Homewood Dialysis Clinic LLC

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 36839 Based on personnel files reviewed and an interview with the clinic manager, the facility’s governing body failed to ensure that all staff members were trained in emergency preparedness on at least an annual basis. This failure denied the patients their rights to receive competent care from the clinical staff, and placed the patients at potential risk of harm in the event of an emergency. Staff #: The Centers for Medicare and Medicaid Services requires a comprehensive emergency preparedness program that includes training and testing: Facilities must provide regular emergency preparedness training for staff and conduct exercises to test their emergency plan at least annually. A review of the facility’s personnel file on 9/5/2025 revealed that 6 out 7 facility staff members did not have any record of annual training on emergency preparedness. This finding was verified by the clinic manager who provided the record to the surveyor on 9/5/2025.”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 36839 Based on review of the facility’s personnel files, and interviews with the clinical manager, the governing body failed to ensure that all clinical staff had current annual Infection Control Practice Training. This failure placed all the patients, and staff at potential risk for exposure to blood borne pathogens and infectious diseases. Findings included: The Centers for Disease Control (CDC) recommends infection control training initially on employment and annually, and the Occupational Safety and Health Administration (OSHA) mandates dialysis staff receive bloodborne pathogen training annually. A review of the personnel file on 9/5/2025 revealed that 6 out of 7 facility staff members did not have any documentation of annual training on infection control. This finding was verified by the clinic manager who provided the record to the surveyor on 9/5/2025.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 36839 Based on observations, the facility’s governing body failed to ensure that the medications being administered to the patients were safe to use. This failure placed the patients at potential risk of harm. Findings included: According to the facility’s policy on Medication Administration, “Once a multiple-dose vial has been punctured in preparation to administer the medicarion, the vial shall be re-labeled with staff initials, the revised expiration date of 28 days past the opened date, unless otherwise specified by the manufacturer.” During observations on the treatment floor on 9/3/2025, an opened multiple-dose vial of Zemplar was noted to be on the medication counter without the revised expiration date and the initials of the staff member who opened it. This finding was confirmed by the charge nurse, and discussed with the administrative body during the exit conference on 9/3/2025.”

“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: 36839 Based on observation, the facility ’ s administration failed to ensure that all supplies used for patient care were maintained in a safe manner. This failure placed patients at risk for potential harm. Findings included: During an inspection of supplies on 9/3/2025, the following expired items were identified: 1. Two bottles of ExSept antiseptic solution (expiration date 5/5/2025), one in the isolation room and one on the nursing staff counter, located in the clinical treatment area. 2. Two disposable vent heat moisture exchangers, or HMEs (expiration dates 8/7/2023 and 12/13/2024), located in the supply room. 3. Twenty-eight tracheostomy/ventilator HME filters with expiration dates ranging from 3/10/2025 to 8/30/2025, located in the supply room. These findings were confirmed by the dialysis clinic manager and discussed with the governing body during the exit conference on 9/3/2025.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 36839 Based on observations, the facility’s governing body failed to ensure that every patient’s vascular access was visible during hemodialysis treatment. This failure placed the patients at potential risk of harm and possible death. Findings included: Dialysis patients must keep their access site and bloodlines visible to staff during treatment to prevent fatal blood loss from a dislodged needle or line. While a patient has the right to refuse, the facility must educate them on the risks and create a care plan. Signing a waiver does not excuse the facility’s responsibility to monitor the patient’s access. During observations on the clinical floor on 9/3/2025, the vascular access site of Patient #5 was covered with a blanket from 12:00 to 12:40 p.m. Upon review of the patient’s post-dialysis treatment flow sheet, the clinical staff responsible for monitoring the patient failed to document or address that the patient’s access site was covered for approximately 40 minutes, or verify proper placement of the access needles. This finding was discussed with the governing body during the exit conference on 9/3/2025.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 36839 Based on the medical records reviewed, the governing body failed to ensure that all initial nursing assessments were completed by the assigned registered nurse (RN) prior to the patients’ initial dialysis treatment when admitted to the facility. This failure placed the affected patients at risk for receiving insufficient and ineffective care and denied them their rights. Patients: #1, #2, and #4 Findings included: According to the facility’s policy on Medical Record Content (Reference #9002, page 3), “An initial nursing assessment must be completed prior to the first dialysis treatment.” A review of 4 sampled patient charts with the clinic manager on 9/3/2025 revealed the following: 1. Patient #1’s first dialysis treatment at the facility was on 1/5/2024. No initial nursing assessment was found in the patient’s medical records. 2. Patient #2’s first dialysis treatment at the facility was on 9/2/2024, with a readmission date of 10/30/2024 after being away from the facility for more than 30 days. No initial nursing assessment was found in the patient’s medical records. 3. Patient #4’s first dialysis treatment at the facility was on 5/1/2024. No initial nursing assessment was found in the patient’s medical records.”

