Davita Brookline Dialysis

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 10249 Based on observation, staff interview, clinical record review, and policy review, the facility was found not to be in compliance with the Condition of Patient Plan of Care for 7 of 11 applicable patients (#2, #3, #4, #5, #6, #9 and #12), out of a total sample of 13 patients. Findings include: 1. The facility failed to ensure that the Interdisciplinary Team (IDT) developed and implemented a written, individualized plan of care (POC) for each patient that included services necessary to address the patient’s needs and changes in the patient’s condition, measurable and expected outcomes and estimated timetables to achieve these outcomes for 3 patients (#2, #4, and #6) of 10 applicable patients, out of a total sample of 13. Please refer to V542. 2. The facility failed to ensure the dialysis treatment was delivered as prescribed, relative to Blood Flow Rate (BFR) (measured in milliliters per minute (ml/min) in which the patient’s blood is pushed through dialyzer and back to the body) during the process of dialysis, for 1 of 4 prescriptions (Patient #12) reconciled, and 1 of 10 applicable patients (Patient #3) reviewed, out of a total sample of 13 patients. Please refer to V544. 3. The facility failed to ensure staff (Certified Clinical Hemodialysis Technician [CCHT] #6) evaluated a vascular access to ensure functionality by the way of listening for a bruit the length of the access (swooshing sound heard with a stethoscope place over the access) for 1 of 2 applicable patients(#12) with arteriovenous fistula/graft (AVF/G) access sites, out of a total sample of 13 patients. Please refer to V551. 4. The facility failed to ensure the care plan for 1 of 10 applicable patients (#9), out of a total sample of 13 patients, was signed by 1.) the patient or the patient’s designees, or if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided, to ensure the patient involvement with his/her plan of care, 2.) the physician. Please refer to V556. 5. The facility failed to ensure an annual care plan was implemented within 15 days of completion of the patient’s comprehensive assessment, for 2 of 10 applicable patients (#5 and #9), from a total sample of 13 patients. Please refer to V558.”

“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: 44223 Based on observation, Centers for Disease Control and Prevention (CDC) guidance and interview, the facility failed to consistently provide a sanitary environment to minimize the transmission of infectious agents within the patient treatment area. Findings Include: The CDC defines a “sanitary environment” as an environment that meets “Standard Precautions” for an in-patient hospital setting plus the more stringent precautions which are recommended for hemodialysis units because of the increased potential for contamination with blood and pathogenic microorganisms. On 11/15/23 at 9:15 A.M., during the flash tour of the dialysis treatment area, the surveyor observed patients receiving dialysis treatment in 13 of 25 hemodialysis treatment stations. Between patients, when the dialysis chair was vacant, the surveyor observed the following: *At station 2, 4, 5, 6, 10, 11, 12, 15, 18, 20, and 21, the hemodialysis chair had a large rip/tear in the material on the seat. There was tape covering the ripped/torn areas, preventing staff from being able to adequately disinfect the area. *At station 24, the hemodialysis chair had a rip/tear in the material on the back of the chair where the patient’s back would be, preventing the staff from being able to adequately disinfect the area. *At station 25, the hemodialysis chair had a rip/tear in the material on both arms rests, preventing staff from being able to adequately disinfect the area. During further observation of the treatment area, the surveyor observed 4 of 25 dialysis machines, located at stations 18, 19, 22, and 24, had cracked or chipped areas at the base of the dialysis machines, preventing staff from adequately disinfecting these areas. During an interview on 11/15/23 at 10:10 A.M., Registered Nurse #8 said he really can’t be sure if the area is getting thoroughly cleaned, he does the best he can.”

“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: 44223 Based on observation, interview, and policy review, the facility failed to 1.) ensure 2 of 2 staff members (Certified Clinical Hemodialysis Technician [CCHT] #4, and Registered Nurse [RN] #3) observed, adequately clean and disinfect contaminated surfaces, medical devices, and equipment within the dialysis station, increasing the risk for cross contamination of blood borne pathogens; 2.) ensure the hemodialysis chair tray tables were free from tape debris to allow for proper disinfection to reduce the spread of infection; and 3.) ensure blood pressure (BP) cuffs were free from lint and debris to allow for proper disinfection to reduce the risk of the spread of infection. Findings include: Review of the facility policy titled, Infection Control For Dialysis Facilities, revised April 2023, included the following: * At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaces to disinfect include, but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel, top, front and sides of dialysis machine, touch screens, countertops). * The Wall box, drain and water supply lines are considered part of the dialysis delivery system. 1 a. The facility failed to ensure CCHT #4 adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, increasing the risk for cross contamination of blood borne pathogens. On 11/15/23 at 10:00 A.M., CCHT #4 was observed cleaning the dialysis machine/treatment area at station 20, for the next patient. She was observed to clean and disinfect the treatment area with 1:100 bleach soaked pads. CCHT #4 failed to disinfect the outside of the hemodialysis chair, under the tray tables on both sides of the chair, prior to folding down the tray tables. She also failed to clean the crevices of the tray tables after folding down the tray tables. CCHT #4 was observed to disinfect a removable arm rest, then place it on a dirty countertop that had not been disinfected. CCHT #4 also failed to disinfect the wall box. During an interview on 11/15/23 at 10:15 A.M., CCHT #4 said she should of cleaned those areas, but thought that she had. CCHT #4 said she was nervous and must of forgot. 1 b. The facility failed to ensure RN #3 adequately cleaned and disinfected contaminated surfaces, medical devices, and equipment within the dialysis station, increasing the risk for cross contamination of blood borne pathogens. On 11/15/23 at 9:30 A.M., during observation of the treatment area, the surveyor observed RN #3 disinfect the dialysis machine at station 2, for the next patient. She was observed disinfecting the dialysis machine using 1:100 bleached soaked pads. RN #3 failed to disinfect the top hangers of the intravenous (IV) pole, the right side of the dialysis machine, and underneath the tray table attached to each side of the dialysis chair. During an interview on 11/15/23 at 9:43 A.M., RN #3 said she did not realize she did not disinfect the top of the IV pole, the right side of the dialysis machine, and underneath the tray table of each side of the dialysis chair. 