Fmc - Greater Baltimore

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 44367 Based on patient record review, the facility’s administration failed to ensure that the clinical staff followed standard clinical practices in addressing blood pressures beyond the normal limits. This failure placed the affected patients at potential risk of injury or harm. Patient: #1 Because of the adverse effects of End Stage Renal Disease, many patients experience the instability of blood pressure and fluid management, the management of which may require reassessment of medication needs, adjustments in target weight, and changes to the plans of care. The patient’s heart rate must be monitored for abnormally high and low in addition to the blood pressure. Patients’ blood pressures must be monitored before, during and after dialysis treatment, and abnormally high and low values must be addressed immediately to ensure patient safety. Review on 09/06/2024 of the facility’s policy entitled “Patient Assessment and Monitoring” page 4 stated, “Follow the steps below for monitoring patient and machine parameters during treatment: recheck blood pressures after a drop that requires interventions such as administering normal saline...Report to the nurse: Systolic blood pressures greater than 180 mm/hg. Diastolic blood pressures greater than 100 mm/hg. Blood Pressures less than or equal to 100 mg/hg systolic.” Review on 09/06/2024 of Patient #1’s flowsheets from 07/05/2024 through 0/9/05/2024 revealed that the clinical staff did not always report abnormal blood pressures to the Registered Nurse. The documentation was as follows: On 07/10/2024 at 06:35 a.m., bp was 186/75 On 07/16/2024 at 09:35 a.m., bp was 98/38 On 08/02/2024 at 09:30 a.m., bp was 94/59 On 08/05/2024 at 09:30 a.m., bp was 99/50 On 09/02/2024 at 06:33 a.m., bp was 189/101 On 09/02/2024 at 07:08 a.m., bp was 185/90 On 09/04/2024 at 05:39 a.m., bp was 208/81 On 09/04/2024 at 06:07 a.m., bp was 193/100 On 09/04/2024 at 07:03 a.m., bp was 187/93 On 09/04/2024 at 07:34 a.m., bp was 191/86 The Clinical Manger was informed of the findings on 09/06/2024.”

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 47759 Based on the overall findings of the survey, it was determined that the facility’s Medical Director failed to provide an effective oversight of the clinical process in the facility, as evidenced by: 1) failure of the facility’s staff members to adhere to the facility’s policies and procedures; 2) failure of staff to complete timely assessments, plans of care, and grievance management; and 3) failure to correct and sustain compliance with previously identified deficient practices. This failure posed a potential risk of safety to the patients and denied patients their rights to quality patient care. The findings included: 1. The Medical Director failed to ensure that all the facility’s staff members adhered to the facility’s policies and procedures. Cross-reference to tag V0715. 2. The Medical Director failed to ensure that the facility staff was completing assessments, care plans, and grievance management timely. Cross-reference to tag V0729. 3. The Medical Director failed to ensure that previously found survey deficiencies were corrected and did not recur. Cross-reference to tags V0403 and E0020.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 47759 Based on the overall findings of the survey, the facility ’ s governing body failed to demonstrate overall responsibility for the governance and operation of this facility, as evidenced by: 1) failure to maintain required staff to patient ratios and meet patient needs; and 2) failure to ensure that members of interdisciplinary team were available to meet the patient needs. This failure posed a potential risk of safety to the patients and denied patients their rights to quality care. The findings include: 1. Cross-reference to Governing Body- Staff to patient ratio meets patient needs (V0757). 2. Cross-reference to Governing Body- Interdisciplinary team available to meet patient needs (V0758).”

