treatments or terminating treatments earlier than prescribed ...Patients requesting early termination of a treatment in an outpatient facility early will be referred to the supervising registered nurse (RN) ...The RN is responsible to notify the physician ...” Patient 1 Review of Patient 1’s medical record showed a prescribed treatment time of three hours and 30 minutes. Review of Patient 1’s treatment record on 11/16/24 showed the treatment was terminated one hour and 30 minutes early. Review of the medical record failed to show documented evidence that a physician was notified of the early termination of treatment. Review of Patient 1’s treatment record on 12/14/24 showed the treatment was terminated 34 minutes early. Review of the medical record failed to show documented evidence that a physician was notified of the early termination of treatment. Patient 3 Review of Patient 3’s medical record showed a prescribed treatment time of three hours and 45 minutes. Review of Patient 3’s treatment record on 12/10/24 showed the treatment was terminated 37 minutes early. Review of the medical record failed to show documented evidence that a physician was notified of the early termination of treatment. Review of Patient 3’s treatment record on 12/12/24 showed the treatment was terminated two hours and 45 minutes early. Review of the medical record failed to show documented evidence that a physician was notified of the early termination of treatment. Review of Patient 3’s treatment record on 12/14/24 showed the treatment was terminated one hour and 30 minutes early. Review of the medical record failed to show documented evidence that a physician was notified of the early termination of treatment. During an interview on 12/17/24 at 12:20 PM, Staff A, Clinical Manager acknowledged shortened treatments on Patient 1 and Patient 3. She acknowledged that documentation failed to show evidence that an RN notified a physician of the early termination of treatments.”