2. The facility failed to ensure the hemodialysis chair tray tables were free from tape debris to allow for proper disinfection to reduce the risk of spread of infection. On 11/15/23 at 9:15 A.M., during an observation of the treatment area, the surveyor observed the residue of previously used paper tape on the hemodialysis chair tray tables at stations 18, 19, 20, 21, 22, 23, 24, and 25, making it difficult to disinfect the tray tables. During an interview on 11/15/23 at 10:10 A.M., RN #8 said he really can’t be sure the area is thoroughly clean, he just does the best he can in those areas. 3 a. The facility failed to ensure blood pressure cuffs were free from lint and debris, to allow for proper disinfection to reduce the risk of spread of infection. On 11/15/23 at 9:15 A.M., during an observation of the treatment area, the surveyor observed blood pressure cuffs at 6 of 8 stations observed, (station 19, 20, 21, 22, 23, and 25) were laden with lint embedded in the Velcro portion of the blood pressure cuff, making it difficult to adequately disinfect between patients. During an interview on 11/15/23 at 10:10 A.M., RN #8 said he really can’t be sure the area is thoroughly clean, he just does the best he can in those areas. 38141 3 b. On 11/15/23 at 9:00 A.M., during an observation of the treatment area, the surveyor observed the blood pressure cuffs at 5 of 8 stations observed, (station 2, 6, 7, 10, and 16) were laden with lint embedded in the Velcro portion of the blood pressure cuff making it difficult to adequately disinfect between patients. During an interview on 11/15/23 at 9:43 A.M., RN #3 said that some of the blood pressure cuffs at the treatment stations were laden with lint embedded in the Velcro portions. She said that she does her best to clean those areas, but was not sure if it is thoroughly clean.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 38141 Based on observation, interview, and policy review, the facility failed to ensure that 1.) 1 of 2 staff members (Patient Care Technician [PCT] #1) observed, failed to provide adequate infection control measures during termination of treatment with a Central Venous Catheter (CVC); and 2.) 1 of 2 staff (Certified Clinical Hemodialysis Technician [CCHT] #3) observed, failed to adhere to appropriate infection control practices to prevent intravascular infections during a CVC exit site dressing change. Findings include: Review of the facility policy, Central Venous Catheter with Clear guard HD Antimicrobial End Caps Procedure, revised October 2023, included the following: * Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason. * 70% alcohol CVC Hubs 15 second scrub. * Remove syringes and disinfect the CVC hubs with new alcohol prep pad for each CVC hub. Scrub the sides, threads and end of hub thoroughly with friction for 15 seconds, making sure to remove any residue, for example blood. Hold the catheter until the antiseptic has dried. 1. For Patient #13, PCT #1 failed to provide adequate infection control measures during termination of treatment with a CVC. On 11/15/23 at 11:15 A.M., the surveyor observed PCT #1 terminate treatment for Patient #13 in station 16. She clamped the arterial limb and disconnected the line. She disinfected the hub with an alcohol swab for 8-10 seconds, and then attached a 10 milliliter (ml) syringe of normal saline. She did the same for the venous line. PCT #1 then removed the syringe from the arterial port and disinfected it with an alcohol pad for 8-10 seconds, before putting the cap in place. She did the same for the venous line. During an interview on 11/15/23 at 11:25 A.M., PCT #1 said she should have disinfected the hubs for 15 seconds. 2. Review of the facility policy titled, Central Venous Catheter with Clearguard HD Antimicrobial End Caps Procedure, revised October 2023, included the following: * Remove old dressing and discard. * Holding the catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds, apply to the CVC exit site in a “back and forth” pattern, using gentle friction progressing from the insertion site to the periphery using both sides of the swab. If site is not free of exudates, repeat this step with new 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab. Then wait 60 seconds for air dry time. * Clean each CVC limb/cap with new LARGE alcohol prep pad starting close to the exit site and finishing with the cap. For Patient #7, CCHT #3 failed to adhere to appropriate infection control practices to prevent intravascular infections, while performing a CVC exit site dressing change. Patient #7 was admitted to the facility in March 2021 with a diagnosis of end stage renal disease, requiring dialysis via a CVC. During an observation on 11/15/23 at 11:45 A.M., the surveyor observed CCHT #3 as he prepared Patient #7 for initiation of his/her dialysis treatment. CCHT #3 prepared supplies which included a sterile bordered dressing. CCHT #3 removed the old CVC exit site dressing and discarded it, but did not remove the gauze dressing that was wrapped around the CVC limbs. He disinfected the CVC exit site, applied antibiotic ointment onto a 2 x 2 gauze, and placed it on the exit site. CCHT #3 then applied a boarder dressing. The new dressing was observed resting on top of the existing gauze dressing on the CVC limbs. CCHT #3 then pulled the gauze dressing from the CVC limbs out from under the clean dressing, therefore contaminating the newly applied CVC exit site dressing. During an interview on 11/15/23 at 12:30 P.M., CCHT #3 said that he should have repeated the disinfection process.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 37349 Based on record review, interview, and policy review, the interdisciplinary team (IDT) of the facility failed to complete an initial comprehensive assessment for 1 of 10 applicable patients (#6), out of a total sample of 13 patients, within 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. Findings include: For Patient #6, the IDT failed to complete an individualized comprehensive assessment as required, within 30 days or 13 treatments. Review of the facility policy titled, Acute Kidney Injury (AKI) Assessment and Monitoring in the Outpatient Dialysis Setting, revised October 2023, included the following: * AKI patients will require an assessment and plan of care as outlined for End Stage Kidney Disease Patients. *Conducted within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines. *And a follow up 90-day reassessment will be completed to evaluate patient’s status and provide information to adjust the patient’s plan of care if applicable. Patient #6 was admitted to the facility in August 2023 with a diagnosis of acute kidney injury, requiring dialysis. Review of the clinical record indicated that as of 11/16/23, no comprehensive assessment had been completed by the IDT. During an interview on 11/16/23 at 9:37 A.M., Social Worker #1 said Patient #6 should have had an initial assessment since admission, but his/her assessments have not been completed. During an interview on 11/16/23 at 9:40 A.M., the Clinical Coordinator said Patient #6 should have had an initial assessment, but it has not been completed.”