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(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:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], 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 RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 47759 Based on observation, staff interview and record review, the facility’s governing body failed to ensure that supplies were available to provide care during an emergency evacuation. This failure placed the patients at potential risk of harm in case of an emergency evacuation. Findings Included: On 06/26/2024 at 09:00 a.m., during review of the facility’s policy titled “Emergency Medications, Equipment and Supplies” (Reference number: 46865), page 2 stated, “An emergency evacuation box must: -be checked monthly or after use for contents, expiration dates, and cleanliness ...An itemized log must be kept indicating the contents and expiration dates of contents.” On 06/24/2024 at 11:10 a.m., emergency evacuation cart inspection revealed that an itemized list was not included in the box. Inspection also revealed 10 bags of expired 1 liter sodium chloride (Lot number 20SU06010) with an expiration year of 2021. Interviews with the Clinical Nurse Manager confirmed that the evacuation box had not been checked on a consistent basis. The finding of expired supplies in the facility was also evident in the previous survey conducted on 05/28/2021.”

“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: 47759 Based on observations and a staff interview, the facility’s governing body failed to 1)provide a clean area for medication preparation and 2) dispose of items that have lost their integrity. This failure increased the risk of cross contamination and placed patients at potential risk for exposures to infectious diseases. Findings Included: According to the American Society for Health Care Engineering (ASHE) in partnership with the Centers for Disease Control and Prevention, “splashes from contaminated handwashing sinks have been implicated as the source of outbreaks that resulted in patient infections...Best practices related to the design of hand hygiene facilities include Ensure adequate space between areas used for medical preparation, and use splash guards where appropriate.” On 06/24/2024 at 11:25 a.m. during observation of the treatment floor, the surveyor observed that the facility’s medication preparation area was set up adjacent to the hand wash sink. Staff #1 corroborated that the medication preparation area adjacent to the hand wash sink posed a cross contamination issue and immediately relocated the medication preparation area away from the sink. On 06/24/2024 at 11:20 a.m., during inspection of supply items near Station #15, the surveyor observed 3 expired dialyzers that were out of the packaging. Staff #1 corroborated that the items were expired and immediately disposed of the items. On 06/17/2024, at 09:51 a.m., during observations of the medication preparation area, the surveyor observed exposed and out of the package syringes on the medication preparation area. During interviews, Staff #1 stated that by taking the syringes out of the package before [he/she] was ready to draw up the medication ruined the integrity of the syringes making it unclear whether the syringes were clean or dirty. Staff #1 stated that moving forward, syringes would not be taken out of the package until [he/she] was ready to draw up medication; once the medications were drawn up, the medication would be labeled and placed in a secured area immediately.”

“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: 47759 Based on observations and record review, the facility’s governing body failed to ensure that the clinical staff followed the standard infection control precaution in the cleaning and disinfection of contaminated equipment being used in the facility. This failure placed the patients at potential risk for exposure to blood-borne pathogens and infectious diseases. Findings Included: On 06/26/2024 at 09:00 a.m., during review of the facility’s policy titled “Cleaning and Disinfecting the Dialysis Station” (Reference Number: 47806), page 6 number 3 and 4 stated, “clean and disinfect the dialysis station, place the chair in Trendelenburg position and open side panels if chair has swing open sides so all surfaces of the chair are accessible ....Clean all surfaces” On 06/17/2024, during observation of the treatment floor, the surveyor observed the following: 1. At 10:16 a.m., during disinfection of Station #14, the surveyor observed that Staff #2 did not disinfect the bottom part of the dialysis machine nor did Staff #2 opened and disinfected the side panels of the dialysis chair. 2. At 11:10 a.m., during disinfection of Station #15, the surveyor observed that Staff #2 did not disinfect the side panels of the dialysis chair. 3. At 11:18 a.m., during disinfection of Station #17, the surveyor observed that Staff #2 did not disinfect the right side panel of the dialysis chair.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 47759 Based on observations, staff interviews and record reviews, the facility’s governing body failed to provide effective oversight and monitoring of staff adherence to infection control practices within the facility. This failure placed all patients, visitors and staff at potential risk for exposure to blood borne pathogens and infectious diseases. Findings Included: On 06/26/2024, at 09:00 a.m., during record review of the facility’s policy titled “Infection Control Overview” (Reference Number: 47661), page 2 stated that one of the facility’s mandatory components of Infection Control is for the facility to have a “Mechanism to evaluate the effectiveness of the program and take corrective action.” During the survey process, the surveyor observed that multiple facility staff did not adhere to infection control policies and procedures in the areas of providing a sanitary environment (cross-reference to tag V0111), practicing disinfection based on standard infection control precaution (cross-reference to tag V0122), and practicing aseptic technique during catheter care (cross-reference to tag V0147). On 06/18/2024, at 10:30 a.m., during record review of the facility’s infection control audit, the surveyor noted that the facility had missing infection control audits for the months of July, August, September, November, and December 2023; January, February, and May 2024. There was an infection control audit documented for April 2024. On 06/24/2024, at 12:15 p.m., Staff #7 corroborated that the audit documentation provided was accurate.”

