Davita Rivertowne Dialysis

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 47759 Based on the overall findings of the survey, it was deteremined that the facility’s governing body failed to 1) provide individualized nutritional needs assessments for patients, 2) provide initial comprehensive patient assessments within latter of 30 calendar days or 13 treatment sessions, and 3) provide patient re-assessments within 90 days after completion of initial assessments. These failures placed the affected patients at potential risk of harm and denied patients the right to a minimum standard of medical care, and resulted in a finding of the facility being out of compliance with the Condition for Coverage: Patient Assessment. Findings Included: 1. The facility’s governing body failed to provide individualized nutritional needs assessment of Patient A. Cross Reference: Patient Assessment-Registered Dietician-Nutritional Status (V0509). 2. The facility’s governing body failed to provide initial comprehensive patient assessments within latter of 30 days of 13 treatment days for patients D, E, F, and G. Cross Reference: Patient Assessment-Initial-30 Day Assessment (V0516). 3. The facility’s governing body failed to provide patient re-assessments within 90 days after completion of initial assessments for patients C and H. See Cross Reference: Patient Assessment-Follow up Reassessment Within 3 Months of Initial Assessments. (V0517).”

“CFC-QAPI CFR(s): 494.110 This Condition is not met as evidenced by: 47759 Based on the overall findings of this survey, the facility’s governing body (GB) failed to 1.) Ensure continuous monitoring of indicators and/or performance improvement activities in regards to: patient grievances, adverse events, incomplete/late patient plan of care, and concerns regarding physical plant and 2.) Track indicators and/or performance improvement activities to ensure that improvements are sustained overtime. These failures placed patients at potential risk of harm by failing to utilize the data gathered to identify potential problems in the facility resulting in delay in interventions aimed at improvement, and resulted in the finding of the facility being out of compliance with Condition for Coverage (CfC: 494.110) for Quality Assessment and Performance Improvement (QAPI). Findings Included: 1. Cross-reference to tag V-0638. The facility’s governing body failed to continuously monitor and track the following QAPI indicators: 1. Patient grievances 2. Adverse events, 3. Incomplete/late patient plan of care, and 4. Concerns regarding physical plant to ensure that improvements are sustained overtime.”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 47759 Based on record review and a staff interview, the facility’s governing body failed to reassess the facility and community based all-hazards risk assessment. This failure placed the patients and staff at potential risk of harm in case of an emergency. Findings Included: On 10/04/2024 from 01:00 p.m.-02:00 p.m., review of the facility’s policy titled “Facility Emergency Management Plan” determined that page 11 number 2 stated, “Facility Administrator (FA), or designee, will identify, evaluate, and rate each hazard annually.” Number 6 stated, “ Maintain copy with Facility Emergency Management Plan. “ On 10/03/2024 from 02:00 p.m.-02:30 p.m., record review of the facility’s Emergency Preparedness/Emergency Management Plan binder revealed that the last documented facility and community based all-hazards risk assessment was completed in 2020. Interviews with the Manager of Clinical Services revealed that all hazards risk assessment per policy should be completed annually.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 47759 Based on record review and a staff interview, the facility’s governing body failed to provide an annual emergency preparedness training related to the facility’s risk assessments. This failure placed the patients and staff at potential risk of harm in case of an emergency. Findings Included: On 10/04/2024 from 01:00 p.m.-02:00 p.m., review of the facility’s policy titled “Facility Emergency Management Plan” determined that page 27 letter E stated, “The facility will conduct and/or participate in one (1) exercise to test the facility Emergency Management Plan (EMP) at least ANNUALLY, conducted on OPPOSITE years (one year full-scale [community based] exercise, next year facility-based / exercise of choice)...” On 10/03/2024 from 02:00 p.m. -02:30 p.m., record review of the facility’s emergency preparedness/Emergency Management Plan binder revealed no documented facility or community based exercise for the year 2023 and 2024. This finding was confirmed by the Manager of Clinical Services.”