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- (1) At least annually for stable patients; This Standard is not met as evidenced by: 44223 Based on record review, interview, and policy review, the facility failed to provide an annual comprehensive assessment and revision of the care plan for 2 of 10 applicable patients (#2, and #4), out of a total sample of 13 patients. Findings Include: Review of the facility policy, Interdisciplinary Team (IDT) Patient Assessment and Plan of Care, revised April 2023, including the following: *The IDT is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care. 1. For Patient #2, the facility staff failed to conduct an annual comprehensive assessment. Patient #2 was admitted to the facility in October 2018 with a diagnosis of end stage renal disease. Review of the clinical record indicated the most recent annual assessment and care plan revision was completed on 6/2/2022. During an interview on 11/15/23 at 8:40 A.M., the Clinical Coordinator said she could not produce a current annual assessment or updated plan of care. She said she did not think an assessment had been completed because they are behind. She said an assessment should have been completed in June of 2023. 2. For Patient #4, the facility staff failed to conduct an annual comprehensive assessment. Patient #4 was admitted to the facility in June 2021 with a diagnosis of end stage renal disease. Review of the clinical record indicated the most current annual assessment and care plan revision was completed on 3/10/22. During an interview on 11/15/23 at 8:40 A.M., the Clinical Coordinator could not produce a current annual assessment or updated plan of care. She said she did not think that an assessment had been completed because they are behind. She said that it should of been completed in March 2023.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 44223 Based on record review and staff interview, the facility failed to ensure the Interdisciplinary Team (IDT) developed and implemented a written, individualized plan of care (POC) for each patient that included services necessary to address patients’ needs and changes in patients’ condition, measurable and expected outcomes, and estimated timetables to achieve these outcomes for 3 of 10 applicable patients (#2, #4 and #6), out of a total sample of 13 patients. Findings include: Review of the facility policy “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care”, revised April 2023, included the following: * The IDT is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care. * The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and will include measurable and expected outcomes and estimated timetables to achieve these outcomes. * Implementation of assessment and plans of care are detailed in the table below: *New Patient -Within 30 days of admission to facility or within 13 treatments. *Annual (stable patient)-complete patient plan of care meeting within 15 days of the completion of the re-assessment and the Plan of Care (POC). 1. For Patient #2, the facility failed to ensure the patient had a complete and individualized plan of care that included services necessary to address patients’ needs and changes in patients’ condition, measurable and expected outcomes, and estimated timetables to achieve these outcomes completed annually per the facility policy. Patient #2 was admitted to the facility October 2018 with a diagnosis of End Stage Renal Disease, requiring hemodialysis. Review of the clinical record indicated the most recent plan of care was completed on 6/2/2022 and that no revision of the plan of care has been completed since then. According to the facility policy an annual plan of care should have been developed and completed by the Interdisciplinary Team (IDT) in June of 2023. During an interview on 11/15/23 at 8:40 A.M., the Clinic Coordinator said that the team was behind on completing assessments and care plans. She said she was not able to produce an updated plan of care. During an interview on 11/16/23 at 10:00 A.M., the Clinic Coordinator said the facility staff were having a problem keeping up with the care plan meetings. She said the team was trying to coordinate the care plan meeting with the various physician’s that work at the center to be present at the care plan meetings for their patients. 2. For Patient #4, the facility failed to ensure the patient had a complete and individualized plan of care that included services necessary to address patients’ needs and changes in patients’ condition, measurable and expected outcomes, and estimated timetables to achieve these outcomes completed annually per the facility policy. Patient #4 was admitted to the facility June 2021 with a diagnosis of End Stage Renal Disease, requiring hemodialysis. Review of the clinical record indicated the most recent plan of care was completed on 3/10/22 and that no revision of the plan of care has been completed since then. According to the facility policy the annual plan of care should have been developed and completed by the IDT in March of 2023. During an interview on 11/15/23 at 8:40 A.M., the Clinical Coordinator said the team was behind on completing assessments and care plans. She said she was not able to produce an updated plan of care. During an interview on 11/16/23 at 10:00 A.M., the Clinical Coordinator said the facility staff were having a problem keeping up with the care plan meetings. She said the team was trying to coordinate the care plan meeting with the various physician’s that work at the center to be present at the care plan meetings for their patients. 37349 3. For Patient #6, the facility failed to ensure the patient had a complete and individualized plan of care that included services necessary to address patients’ needs and changes in patients’ condition, measurable and expected outcomes, and estimated timetables to achieve these outcomes completed within 30 days or 13 treatments per the facility policy. Patient #6 admitted to the facility in 8/2023 with a diagnosis of Acute Kidney Injury requiring dialysis. Review of the clinical record failed to indicate that an initial plan of care had been completed since admission. According to the facility policy an initial plan of care should have been developed and completed by the Interdisciplinary Team (IDT) in September of 2023. During an interview on 11/16/23 at 9:37 A.M., Social Worker #1 said that an initial care plan for Patient #6 should have been done, but it has not been completed yet. During an interview on 11/16/23 at 9:40 A.M., the Clinical Coordinator said that an initial care plan should have been done for Patient #6, but it has not been completed yet.