“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: 47759 Based on observations and review of the facility’s policies and procedures, the facility’s governing body failed to ensure that the clinical staff complied with the appropriate catheter care techniques and procedures to prevent intravascular catheter-related infections and failures. This failure placed patients at potential risk of infection or harm in maintaining their central venous catheter. Findings include: On 06/26/2024, at 09:00 a.m., during record review of the facility’s policy titled “Changing the Catheter Dressing Procedure” (Reference Number: 45664), page 1 stated, “ Catheter exit site disinfection and dressing change is to be completed prior to cap and hub connector disinfection. This provides an opportunity to view the exit site for infection or complications and if applicable, notify team leader, charge nurse or home therapy nurse prior to initiating treatment.” On 06/17/2024 at 11:42 a.m., during Central Venous Catheter (CVC) dressing change procedure, the surveyor observed that Staff #2 did not assess the exit site first prior to cap and hub connector disinfection and CVC access. On 06/24/2024 at 10:55 a.m., during CVC dressing change procedure, the surveyor observed that Staff #6 failed to apply the catheter dressing over the exit site first prior to proceeding to the cap and hub connector disinfection and CVC access procedure leaving the exit site exposed at a longer time.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 47759 Based on observations and a staff interview, the facility’s governing body failed to provide a safe environment of care to the patients of the facility, as evidenced by: 1) failure to ensure adequate staffing at all times; 2) failure to ensure an environment free from defects; and 3) failure to ensure that a warning label was posted on all machines following disinfection. This failure placed the patients, staff and visitors at potential risk of harm including injury or infection. Findings Included: 1. According to the Code of Maryland Regulations 10.05.04.06C (Dialysis Monitoring for Freestanding Kidney Dialysis Centers), “(a) In-Center Daytime Hemodialysis. When in-center daytime hemodialysis is performed, the monitoring individual-to-patient ratio at each center shall be: (i) A minimum of one staff member to three participants; and (ii) Sufficient to meet the needs of patients.” On 06/17/2024, during observation of the treatment floor, the surveyor observed a patient ratio of 4:1 in addition to one nurse in charge of 18-20 patients. This ratio impacted the facility in several ways. i. Due to the ratio, staff promptness to address machine alarms was affected. At 11:57 a.m. surveyor had to intervene when machine at Station #16 was alarming stating “conductivity level low. Staff #1 was called to assist Staff #2 while Staff #2 was occupied with another patient. At 03:30 p.m. Staff #2 approached the surveyor concerned about the staffing ratio. According to Staff #2, the facility was short staffed. Staff #2 stated that a lot of the patients were in need of help, were dependent, and often came with a hoyer lift. ii. On 06/24/2024, an anonymous staff member stated in an interview that on one day in the previous week, the anonymous staff member worked from 06:00 a.m.-07:30 p.m., and did not get a break until 05:00 p.m. due to inadequate staffing. See tag V0757 for more details. iii. On 06/17/2024, 3 of the 7 (42%) selected patients (Patients A, B, and G) had late nursing assessments documented on the treatment flow sheet. 2. According to the Centers for Medicare and Medicaid Services (CMS), intact surface integrity provides for effective cleaning and limits microbiological development on surfaces. a. On 06/17/2024 at 11:00 a.m., during observation of the treatment floor, the surveyor observed orange, brown and black discoloration surrounding the sink located across Station #20. 3. On 06/18/2024 at 12:00 p.m., during an interview, the Area Technical Operations Manager (ATOM) informed the surveyor of the following process: after machine bleach disinfection, the staff member in charge of disinfection should place a warning label on the machines to inform the openers (staff members who would come in the morning) to test for residuals. a. On 06/18/2024, at 11:57 a.m., during observation of the treatment floor, the surveyor observed that machines #4, #24 and #10 did not have a warning label following chemical disinfection. This observation was verified by the ATOM and the Area Team Lead who immediately obtained a warning label to place on machines #4, #24, and #10.”