“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, a staff interview and record review, the facility’s governing body failed to ensure staff compliance in providing a sanitary environment to minimize the transmission of infectious agents within and between the unit and any public areas. This failure placed the patients and staff at potential risk for exposure to blood-borne pathogens and other infectious diseases. Findings Included: On 10/04/2024 from 01:00 p.m.-02:00 p.m., review of the facility’s policy titled “Infection Control for Dialysis Facilities” (Policy 1-05-01) determined that page 2 number 8 stated, “Supplies will be stored in a manner that maintains their integrity.” Number 8 letter D stated, “Anytime the integrity of a package with or without an expiration date is in question, i.e., torn, ripped, wet or contaminated, the package and its contents must be disposed of and not used.” Page 5 number 16 stated, “Clean areas should be clearly designated for the preparation, handling, and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled.” 1. On 10/01/2024, during observations of the facility, the surveyor observed the following: a. At 08:45 a.m., the surveyor observed two dialysis chairs located inside the conference room 1.) had no label, 2). had ripped upholsteries, and 3.) had brown stains on its side tables. b. From 09:10 a.m. -10:20 a.m., the surveyor observed that 5 out of the 10 dialysis chairs inspected had ripped upholsteries. (Dialysis chairs located in stations number 2, 3, 11, 17, and 18). Interviews with the Manager of Clinical Services (MCS) revealed knowledge of the ripped chairs. Review of the facility’s Quality Assurance and Performance Improvement (QAPI) revealed no documentation of monitoring and/or action plan in regards to the identified problem. According to the MCS, the facility staff members should have had documentation of the action plan and documentation of follow ups. c. At 10:25 a.m., the surveyor observed medical tapes located on the handles of the air concentrates ready for patient use. 2. On 10/02/2024 at 10:18 a.m., during observations of the facility, the surveyor observed that the drawers near the isolation room had brown residuals inside. In the bottom drawer, the surveyor observed two boxes of gloves ready for patient use. 3. On 10/03/2024, at 01:45 p.m., during observations of the facility’s emergency crash cart, the surveyor observed two Ambubags and two non-rebreathers with torn packaging.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 47759 Based on record reviews and a staff interview, the facility’s governing body failed to ensure that all susceptible patients were offered Hepatitis B Vaccination. This failure placed susceptible patients and staff members at potential risk of exposure to blood borne pathogens with a risk for seroconversion. Findings Included: On 10/04/2024 from 01:00 p.m.-02:00 p.m., review of the facility’s policy titled “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance,” determined that page 2 stated that for patients with antibody of less than 10, next step is to “Offer vaccination series.” Page 3 number 10 stated, “The patient is provided the Vaccination Information Sheet (VIS) and a consent form (included in the Patient Registration Packet found in Reggie). The patient will consent to the vaccination or will decline. The completed form will be kept in the patient’s health record.” On 10/04/2024 at 12:00 p.m., during record review of the facility’s “Vaccination and Surveillance Report,” the surveyor observed that 20 out of the 84 patients audited had “ no current hepatitis B vaccination documentation.” At 12:30 p.m., the surveyor requested for the vaccination consent or declination form for the 20 susceptible patients audited. No consent or declination form for Hepatitis B Vaccine could be presented by the facility. According to the Manager of Clinical Services, the staff members had not been completing the forms.”