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 38141 Based on observation, interview, and record review, the facility failed to ensure the dialysis treatment was delivered as prescribed, relative to Blood Flow Rate (BFR) (measured in milliliters per minute (ml/min) in which the patient’s blood is pushed through dialyzer and back to the body) during the process of dialysis, for 1 of 4 prescriptions (Patient #12) reconciled, and 1 of 10 applicable patients (Patient #3) reviewed, out of a total sample of 13 patients. Findings include: 1. Patient #12 was admitted to the facility in January 2021 with diagnoses which included End Stage Renal Disease, requiring dialysis. Review of the physician’s order indicated the blood flow rate should run at 500 ml/min. On 11/15/23 at 9:20 A.M., a verification of dialysis treatment was conducted with Certified Clinical Hemodialysis Technician [CCHT] #3 for Patient #12 in station #9. The surveyor observed Patient #12 receiving dialysis treatment and the dialysis machine was set to a blood flow rate of 400 ml/min, not 500 ml/min as ordered. During an interview on 11/15/23 at 9:28 A.M., CCHT #3 said that he lowered the BFR to 400 ml/min 15 minutes ago because the dialysis machine was beeping. CCHT #3 said that he will adjust the BFR back to 500 ml/min as ordered. Review of the dialysis treatment flow sheets, dated 11/15/23, indicated the BFR was delivered at 400 ml/min, not 500 ml/min as ordered from 6:34 A.M. through 9:30 A.M., and there was no documentation to indicate why the physician’s order was not followed. During an interview on 11/15/23 at 1:45 P.M., the Clinical Coordinator said there should be a note on the treatment sheet indicating why BFR could not be delivered as prescribed. 44223 2. For Patient #3, the facility failed to ensure that the dialysis prescription was delivered as prescribed relative to BFR. Patient #3 was admitted to the facility in July 2017 with a diagnosis of End Stage Renal Disease, requiring dialysis. Review of the current dialysis treatment order, dated 9/29/23, indicated that the BFR was to be delivered at a rate of 450. Review of 9 treatment sheets, dated 10/25/23 through 11/13/23, indicated the BFR was not delivered as prescribed for 4 of 9 treatments including the following: *10/25/23 - the BFR was delivered at 400, not 450 as prescribed, with no documented reason as to why. *10/30/23 - the BFR was delivered at 400, not 450 as prescribed, with no documented reason as to why. *11/3/23 - the BFR was delivered at 400, not 450 as prescribed, with no documented reason as to why. *11/10/23 - the BFR was delivered at 350, not 450 as prescribed, with no documented reason as to why. During an interview on 11/16/23 at 1:05 P.M., the Clinical Coordinator said staff should be documenting a reason as to why the BFR was run at a different rate. She said she was not sure why Patient #3’s BFR was changed.”

“POC-VA MONITOR/PREVENT FAILURE/STENOSIS CFR(s): 494.90(a)(5) The patient’s vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis. This Standard is not met as evidenced by: 38141 Based on observation, interview, and policy review, the facility failed to ensure staff (Certified Clinical Hemodialysis Technician [CCHT] #6) evaluated a vascular access to ensure functionality by the way of listening for a bruit the length of the access (swooshing sound heard with a stethoscope place over the access) for 1 of 2 applicable patients (Patient #12) with arteriovenous fistula/graft (AVF/G) access sites, out of a total sample of 13 patients. Findings include: Review of the facility policy titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles”, last revised October 2022, included the following: *perform inspection, auscultation, and palpation on entire length of the access. Determine presence of bruit and thrill. The presence of bruit and thrill indicates flow through the access. During an observation on 11/15/23 at 11:00 A.M., the surveyor observed CCHT #6 as she was preparing Patient #12 for his/her dialysis treatment via AVF. CCHT #6 palpated the vascular access with her fingertips for the presence of thrill, disinfected the fistula sites, applied the tourniquet, and inserted the needle into the lower access and then the upper access. CCHT #6 did not assess Patient #12’s AVF access for the presence of bruit. During an interview on 11/15/23 at 11:15 A.M., CCHT #6 said Patient #12’s AVF access is not new. CCHT #6 said she knew the patient well and did not feel she needed to listen for bruit. During an interview on 11/15/23 at 1:45 P.M., the Clinical Coordinator said that staff must look, listen, and feel the access for 60 seconds. She said it is not enough to just look and feel it.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 31240 Based on record review, interview, and policy review, the facility failed to ensure the care plan for 1 of 10 applicable patients (#9), out of a total sample of 13 patients, was signed by 1.) the patient or the patient’s designees, or if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided, to ensure the patient involvement with his/her plan of care, and 2.) the physician. Findings include: Review of the facility policy, Interdisciplinary Team (IDT) Patient Assessment and Plan of Care, revised April 2023, included the following: *The facility’s IDT consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician or non-physician practitioner, if allowed by state end stage renal dialysis (ESRD) licensure regulations, treating the patient for ESRD, a social worker, and a dietitian. *The patient’s plan of care will be completed by the facility’s IDT, including the patient or personal representative, and be signed by the team members including the patient or the patient’s personal representative. If the patient chooses to not sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided. Patient #9 was admitted to the facility in November 2017 with a diagnosis of End Stage Renal Disease, requiring hemodialysis treatments. Review of the comprehensive assessment, dated 9/14/23, indicated the reason for the assessment was documented as initial modality change, transfer. Further review of the assessment indicated that the changed modality status, HHD, occurred on 8/8/23. Review of Patient #9’s plan of care, dated 10/24/23, included a signature page which was signed by the registered nurse, the dietitian, and the social work. The signature page did not include Patient #9’s signature nor the provider’s signature. There was no documentation indicating why the patient and the physician had not signed the plan of care. During an interview on 11/16/23 at 1:20 P.M., the Regional HHD Nurse said the IDT staff had not had a meeting with Patient #9 to review the plan of care. She also said the plan of care had not been reviewed by the physician.”