“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: 47759 Based on observations and review of the facility’s policies and procedures, the facility’s governing body failed to ensure that all patient supplies used for dialysis treatment were maintained in a manner that provided for patient safety. This failure denied patients their rights to a minimum standard of care. Findings Included: On 06/26/2024 at 09:00 a.m., during review of the facility’s policy titled “Emergency Medications, Equipment and Supplies (Reference number: 46865), page 2 stated, “An itemized log must be kept indicating the contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date.” On 06/24/2024 at 11:20 a.m., during observations on the treatment floor, the surveyor observed the following expired items: 1. 7 (seven) Optiflux advanced fresenius polysulfone dialyzer with lot #20BU06026 and the expiration date of 02/28/2023 were found located among the supplies across station #14. 2. 10 (ten) Sodium Chloride 0.9% with lot #20SU06010 and the expiration date of 03/2021 were found located inside the emergency evacuation cart. The finding of expired supplies present in the facility was a repeat finding from 2021 recertification survey.”

“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: 47759 Based on record review and staff interview, the facility’s governing body failed to ensure a complete, comprehensive reassessment of all stable patients and a plan of care (PoC) was done annually. This was evident for 4 of 6 patients reviewed (A, D, E, and F). This failure placed the affected patients at potential risk of harm and denied patients their rights to a minimum standard of care. Findings included: On 06/26/2024 at 09:00 a.m., during review of the facility ’ s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” (Reference Number 45283), page 3 stated, “Comprehensive interdisciplinary assessments and modifications to the Plan of Care (PoC) must be conducted 12 months after the completion of the 3-month assessment and then reassessed annually thereafter on all stable patients.” On 06/24/2024 from 12:30 p.m. -01:30 p.m., during a review of 6 selected patients’ annual plans of care (PoC), the surveyor observed that 4 of the 6 plans of care reviewed (66%) were not performed according to the facility’s policy. The review demonstrated the following: 1. Patient A’s last documented PoC was 05/13/2022. Staff #7 corroborated that there’s no documented PoC completed for the year 2023 or 2024. 2. Patient D’s last documented PoC was 05/04/2023. Staff #7 corroborated that there’s no documented PoC completed for the year 2024. 3. Patient E’s last documented PoC was 05/04/2023. Staff #7 corroborated that there’s no documented PoC completed for the year 2024. 4. Patient F’s last documented PoC was 05/04/2023. Staff #7 corroborated that there’s no documented PoC completed for the year 2024.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 47759 Based on observations and review of the facility’s policies and procedures, the facility’s governing body failed to ensure that the clinical staff complied with the appropriate procedures in assessing the patients’ vascular access prior to cannulation and practiced the correct infection control protocol. This failure placed the safety and well-being of the patients at potential risk of harm in maintaining their vascular access. Findings included: On 06/26/2024 at 09:00 a.m., review of the facility’s policy titled “Access Assessment and Cannulation (reference number 45178)”, page 2 step 6 stated, “Staff/patients/care partners who have been trained to auscultate vascular access should listen to the entire length of the access for changes in the sound of the bruit-A low pitched bruit should be present.” Page 4 step 1: “Using gentle friction, clean the access site beginning in the center and continuing outward 2 inches in a concentric circle for 30 seconds and allow it to dry before cannulating.” Step 2: “Do not touch cannulation sites after skin disinfection.” On 06/17/2024, during observations of the treatment floor, the surveyor observed the following: 1. At 10:34 a.m., Staff #3 disinfected the patient [Sitting at Station #8]’s access site for 10 seconds for one of the access sites and 6 seconds for the other. 2. At 10:45 a.m., Staff #2 palpated the patient [Sitting at Station #14]’s access site more than 10 times after disinfecting it and cannulated. On 06/24/2024, during observations of the treatment floor, the surveyor observed the following: 1. At 10:08 a.m., Staff #5 disinfected the patient [Sitting at Station #3]’s access site for 7 seconds each and palpated prior to cannulation. 2. At 11:07 a.m., Staff #9 did not auscultate (or listened to the access site’s bruit) prior to cannulation.