“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, patient interviews and record reviews, the facility’s governing body failed to provide dialysis patients, staff and the public a safe, functional and comfortable treatment environment. This failure placed the patients, staff and visitors at potential risk of harm including injury or infection. Findings included: On 10/04/2024 from 01:00 p.m.- 02:00 p.m., review of the facility’s policy titled “Physical Environment” (Policy 08-04-01) determined that page 1 number 1 stated: “The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment.” According to the Food and Drug Administration (FDA), the sharps disposal container opening must not be big enough for a hand to enter. According to a pest control company Orkin, Biting Gnats, “Bites are most likely to occur on any exposed, uncovered skin and most often occur on the head, neck, forearms, hands, face, legs and feet. General symptoms are itchiness, irritation, redness and swelling at the site of the bite ... Continuous scratching can lead to open sores that are susceptible to secondary bacterial infection of the bite wound. In some cases, the transmission of infectious diseases by the biting gnat is possible.” 1. On 10/01/2024, during observations of the treatment floor, the surveyor observed the following: a. From 09:10 a.m. -10:20 a.m., the surveyor observed that 5 out of the 10 dialysis chairs inspected had ripped upholsteries. (Dialysis chairs located in stations number 2, 3, 11, 17, and 18). i. On 10/01/2024 at 10:30 a.m., Patient A stated that the “ dialysis chairs are horrible. They hurt my back. “ ii. On 10/02/2024 at 11:00 a.m., Patient J stated that the dialysis chairs are old and need to be replaced. b. At 09:12 a.m., the surveyor observed a pipe underneath the sink near stations #20 and 21 that was leaking. c. At 09:45 a.m., the surveyor observed 4 out of 9 sharps containers that had an opening that was big enough for a hand to enter. 2. On 10/02/2024, during observations of the treatment floor, the surveyor observed the following: a. At 10:18 a.m., the surveyor observed that the bottom drawer outside the isolation room was difficult to open b. At 10:20 a.m., the surveyor observed that the hand sanitizer dispensers located in three different places were non functional. i. Location #1: Between the treatment room and the water room ii. Location #2: Between the treatment room and the clinical manager’s office iii. Location #3: Between the waiting room and the office area. 3. On 10/02/2024 from 12:00-12:20 p.m., review of the facility ’ s grievance records revealed two complaints regarding presence of “ gnats “ on the treatment floor (July 2024 and August 2024). On 10/01/2024, a 3rd complainant expressed concerns of “ gnats “ on the treatment floor to the surveyor. From 10/01/2024 through 10/02/2024, on multiple occasions, the surveyor observed gnats flying around the surveyor ’ s face while in the conference room. On 10/02/2024 at 12:20 p.m., interviews with the Manager of Clinical Services and the covering Social Worker both confirmed that the facility ’ s governing body did not have documentation on the FHM records that evaluated the success of the plan to manage “ gnats “ or documentation that demonstrated that improvements were sustained.”

“PR-INFORMED OF OWN MEDICAL STATUS CFR(s): 494.70(a)(10) The patient has the right to- (10) Be informed by the physician, nurse practitioner, clinical nurse specialist, or physician’s assistant treating the patient for ESRD of his or her own medical status as documented in the patient’s medical record, unless the medical record contains a documented contraindication; This Standard is not met as evidenced by: 47759 Based on record review, the facility’s governing body failed to ensure that all of the facility’s patients had a completed Medical Orders for Life-Sustaining Treatment Form (MOLST) placed in their patient records in a prompt manner. This failure denied the patients their rights to formulate treatment decisions that served their end of life needs. Findings Included: The Code of Maryland Regulations (COMAR) at 10.01.21.04B states the following: “Beginning July 1, 2013, the following health care facilities are required to accept, update if appropriate, and complete the MOLST form for each patient during the admission process in accordance with the form’s instructions: ... (4) A kidney dialysis center.” Additionally, COMAR 10.01.21.04E requires: When initially completing a MOLST form or updating an existing MOLST form, a health care facility shall: (1) Offer the patient or authorized decision maker the opportunity to participate in completing or updating the MOLST form, and on request of the patient, offer any physician [or], nurse practitioner, or physician assistant selected by the patient the opportunity to participate in updating or completing the MOLST form; (2) Note in the medical record when a patient or an authorized decision maker declines to participate in completing or updating the MOLST form, indicating the date and time of discussion, with whom the form was discussed, and a summary of the discussion; [and] (3) Inform the competent patient or authorized decision maker that the MOLST form will become part of the medical record and can be accessed through the procedures used to access a medical record. On 10/03/2024 at 10:30 a.m., during record review of the sampled patient’s medical records, the surveyor observed that Patients G, H, and I had incomplete MOLST forms.