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 10249 Based on record review, interview, and policy review, the facility failed to implement a plan of care for 2 of 10 applicable patients (#5 and #9), from a total sample of 13 patients. Findings include: Review of the facility policy, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care”, revised April 2023, including the following: *The IDT is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care. *The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and will include measurable and expected outcomes and estimated timetables to achieve these outcomes. *Implementation of assessment and plans of care are detailed in the table below: *Annual (stable patient)-complete patient plan of care meeting within 15 days of the completion of the re-assessment and the Plan of Care (POC). *Modality Change-complete patient plan of care within 30 days of change in modality, or within 13 treatments. 1. For Patient #5, the facility failed to implement an annual plan of care and hold a patient care meeting with the patient and the IDT timely, per facility policy. Patient #5 was admitted to the facility in October 2019 with a diagnosis of End Stage Renal Disease, requiring dialysis. Review of the clinical record indicated the most recent annual assessment was completed on 9/5/23, however the care plan meeting was not held until 11/3/23, a delay of 2 months. During an interview on 11/16/23 at 10:00 A.M., the Clinical Coordinator said the facility staff were having a problem keeping up with the care plan meetings. She said the team was trying to coordinate the care plan meeting with the various physician’s that work at the center so they could be present at the care plan meetings for their patients. 31240 2. For Patient #9, the facility failed to ensure the care plans were completed within 30 days of a change in modality, from in-center hemodialysis treatments to home hemodialysis (HHD) treatments. Patient #9 was admitted to the facility in November 2017 with a diagnosis of End Stage Renal Disease, requiring hemodialysis treatments. Review of the comprehensive assessment, dated 9/14/23, indicated the reason for the assessment was documented as initial modality change, transfer. Further review of the assessment indicated the change in modality status to HHD occurred on 8/8/23. Review of Patient #9’s plan of care indicated it was completed on 10/24/23, which was greater than 30 days after the assessment was completed. During an interview on 11/16/23 at 1:20 P.M., the Regional HHD Nurse said the plan of care was not developed within the time frame required, when a change in modality occurred.”

“H-TRAIN CONTENT INCLUDES ER PREP HOME PTS CFR(s): 494.100(a)(3) The training must- (3) Be conducted for each home dialysis patient and address the specific needs of the patient, in the following areas: (i) The nature and management of ESRD. (ii) The full range of techniques associated with the treatment modality selected, including effective use of dialysis supplies and equipment in achieving and delivering the physician’s prescription of Kt/V or URR, and effective administration of erythropoiesis-stimulating agent(s) (if prescribed) to achieve and maintain a target level hemoglobin or hematocrit as written in patient’s plan of care. (iii) How to detect, report, and manage potential dialysis complications, including water treatment problems. (iv) Availability of support resources and how to access and use resources. (v) How to self-monitor health status and record and report health status information. (vi) How to handle medical and non-medical emergencies. (vii) Infection control precautions. (viii) Proper waste storage and disposal procedures. This Standard is not met as evidenced by: 31240 Based on record review, interview, and policy review, the facility failed to ensure that 1 of 2 home hemodialysis (HHD-process used to remove excess water and waste from the blood) patients (#9), out of a total sample of 13 patients, received instructions on how to document the administration of heparin (a blood thinning medication to prevent blood clots) on their treatment flowsheet. Findings include: Review of the facility policy, Central Venous Catheter with Clearguard HD Antimicrobial End Caps Procedure, revised October 2023, included the following: *Attach heparin loading dose to the venous limb, as applicable. Unclamp and gently flush back and forth 3-5 times into the catheter. Reclamp. Do not initiate dialysis for a minimum of 3-5 minutes after heparin administration to allow heparin to circulate systemically. Patient #9 was admitted to the facility in November 2017 with a diagnosis of end stage renal disease, requiring hemodialysis treatments. Review of the clinical record indicated Patient #9 had a CVC in the left chest wall that was place on 8/16/22. Review of the treatment flowsheets dated 10/3/23, 10/5/23, 10/6/23, 10/10/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/19/23 and 11/14/23 included the following HHD prescription to be utilized 4 times a week: -Dialysate SAK type: SAK-401 -Average dialysate rate: 17.0 liters (L)/hour. -Average ultrafiltration rate: 1 L/hour -Cartridge type: CAR-170-C -Target blood flow rate (BFR) 450 milliliters (ml)/minute -Heparin dose: 4000 -Heparin route: Access. Review of a Physician’s order, dated 10/20/23, indicated there was no order for a heparin bolus of 4000 units. Further review of the 10 treatment sheets failed to indicate the time the heparin doses were administered compared to when the treatments were initiated, to determine if Patient #9 followed the policy to wait 3-5 minutes before starting treatments. During an interview on 11/16/23 at 1:35 P.M., the Clinical Coordinator said the HHD treatment prescription did not include an order for heparin, but called the physician and confirmed there should be an order. She there was a discrepancy in the orders. She said the treatment sheets did not indicate the time the patient was administering the heparin, therefore could not confirm he/she was waiting 3-5 minutes before initiating the treatments. She said she believed the patient had been educated on this in the past as he/she has been a long term HHD patient, but would need re-education on documenting the time of medication administration. Please refer to V 726.”