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 47759 Based on record review and staff interview, the facility’s governing body and interdisciplinary team (IDT) failed to ensure that an initial comprehensive assessment has been conducted on all new patients within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first outpatient dialysis session. This failure placed the affected patients at potential risk of harm and denied patients their rights to a minimum standard of care. Findings included: On 06/26/2024 at 09:00 a.m., during review of the facility ’ s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” (Reference Number 45283), page 2 stated, “An initial comprehensive interdisciplinary assessment (CIA) and plan of care (PoC) must be conducted on all patients new to dialysis within the later of 30 calendar days or 13 outpatient dialysis sessions for hemodialysis beginning with the first outpatient dialysis session.” On 06/24/2024 from 12:30 p.m. -01:30 p.m., during review of 7 selected patients’ 30 day PoC, the surveyor noted that 2 of the 7 plans of care reviewed (29%) were not performed according to the facility’s policy. The review demonstrated the following: 1. Patient G was admitted on 05/20/2024, but no documented PoC could be presented to the surveyor. Interviews with the Clinical Manager corroborated that the PoC had not been completed and was late. 2. Patient H was admitted on 05/20/2023. Patient H’s 30 day PoC was completed on 08/11/2023, which was approximately 2 months late. Patient H has not had another care plan meeting since 08/11/2023. The Clinical Manager corroborated that Patient H had not had another care plan meeting since 08/11/2023.”

“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: 47759 Based on staff interviews, observation, and record reviews, the medical director and the facility’s administration failed to ensure that the staff adhered to their own policies and procedures. This failure posed a potential risk of safety to the patients, and denied patients their rights to a minimum standard of medical care. The findings included: 1. On 06/24/2024, emergency evacuation cart inspection revealed expired items and missing itemized log. This finding failed to meet the facility ’ s policy titled “Emergency Medications, Equipment and Supplies” (Reference number: 46865) - See tag E0020 and tag V0403 for a cross reference. 2. On 06/17/2024, during treatment floor observation, the surveyor observed that Staff #2 did not clean all surfaces of the dialysis machine and dialysis chair. This finding failed to meet the facility ’ s policy titled “Cleaning and Disinfecting the Dialysis Station” (Reference Number: 47806) - See tag V0122 for a cross reference. 3. On 06/18/2024, infection control audit review revealed a lack of infection control oversight for the months of July, August, September, November, and December 2023; January, February, May 2024. This finding failed to meet the facility ’ s policy titled “Infection Control Overview” (Reference Number: 47661) - See tag V0142 for a cross reference. 4. On 06/17/2024 and 06/24/2024, during treatment floor observation, the surveyor observed that Staff #2 and Staff #6 did not follow the steps written on the facility ’ s procedure. This finding failed to meet the facility ’ s policy titled “Changing the Catheter Dressing Procedure” (Reference Number: 45664) -See tag V0147 for a cross reference. 5. On 06/24/2024 during record review of the selected patients ’ plan of care, the surveyor observed that 4 out of the 6 patients ’ annual plan of care for the year 2024 were not completed. This finding failed to meet the facility ’ s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” (Reference Number 45283) - See tag V0519 for a cross reference. 6. On 06/24/2024, during record review of the selected patients ’ plan of care, the surveyor observed that 2 out of the 7 patients ’ 30 day Plan of Care were either late or had not been completed. This finding failed to meet the facility ’ s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” (Reference Number 45283) - See tag V0557 for a cross reference. 7. On 06/17/2024, during observations of the treatment floor, the surveyor observed that Staff members were 1. Palpating the patients ’ access site prior to cannulation; 2. Failing to assess the patients ’ access site to assess for bruit; and 3. Failing to disinfect for 30 seconds . These findings failed to meet the facility ’ s policy titled “Access Assessment and Cannulation (reference number 45178)” - See tag V0550 for a cross reference. 8. On 06/26/2024, during review of the selected patients ’ treatment flowsheet, the surveyor observed late entries on the patient assessment. This finding failed to meet the facility ’ s policy titled “Nursing Supervision and Delegation” (Reference Number: 45265) - See tag V0729 for a cross reference.”