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 47759 Based on observations, the facility’s governing body failed to ensure that the correct mailing address of the State survey agency was prominently displayed where it can be easily seen and read by the patients. This failure denied the patients their rights. Findings Included: On 10/01/2024, at 08:30 a.m., during a flash tour of the facility, the surveyor observed that the complaint poster was outdated. According to the poster, the address written for the Office of Health Care Quality was 55 Wade Avenue, Catonsville, MD 21228. The correct address for the Office of Health Care Quality is 7120 Samuel Morse Drive, Second Floor, Columbia, MD 21046-3422.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 47759 Based on observations, a staff interview and record reviews, the facility’s governing body failed to ensure that all patients’ nutritional assessments and nutritional plan of care were individualized to address the patients’ needs. This failure placed the affected patient at potential risk and denied their rights to a minimum standard of medical care. Findings Included: On 10/04/2024 from 01:00 p.m.-02:00 p.m., review of the facility’s policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” (Policy 1-14-01) determined that page 1 number 2 stated, “The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs.” Number 2 stated, “ Assessment criteria will include, but not be limited to, evaluation of: Nutritional status by dietitian.” On 10/01/2024 from 11:30 a.m. - 12:00 p.m., during review of the facility’s hospitalization log, the surveyor observed that Patient A was hospitalized due 06/2024 due to diabetes (hyperglycemic event). On 10/02/2024 at 12:30 p.m., the surveyor requested documentation for the months of June through August regarding evaluation of patient A’s nutritional status regarding glycemic control. The dietician was unable to provide documentation of the assessment of Patient A’s nutritional condition based on metabolic parameters, particularly glycemic control, or of strategies to avoid hospitalization in the future.”

“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: 47759 Based on record reviews and a staff interview, the facility’s governing body 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 patient at potential risk of harm and denied patients right to a minimum standard of care. Findings Included: On 10/04/2024 from 01:00 p.m.- 02:00 p.m., during record review of the facility’s policy titled “Interdisciplinary team (IDT) Patient Assessment and Plan of Care” (Policy 01-14-01), page 2 number 4 stated: “A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.” On 10/03/2024 from 10:30 a.m. - 01:30 p.m., during record review of the selected patients’ Plan of Care (PoC), the surveyor observed the following: 1. Patient D was admitted 10/13/2021. During review of the patient’s plan of care, the surveyor observed that the Interdisciplinary team (IDT) assessments were completed 12/13/2021, which was approximately one month late. 2. Patient E was admitted 12/14/2023. During review of the patient’s plan of care, the surveyor observed that the Interdisciplinary team (IDT) assessments were completed 02/13/2024 , which was approximately one month late. 3. Patient F was admitted 07/19/2023. During review of the patient’s plan of care, the surveyor observed that the Interdisciplinary team (IDT) assessments were completed 11/14/2023, which was approximately three months late. 4. Patient G was admitted 08/02/2024, during review of the patient’s plan of care, the surveyor observed that the assessment from the nurse had not been completed. On 10/04/2024, at 01:30 p.m., the Manager of Clinical Services (MCS) stated during an interview that the Comprehensive Assessments should have been completed within 30 days.”

“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: 47759 Based on record reviews and a staff interview, the facility’s governing body failed to ensure that a follow up comprehensive reassessment occurs within 3 months after the completion of the initial assessment. This failure placed the affected patient at potential risk of harm and denied patients right to a minimum standard of care. Findings Included: On 10/04/2024 from 01:00 p.m.-02:00 p.m., during record review of the facility’s policy titled “Interdisciplinary team (IDT) Patient Assessment and Plan of Care” (Policy 01-14-01), page 2 number 5 stated, “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.” On 10/03/2024 from 10:30 a.m. - 01:30 p.m., during record review of the selected patients’ Plan of care (PoC), the surveyor observed the following: 1. Patient C’s 30 day Plan of Care (PoC) was completed 02/02/2023. The follow up 90-day reassessment was not completed until 08/07/2023, which was approximately 3 months late. 2. Patient H was a patient who transferred and was admitted 04/29/2024. As of 10/03/2024, the follow up 90 day reassessment has not been completed. On 10/04/2024, at 01:30 p.m., the Manager of Clinical Services (MCS) stated during an interview that the follow up comprehensive assessments should have been completed within 90 days.”