“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: 37349 Based on observation, interview, record review, and policy review, the Medical Director failed to ensure that 1.) 1 staff member (Certified Clinical Hemodialysis Technician [CCHT] #3) followed the policy related to Central Venous Catheter (CVC) Exit Site Care and did not administer an antibiotic ointment without a prescription; 2.) 1 staff member (CCHT #3) followed the policy related to Central Venous Catheter initiation of treatment care and notified the Registered Nurse (RN)/physician when reversing the dialysis treatment lines for 1 patient (#7); and 3.) staff adhered to the heparin administration policy and documented that they waited 3-5 minutes after administration of heparin (blood thinning medication) bolus to initiate the dialysis treatment for 4 of 4 applicable patients (#2, #3, #4, #5) during record review; and 4.) staff administered a heparin infusion as ordered by the physician for 1 applicable patient (#4), out of a total sample of 13 patients. Findings include: 1. For Patient #7, the Medical Director failed to ensure that CCHT #3 followed the policy related to CVC exit site care and did not administer an antibiotic ointment without a prescription. Patient #7 was admitted to the facility in March 2021 with a diagnosis of end stage renal disease, requiring dialysis via a CVC. Review of the facility policy titled, Central Venous Catheter with Clearguard HD Antimicrobial End Caps Procedure, revised October 2023, included the following: * Apply antibiotic ointment to exit site, if prescribed. Review of physician orders for Patient #7 failed to include an order for antibiotic ointment to the CVC exit site. On 11/15/23 at 11:25 A.M., the surveyor observed CCHT #3 perform exit site care for Patient #7. CCHT #3 removed the old dressing and discarded it. The skin had a rash like appearance with red raised irritated skin approximately 3 cm circular area surrounding the exit site. He removed his gloves and performed hand hygiene. He disinfected the site with 2% Chlorhexidine and waited 60 seconds for a dry time. He then applied antibiotic ointment to a 2 x 2 gauze, covered the exit site with the 2 x 2 gauze, and then covered the 2 x 2 gauze with a border dressing. During an interview on 11/16/23 at 8:45 A.M., the Clinic Coordinator said antibiotic ointment should only be applied if ordered, and Patient #7 did not have an order for antibiotic ointment. 2. For Patient #7, the Medical Director failed to ensure that CCHT #3 follow the policy related to CVC initiation and notified the RN/physician when reversing treatment lines. Patient #7 was admitted to the facility in March 2021 with a diagnosis of end stage renal disease, requiring dialysis via a CVC. Review of the facility policy titled, Central Venous Catheter with Clearguard HD Antimicrobial End Caps Procedure, revised October 2023, included the following: *Attach sterile 10 ml syringes to the arterial and venous limbs. *Aspirate an amount greater than the catheter limb lumen, generally about 5 ml from each limb. Proceed to step 20 if both limbs are patent. If they are not patent, proceed with step 19. *If unable to aspirate from either arterial or venous limb, attach a 10 ml saline filled syringe to affected limb and gently infuse saline. Re-attempt to aspirate. If able to infuse saline into arterial limb but unable to aspirate, check venous limb for patency. If venous limb is patent, use venous limb for arterial source for this one treatment only. Notify the RN/physician of access insufficiency. If unable to infuse or aspirate from arterial limb, check venous limb, check venous limb for patency, DO NOT use catheter. Notify RN/physician. On 11/15/23 at 11:25 A.M., the surveyor observed CCHT #3 initiate dialysis treatment for Patient #7. CCHT #3 removed and discarded the old dressing over the limbs. He disinfected the limbs and placed a field underneath. He disinfected the hubs and attached an empty 10 ml syringes to the arterial and venous limbs, and aspirated about 5 ml from each. He disinfected the hubs and attached saline filled syringes, unclamped each limb, flushed and reclamped. As CCHT #3 went to secure the connections he said “with him/her we switch the lines”, and proceeded to connect the lines in a reverse manner (using venous for the arterial source). Review of the treatment flowsheet, and notes for Patient #7 for 11/15/23, failed to indicate that treatment had been initiated with the lines reversed and failed to indicate that the RN/physician had been notified per policy. During an interview on 11/16/23 at 8:45 A.M., the Corporate Nurse said she reviewed the medical record for Patient #7 and was not able to locate any documentation to indicate that CCHT #3 had initiated dialysis treatment for Patient #7 on 11/15/23 with the treatment lines reversed or that the RN/physician had been notified on 11/15/23 or any time since admission that there had been any flow issues or need to reverse lines for this patient. She said reversing the lines would be a one time intervention, and would need a physicians order if it was to be done on a routine basis. She further said Patient #7 did not have an order to reverse lines as part of his/her plan of care. 44223 3. Review of the policy titled, Anticoagulation, revised October 2023, included the following but is not limited to: * Heparin is administered per physician’s order * To anticoagulant the patient, the initial loading dose of heparin is administered through the venous fistula needle or venous port of the central venous catheter (CVC) at least three (3) to five (5) minutes prior to the initiation of the