“MR-COMPLETE RECORDS PROMPTLY CFR(s): 494.170(b)(1) (1) Current medical records and those of discharged patients must be completed promptly. This Standard is not met as evidenced by: 47759 Based on record review and staff interviews, the facility ’ s governing body failed to ensure that the facility staff completed medical records promptly, as evidenced by: 1) failure of to complete nursing assessments within an hour of treatment initiation; 2) failure to complete a 30 day and annual plan of care (PoC) within the defined time period; and 3) failure to address and document grievances in accordance with the facility policy. This failure placed patients at a potential risk of harm and denied patients their rights to a minimum standard of care. Findings Included: 1. On 06/26/2024 at 09:00 a.m., during reviews of the facility’s policies and procedures titled “Nursing Supervision and Delegation” (Reference Number: 45265), page 5 stated, “The registered nurse must evaluate each patient preferably within an hour.” a. On 06/26/2024 at 04:46 p.m., during record review of the treatment flowsheet of the selected patients, the surveyor observed the following: i. On 06/17/2024, 3 of the 7 (42%) selected patients (Patients A, B, and G) had late nursing assessments documented on the treatment flow sheet. ii. On 06/12/2024, 2 of the 7 (28%) selected patients (Patient D and E) had late nursing assessments documented on the treatment flowsheet. iii. On 06/14/2024, 1 of the 7 (14%) selected patients (Patient G) had late nursing assessments documented on the treatment flowsheet. 2. On 06/24/2024 from 12:30 p.m. -01:30 p.m. during review of 7 selected patients’ 30 day PoC, the surveyor observed that 2 of the 7 plans of care reviewed (29%) were either incomplete or were completed late. Cross-reference to tag V0557. On 06/24/2024 from 12:30 p.m. -01:30 p.m. during a review of 6 selected patients’ annual plans of care (PoC), the surveyor observed that 4 of the 6 plans of care reviewed (66%) were incomplete either for 2023, 2024, or both. See Cross-reference to tag V0519. 3. On 06/24/2024 at 04:00 p.m., during review of the facility’s grievance log, the surveyor observed a grievance from Patient G filed on 06/12/2024. According to the Clinical Manager on 06/24/2024, (he/she) had not yet met with Patient G about the grievance. Interviews with the Area Team Leader confirmed that a meeting with the patient should have occurred within 72 hours of the grievance submission.”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 47759 Based on record review, patient interviews, and staff interviews, the facility’s governing body failed to ensure an adequate number of qualified and trained staff to meet the needs of the patients. This failure placed the patients at potential risk and denied their rights to a minimum standard of medical care. Findings Included: The Code of Maryland Regulations 10.05.04.06C (Dialysis Monitoring for Freestanding Kidney Dialysis Centers) states: (a) In-Center Daytime Hemodialysis. When in-center daytime hemodialysis is performed, the monitoring individual-to-patient ratio at each center shall be: (i) A minimum of one staff member to three participants; and (ii) Sufficient to meet the needs of patients. ... (c) The center shall establish provisions for back-up staff coverage during unexpected illnesses, vacations, and holidays. 1. On 06/17/2024, 06/24/2024 and 06/28/2024, during the recertification survey, the facility had a staff to patient ratio of 1 staff member to 4 patient ratio for at least two out of the three shifts. This finding was confirmed by means of observation and/or staff interviews. 2. On 06/24/2024, at 04:10 p.m., during record review of the facility’s staffing records for the months of May through June, only one exception report was provided to the surveyor which was inconsistent with the staff interviews conducted. 