“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, the facility’s governing body and interdisciplinary team (IDT) failed to ensure that the implementation of the initial plan of care began within 30 days after admission to the dialysis facility 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 10/04/2024 from 01:00 p.m.-02:00 p.m., during record review of the facility’s policy titled “ Interdisciplinary Team (IDT) Patient Assessment and Plan of Care “ (Policy 1-13-01) page 4 number 10 stated, “ An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.” On 10/03/2024 from 10:20 a.m. -01:30 p.m., during review of 9 selected patients’ 30 day PoC, the surveyor observed that 4 out of the 9 plan of care reviewed ( 44%) were not completed within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis). The review demonstrated the following 1. Patient G was admitted 08/02/2024, as of 10/03/2024, no completed Plan of Care (PoC) could be presented to the surveyor. 2. Patient D was admitted 10/13/2021, patient D’s 30 day PoC was completed and signed on 12/18/2021 which was 1 month late 3. Patient E was admitted 12/14/2023, patient E’s 30 day PoC was completed and signed on 03/15/2024 which was 2 months late. 4. Patient F was admitted 07/19/2023, patient F’s 30 day PoC was completed and signed on 11/22/2023 which was 3 months late.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 47759 Based on a review of the facility’s Quality Assurance and Performance Improvement (QAPI) and staff interviews, the facility’s governing body failed to 1. Ensure continuous monitoring of indicators and/or performance improvement activities in regards to: patient grievances, adverse events, incomplete/late patient plan of care, and concerns regarding physical plant; 2.Track indicators and/or performance improvement activities to ensure that improvements are sustained overtime. These failures placed patients at potential risk of harm by failing to utilize the data gathered to identify potential problems in the facility resulting in delay in interventions aimed at improvement. Findings Included: On 10/04/2024 from 01:00 p.m.-02:00 p.m., the surveyor reviewed the policy titled “ Continuous Quality Improvement Program “ (Policy 1-14-06) Page 1 number 7 stated, “ The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not be limited to,... “ Review of trends of adverse patient occurrences ...Review of product, equipment, or medication notices or recalls ...Patient Satisfaction and Grievances. “ Number 8 stated, “ Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement, and will track this change in performance over time to verify improvements are sustained. “ 1. On 10/04/2024 from 03:00 p.m. -04:00 p.m., during review of the facility’s Facility Health Meetings (FHM, also known as Quality Assurance and Performance Improvement or QAPI), the surveyor observed that the facility’s FHM records did not have documentation of analyses and discussions regarding unexpected hospitalization which occurred three times in April 2024, once in June 2024 and once in July 2024. Interviews with the manager of clinical services confirmed that no analyses or discussions of trends were documented in any of the FHM meetings that occurred in April, June, or July of 2024. 2. On 10/02/2024 from 12:00-12:20 p.m., review of the facility’s grievance records revealed two complaints regarding presence of “ gnats “ on the treatment floor (July 2024 and August 2024). On 10/01/2024, a 3rd complainant expressed concerns of the “ gnats “ on the treatment floor to the surveyor and the surveyor also observed gnats being present at the time of the complaint. On 10/02/2024 at 12:20 p.m., Interviews with the Manager of Clinical Services and the covering Social Worker both confirmed that the facility ’ s governing body did not have documentation on the FHM records that evaluated the success of the plan to manage “ gnats “ or documentation that demonstrated that improvements were sustained. 3. On 10/02/2024 from 12:00-12:20 p.m., review of the FHM records revealed no discussion of patient satisfaction surveys. According to the covering Social Worker, satisfaction surveys were done through Consumer Assessment of Healthcare Providers and Systems (CAPHS), which [he/she] stated was not addressed in FHM. 4. On 10/01/2024, from 09:10 a.m. -10:20 a.m., during observations of the treatment floor, the surveyor observed that 5 out of the 10 dialysis chairs inspected had ripped upholsteries. (Dialysis chairs located in stations number 2, 3, 11, 17, and 18). On 10/04/2024 from 03:00 p.m. -04:00 p.m., review of the FHM records revealed no documentation of monitoring and/or action plan in regards to the identified problem. According to the Manager of Clinical Services (MCS), the facility staff members should have had documentation of the action plan and documentation of follow ups. 5. On 10/03/2024 from 10:20 a.m. -01:30 p.m., during review of 9 selected patients’ 30 day PoC, the surveyor observed that 4 out of the 9 plan of care reviewed (44%) were not completed within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis). On 10/04/2024 from 03:00 p.m.-04:00 p.m., review of the FHM records revealed no documentation of monitoring and/or action plan in regards to the identified problem.”