hemodialysis treatment. * A heparin pump is used to deliver a constant infusion of heparin over the course of the hemodialysis treatment in order to avoid heparin fluctuations that occur with intermittent injections. * It is recommended that the heparin hourly infusions be discontinued 60 minutes prior to end of treatment for patients with arterio-venous (AV) and/or AV grafts per physician order. It is recommended that the heparin hourly infusion be continued for the entire treatment for patients with CVC’s. A. For Patient #2 the Medical Director failed to ensure the staff adhered to the heparin administration policy and waited 3-5 minutes after administration to initiate treatment. Review of the clinical record indicated Patient #2 had a physician’s order to administer heparin bolus 3500 units intravenously (IV) every dialysis treatment. Review of 9 treatment sheets, dated 10/26/23 through 11/14/23, indicated for 4 of 9 treatments staff failed to wait 3-5 minutes after administration of heparin to initiate treatment including the following: *On 10/26/23 treatment started at 6:25 A.M., heparin was documented as administered at 6:27 A.M., 2 minutes after the initiation of treatment, not the 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 11/4/23 treatment started at 6:03 A.M., heparin was documented as administered at 6:01 A.M., staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 11/7/23 treatment started at 6:05 A.M., heparin was documented as administered at 6:05 A.M., staff did not wait the 3-5 minutes prior to the initiation of dialysis per the facility policy. During an interview on 11/16/23 at 11:30 A.M. the Clinical Coordinator (CC) said that the heparin was most likely given as ordered but based on the documentation she could not determine for sure if staff were waiting the 3-5 minutes before initiating treatment. B. For Patient #3, the Medical Director failed to ensure that staff adhered to the heparin administration policy and waited 3-5 minutes after administration to initiate treatment. Review of the clinical record indicated that Patient #3 had a physician’s order to administer heparin bolus 3500 units IV every dialysis treatment. Review of 9 treatment sheets, dated 10/25/23-11/13/23, indicated that for 3 of 9 treatments, staff failed to wait 3-5 minutes after the administration of heparin to initiate treatment including the following: *On 10/25/23 treatment began at 11:00 A.M., heparin was documented as administered at 11:01 A.M., 1 minute after dialysis treatment was initiated, not the 3-5 minutes prior to the initiation of dialysis per the facility policy. *On 11/10/23 treatment began at 11:17 A.M., heparin was documented as administered at 11:15 A.M., staff failed to wait the 3-5 minutes after the administration of heparin to initiate dialysis treatment. *On 11/13/23 treatment began at 11:24 A.M., heparin was documented as administered at 11:25 A.M., 1 minute after dialysis treatment was initiated not the 3-5 minutes prior to the initiation of dialysis per the facility policy. During an interview on 11/16/23 at 11:30 A.M., the CC said that the heparin was most likely given as ordered, but based on the documentation she could not determine for sure if staff were waiting the 3-5 minutes before initiating treatment. C. For Patient #4, the Medical Director failed to ensure staff adhered to the heparin administration policy and waited 3-5 minutes after administration to initiate treatment. Review of the clinical record indicated Patient #4 had a physician’s order to administer heparin bolus 2000 units IV every dialysis treatment. Review of 9 treatment sheets, between 10/26/23-11/14/23, indicated that for 5 of 9 treatments, staff failed to wait 3-5 minutes after the administration of heparin to initiate treatment including the following: * On 10/26/23 treatment began at 6:17 A.M., heparin was documented as administered at 6:39 A.M., 22 minutes after dialysis treatment was initiated, not the 3-5 minutes prior to the initiation of dialysis per the facility policy. * On 10/28/23 treatment began at 6:08 A.M., heparin was documented as administered at 6:45 A.M., 37 minutes after dialysis treatment was initiated, not the 3-5 minutes prior to the initiation of dialysis per the facility policy. * On 11/7/23 treatment began at 6:09 A.M., heparin was documented as administered at 6:26 A.M., 17 minutes after dialysis treatment was initiated, not the 3-5 minutes prior to the initiation of dialysis per the facility policy. * On 11/9/23 treatment began at 6:19 A.M., heparin was documented as administered at 6:36 A.M., 17 minutes after dialysis treatment was initiated, not the 3-5 minutes prior to the initiation of dialysis per the facility policy. * On 11/11/23 treatment started at 6:07 A.M., heparin documented as administered at 6:37 A.M., 30 minutes after dialysis treatment was initiated, not the 3-5 minutes prior to the initiation of dialysis per the facility policy. During an interview on 11/16/23 at 11:30 A.M., the Clinical Coordinator said that the heparin was most likely given as ordered but based on the documentation she could not determine for sure if staff were waiting the 3-5 minutes before initiating treatment. 