3. a. From 06/17/2024 through 06/24/2024, interviews with 3 out of the 5 staff members revealed that the staff members considered the facility to have been short staffed for at least a month. 2 Staff members confirmed short staffing but were unable to recall when it started. i. According to [Anonymous Staff #1], the facility had been short staffed since the beginning of May. (He/She) at times felt “stretched” due to the various responsibilities when short staffed. See tag V0729 for a cross reference. ii. According to [Anonymous Staff #2], the facility had been short staffed for more than 6 months with no effective back up plan. iii. According to [Anonymous Staff #3], the facility had been short staffed for months with no effective back up plan. The staff member gave an example of starting a shift at 6:00 am on one day and not having a break until 5:00 pm due to lack of coverage. iv. According to [Anonymous Staff #4], the facility was short staffed when somebody called out and there were no effective back up plans for staffing. v. According to [Anonymous Staff #5], the facility was short staffed. b. On 06/26/2024 at 04:09 p.m., interviews with the Clinical Manager revealed that “the facility has a lot of staff call outs. I am on the floor almost every day to cover during turnovers.” i. When the Clinical Manager was asked how the call outs and the Clinical Manager’s coverage were being monitored and presented to Quality Assurance and Performance Improvement, the Clinical Manager stated that this was not being monitored and that it will be done moving forward.”

“GOV-RN, MSW, & RD AVAIL TO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs; This Standard is not met as evidenced by: 47759 Based on staff interviews, observation, and record review, the facility’s governing body failed to ensure that the interdisciplinary team (consisting of the registered nurse, dietician, and social worker) were available to meet patient needs, conduct timely assessments, and develop timely plans of care. This failure placed patients at potential risk and denied their rights to a minimum standard of care. Findings Included: 1. On 06/24/2024 from 12:30 p.m. -01:30 p.m. during review of 7 selected patients’ 30 day plans of Care (PoC), the surveyor observed that 2 of the 7 plans of care reviewed (29%) were either incomplete or were completed late. Cross-reference to tag V0557. On 06/24/2024 from 12:30 p.m. -01:30 p.m. during a review of 6 selected patients’ annual plans of care (PoC), the surveyor observed that 4 of the 6 plans of care reviewed (66%) were incomplete either for 2023, 2024, or both. See Cross-reference to tag V0519. a. On 06/26/2024 at 04:09 p.m., the Clinical Manager stated in an interview: “...the facility has a lot of staff call outs. I am on the floor almost every day to cover during turnovers.” The surveyor asked the Clinical Manager if they had sufficient time to complete PoCs. The Manager responded: “I don’t have the time to do the PoC” “[Staff #1] does not have time to do the PoC ... I need another nurse on the floor.” b. On 06/26/2024, at 10:50 a.m., the surveyor interviewed the dietician about the lack of timeliness of the PoC. According to the dietician, the late PoC was due to late registered nurse assessment. 2. On 06/17/2024, 06/24/2024, and 06/26/2024, during the surveyor’s in person visit at the facility, the surveyor observed the lack of in person presence of the social worker. On 06/17/2024 from 02:00 p.m. - 03:00 p.m., during patient interviews, the surveyor determined that 4 out of the 7 (57%) interviewed patients did not know who the social worker was. a. On 06/28/2024 at 02:23 p.m., an interview with the social worker revealed that the social worker was covering via remote/phone call only and confirmed that [he/she] had not been in the facility to meet patients in person. The social worker confirmed that there were times in which [he/she] was not able to reach out to patients due to the lack of success in phone call answers.”