“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: 36839 Based on the review of patient records and the facility’s policies and procedures (P&P), the governing body failed to ensure that all clinical staff complied with the monitoring and execution of appropriate procedures when certain parameters exceeded normal values during patients’ dialysis treatments. This failure placed the affected patient at potential risk of harm. Patient: #2 Findings included: The facility’s Hypertension Protocol states: (a) For SBP (systolic blood pressure) >180 mmHg or DBP (diastolic blood pressure) >100 mmHg, call MD/NP (Medical Doctor/Nurse Practitioner) for permission to administer clonidine 0.1 mg PO (by mouth) x 1. (b) Reassess blood pressure 30 minutes after administration of clonidine. If SBP remains >180 mmHg or DBP remains >100 mmHg, call MD/NP for further instructions. A review of the sampled patient’s medical records on 9/3/2025 revealed that on the treatment date of 8/27/2025, Patient #2 had persistently high blood pressures ranging from 182/74 mmHg to 202/106 mmHg. No documentation was found indicating that the patient’s high blood pressures were addressed. The facility’s hypertension protocol was not followed. This finding was discussed with the governing body during the exit conference on 9/3/2025.”

“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: 36839 Based on review of the sampled patients’ medical records, the governing body and the interdisciplinary team (IDT) failed to ensure that a comprehensive assessment was conducted for all new patients within the latter of 30 calendar days or 13 treatments, beginning with the first outpatient dialysis session. This failure placed the affected patient at potential risk of harm and denied the patient their rights. Patient #1 Findings included: The facility’s policy on Comprehensive Assessments (Reference #8005) states: “An initial comprehensive assessment shall be conducted on all patients (all admissions to a dialysis facility) within the latter of 30 calendar days or 13 outpatient hemodialysis sessions, beginning with the first outpatient dialysis session.” A review of Patient #1’s comprehensive assessment on 9/3/2025 showed that the patient’s first dialysis treatment at the facility was on 1/5/2024, with an initial comprehensive assessment completed on 3/5/2024, which was greater than 30 days from the patient’s first dialysis session. This finding was confirmed by the dialysis clinic manager upon review of the patient’s medical record.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 36839 Based on a review of the sampled patients’ medical records, the governing body failed to ensure that the facility’s interdisciplinary team (IDT) completed the required 90-day follow-up comprehensive assessment at the appropriate time frame. This failure placed the affected patient at risk of receiving inadequate health care and denied the patient their rights. Patient: #4 Findings included: The facility’s policy on Comprehensive Assessments, reference #8005, states: “A follow-up comprehensive assessment must occur within three months after the completion of the initial assessment to provide information to adjust the patient’s plan of care.” A review of Patient #4’s medical records with the dialysis clinic manager on 9/3/2025 revealed that the patient, whose first dialysis treatment at the facility occurred on 5/1/2024, received an initial comprehensive assessment on 5/29/2024. However, the follow-up comprehensive assessment was not completed until 9/18/2025, which exceeded 90 days from the initial assessment. This finding was discussed with the governing body during the exit conference on 9/3/2025.”