“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 observations, staff interviews, and review of the facility’s policies and procedures, the medical director failed to ensure that the staff members adhered to the facility’s 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. Findings Included: On 10/04/2024 at 11:30 a.m., during record review of the facility’s “Medical Director Agreement,” page 25 under “Summary of Duties for a Medical Director “ stated the following: -Participate in development, implementation, review and approval of all Center policies and procedures -Actively oversee, lead and participate in the Center ’ s monthly Facility Health Meeting ( “ FHM “ ) -Review all patient grievances during FHM -Provide general oversight for safety activities at Center -Work with Center staff to monitor potential safety issues at Center The Medical Director’s signature on the “Medical Director Agreement” and interviews conducted on 10/04/2024 at 12:30 p.m. both confirmed awareness of the duties outlined in the agreement. 1. On 10/03/2024, review of the facility’s emergency preparedness/Emergency Management Plan binder revealed failure to reassess the facility and community based all-hazards risk assessment on an annual basis. This finding failed to meet the facility’s policy titled “Facility Emergency Management Plan.” 2. On 10/03/2024, review of the facility’s emergency preparedness binder revealed failure to conduct facility and community based exercises as evidenced by the lack of documentation. This finding failed to meet the facility’s policy titled “Facility Emergency Management Plan.” 3. From 10/01/2024-10/03/2024, facility and treatment floor observations revealed lack of staff compliance in providing a sanitary environment. This failure failed to meet the facility’s policy titled “Infection Control for Dialysis Facilities” (Policy 1-05-01). 4. On 10/04/2024, review of the facility’s “Vaccination and Surveillance Report” revealed failure to ensure that all susceptible patients were offered Hepatitis B Vaccination and were documented. This failure failed to meet the facility’s policy titled “ Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance. “ 5. On 10/01/2024-10/02/2024, observations of the treatment floor revealed failure to ensure an environment that is equipped and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This finding failed to meet the facility’s policy titled “Physical Environment” (Policy 08-04-01). 6. On 10/01/2024, review of Patient A’s progress notes and interviews with the registered dietician revealed failure to ensure all patients’ nutritional assessments and nutritional plan of care were individualized to address the patients’ needs. This finding failed to meet the facility’s policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” (Policy 1-14-01). 7. On 10/03/2024, review of selected patients’ plan of care revealed the facility’s failure to ensure that initial and 90 day comprehensive assessments and plans of care were completed on time. This finding failed to meet the facility’s policy titled “Interdisciplinary team (IDT) Patient Assessment and Plan of Care” (Policy 01-14-01). 8. On 10/04/2024, review of the facility’s “Facility Health Meetings” (FHM, also known as QAPI), the surveyor observed the lack of documentation on discussions pertaining to 1. Adverse Events 2. Grievances 3. Concerns with Physical Plant 4. Patient Plan of Care This finding failed to meet the facility’s policy titled “Continuous Quality Improvement Program” (Policy 1-14-06).”