10249 D. For Patient #5, the Medical Director failed to ensure that staff adhered to the heparin administration policy and waited 3-5 minutes after administration to initiate treatment. Review of the clinical record indicated that Patient #5 had a physician’s order to administer heparin bolus 3000 units, every dialysis treatment. Review of 9 treatment sheets, dated 10/25/23 through 11/15/23, indicated that for 3 of 9 treatments, staff failed to wait 3-5 minutes after the administration of heparin to initiate treatment, including the following: *On 10/25/23 treatment began at 11:17 A.M., a bolus dose of heparin 3000 units was documented as given at 11:22 A.M., 5 minutes after the dialysis treatment started, not the 3-5 minutes prior to the start of the treatment, per facility policy. *On 11/1/23 treatment began at 11:15 A.M., a bolus dose of heparin 3000 units was documented as given at 11:25 A.M., 10 minutes after the dialysis treatment started, not the 3-5 minutes prior to the start of the treatment, per facility policy. *On 11/8/23 treatment began at 11:20 A.M., a bolus dose of heparin 3000 units was documented as given at 11:19 A.M., not the 3-5 minutes prior to the start of the treatment, per facility policy. During an interview on 11/16/23 at 11:30 A.M. the Clinical Coordinator said that the heparin was most likely given as ordered, but based on the documentation she could not determine for sure if staff waiting the 3-5 minutes before initiating treatment. 4. For Patient #4, the Medical Director failed to ensure staff administered a heparin infusion as ordered by the physician. Review of the clinical record indicated Patient #4 had a physician’s order to administer 500 units/hour (hr) of heparin IV infusion, stop 60 minutes prior to end of treatment. Review of 9 treatment sheets, dated 10/26/23 through 11/14/23, indicated for 5 of 9 treatments, the physician’s order for the heparin 500 units/hr IV infusion was not followed, including the following: * On 10/26/23 treatment started at 6:17 A.M. and ended at 10:20 A.M. The 500 unit/hr IV heparin infusion was documented as administered until 10:23 A.M. and not stopped 60 minutes prior to the end of treatment as ordered. *On 10/28/23 treatment started at 6:08 A.M. and ended at 10:03 A.M.. The 500 unit/hr IV heparin infusion was documented as administered until 10:34 A.M. and not stopped 60 minutes prior to the end of treatment as ordered. *On 11/7/23 treatment started at 6:09 A.M. and ended at 10:06 A.M. The 500 unit/hr IV heparin infusion was documented as administered until 10:17 A.M. and not stopped 60 minutes prior to the end of treatment as ordered. *On 11/9/23 treatment started at 6:19 A.M. and ended at 10:20 A.M. The 500 unit/hr IV heparin infusion was documented as administered until 10:21 A.M. and not stopped 60 minutes prior to the end of treatment as ordered. *On 11/11/23 treatment started at 6:07 A.M. and ended at 10:11 A.M. The 500 unit/hr IV heparin infusion was documented as administered until 10:46 A.M. and not stopped 60 minutes prior to the end of treatment as ordered. During an interview on 11/16/23 at 1:05 P.M., the Clinical Coordinator said staff should document when the infusion stops, not at end of treatment. She said based on the documentation, she could not determine for sure if staff followed the physician’s order.”

“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: 31240 Based on record review, premixed dialysate solution (used during dialysis treatment to pull toxins from the blood) documentation, and interview, the facility failed to ensure staff maintained complete and accurate records for 1 patient (#9), out of a total sample of 13 patients, by 1.) ensuring the dialysate solution being utilized was reflected in the Physician’s order, and 2.) the clinical record included an order to administer heparin (a medication to prevent the formation of blood clots). Findings include: Review of the facility’s Dialysate Catalog-Appendix A, undated, indicated the following formulas for SAK-301/401 and SAK 302/402: SAK-301/401 -Lactate (chemical): 45 milliequivalent (mEq)/liter (L). -Potassium (supplement): 1 mEq/L. -Sodium (chemical element): 140 mEq/L. -Calcium (mineral): 3 mEq/L. -Magnesium (mineral): 1 mEq/L. -Chloride (mineral): 100 mEq/L. -Glucose (sugar): 100 milligrams (mg)/deciliter (dl). -Batch size: 60 L. SAK-302/402 -Lactate: 40 mEq/L. -Potassium: 1 mEq/L. -Sodium 140 mEq/L. -Calcium: 3 mEq/L. -Magnesium: 1 mEq/L. -Chloride: 105 mEq/L. -Glucose: 100 mg/dl. -Batch size: 60 L. Patient #9 was admitted to the facility in November 2017 with a diagnosis of end stage renal disease, requiring hemodialysis. Review of the clinical record indicated the patient began home hemodialysis (HHD) on 8/8/23. 1. Review of the treatment flowsheets 10/3/23, 10/5/23, 10/6/23, 10/10/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/19/23 and 11/14/23 included the following HHD prescription for each treatment: -Dialysate SAK type: SAK-401. Review of the clinical record indicated a Physician’s order, dated 10/20/23, included, but not limited to, the following: -Dialysate Bath: 1 K, 3 Ca, 40 Lactate. During an interview on 11/16/23 at 1:35 P.M., the Clinical Coordinator said Patient #9’s dialysate SAK order did not match what he/she was being provided with for HHD treatments. She said she confirmed that Patient #9 was provided and utilizing SAK-402. She said the clinical record was inaccurate relative to the transcription of the dialysate SAK. 2. Review of the treatment flowsheets 10/3/23, 10/5/23, 10/6/23, 10/10/23, 10/11/23, 10/13/23, 10/16/23, 10/18/23, 10/19/23 and 11/14/23 included, but not limited to, the following HHD prescription: -Heparin dose: 4000. Review of a Physician’s order, dated 10/20/23, indicated no order for the heparin bolus 4000 units. During an interview on 11/16/23 at 1:35 P.M., the Clinical Coordinator said the HHD treatment prescription did not include an order for heparin, but she had called the Physician and confirmed there should have been an order. She said the clinical record was incomplete relative an order for heparin administration.”