Fmc Hastings Ave - Holland

“Develop EP Plan, Review and Update Annually CFR(s): §403.748(a), §416.54(a), §418.113(a), §441.184(a), §460.84(a), §482.15(a), §483.73(a), §483.475(a), §484.102(a), §485.68(a), §485.542(a), §485.625(a), §485.727(a), §485.920(a), §486.360(a), §491.12(a), §494.62(a). The [facility] must comply with all applicable Federal, State and local emergency preparedness requirements. The [facility] must develop establish and maintain a comprehensive emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: (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 all of the following: * [For hospitals at §482.15 and CAHs at §485.625(a):] Emergency Plan. The [hospital or CAH] must comply with all applicable Federal, State, and local emergency preparedness requirements. The [hospital or CAH] must develop and maintain a comprehensive emergency preparedness program that meets the requirements of this section, utilizing an all-hazards approach. * [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. * [For ESRD Facilities at §494.62(a):] Emergency Plan. The ESRD facility must develop and maintain an emergency preparedness plan that must be [evaluated], and updated at least every 2 years. . This Standard is not met as evidenced by: 38905 Based on interview and record review the facility did not update their Emergency Preparedness Plan on a bi-annual basis. This has the potential to decrease the effectiveness of the Emergency Preparedness Plan by increasing the likelihood of outdated information that could hinder the response to protect and aid patients and staff in the event of an emergency. Findings Include: During an onsite review of an emergency preparedness plan, provided by Clinical Manager “B”, it was found that the last update on the facility’s “Guidelines for Emergency Preparedness” policy, stated “23-Jan-2019” as the most recent date. The policy goes on to state that “The Governing Body will: Review and approve the Facility Specific Disaster Safety plan initially and annually ...”. No documentation was found in the provided Emergency Plan that shown this had been done. An interview with Clinical Manager “B” on 3/18/25 at 13:33, found that he has been in the process of updating the plan and not all updated material made it to the Emergency Preparedness binder that he provided the surveyor for review. When asked if there was documentation that showed a bi-annual review had been done, Clinical Manager “B” did not have documentation of such review.”

“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: 38905 Based on interview and record review, the facility did not conduct and document exercises to test the emergency plan. This has the potential to decrease the effectiveness of the facility’s emergency preparedness which could affect all patients and staff in the event of an emergency. Findings Include: During an onsite review of an emergency preparedness plan, provided by Clinical Manager “B”, it was found in the facility’s “Guidelines for Emergency Preparedness” policy, dated 23-Jan-2019, that “Annually, each facility MUST participate in community-based disaster drill. If unable to participate, document who you contacted in the community and why the clinic was unable to participate on the Facility Specific Disaster Safety Plan form (FMS-CS-IC-11-130-014Dl). If the EOC or similar agency has not performed a community-based drill, or it was missed for a particular year, the DO should coordinate a dialysis facility area-based drill.” A further review of the Emergency Preparedness plan, it was revealed there was no documentation for a tabletop or community-based exercise being completed. The facility policy goes on to state “If facility is involved in an actual disaster, it can take the place of community-based drill or tabletop drill. The facility must have pictures and news articles to document the event. The DO/AM must complete an after-action review and make any revision to the emergency plan as needed.” An interview with Clinical Manager “B”, on 3/18/25 at 13:35, found that he has been in the process of updating the plan and not all updated material made it to the Emergency Preparedness binder that he provided the surveyor for review. When asked if there was documentation of a tabletop or community-based exercises, Clinical Manager “B” stated they had worked with the Region 6 Emergency Operations Center and have had some real-life emergencies but was unable to provide documentation of such events or drills in the last two years.”

“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: 48030 Based on observation, interview, and record review, the facility failed to ensure that IV (intravenous) medications and parenteral vials of injectable medications were dated with expiration dates after they were pre-drawn or were accessed, resulting in the potential for negative outcomes for all patients receiving treatment at the time of observations. Findings include: On 3/17/25 at approximately 1100, two 25 gram (0.5 g/ml) syringes of 50% Dextrose Injection was stored in the cabinet storing medications in the dialysis treatment area with a marker date of 3/1/2025. The dialysis nurse (staff G) was queried about the expiration date and stated, “yes, that is expired, I will get rid of it”. 15195 Additionally, on 3/17/25 at approximately 1140, a 30 milliliter vial of Heparin 30,000 units was stored in the home program medication cabinet with a marker date of 2/4/24. The home nurse (staff I) was queried about the expiration date and she was unsure of the expiration date, then said in 30 days. On 3/19/25 at approximately 0930, review of the facility policy provided regarding expired medications titled “Medication Preparation and Administration for Inpatient Services, dated 9/2/24” documented, “Multi-dose vials must be labeled with the date opened, expiration date, and initials of the (facility acronym) nurse. Note: Multi-dose vials expired on day 28 or sooner per manufacturer’s instructions for use (IFU). Expired medications are to be discarded using the off-site return program or in accordance with local and/or state law.” On 3/19/25 at approximately 1145, review of a second policy provided by the facility titled “Medication Preparation and Administration IC, HT, dated 2/6/23” documented, “Expiration dates for all stored medications are to be monitored on a monthly basis. Any open multi dose vials must be discarded 28 days after opening or per manufacturer’s expiration date.” This had not been done.”

“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: 36887 Based on observation and interview, the facility failed to maintain the clean supply cart resulting in the potential to spread infectious agents to all patients served by the facility. Findings include: On 3/17/2025 at 1117, a metal cart containing clean supplies was observed to be sitting in front of the isolation room. The bottom rack and wheel mechanisms were observed to have a moderate amount of rust present. This finding was confirmed by Clinic Manager Staff B at the time of discovery.”

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to have all members of the interdisciplinary team participate in evaluation of all patients for stability resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: During an interview with Social Worker Staff O on 3/18/2025 at 1334, she stated the interdisciplinary team (IDT) would meet at a time that was convenient for the nurse and the physician would not attend the meeting. When queried who was present, she stated it was the dietician, nurse, clinic manager, and herself. She confirmed that the nurse practitioners did not participate. Dietician Staff N stated on 3/18/2025 at 1358 the IDT consisting of the nurse, social worker, dietician and clinical manager would meet to discuss patients who may be unstable and those who were due for their annual plan of care. When queried as to if the physician or advanced practice provider (APP) were involved in the meeting, Staff N stated the physician was involved, but not in the building. She stated the nurse would call him after the meeting to update him and obtain his input regarding the patients that were discussed. On 3/18/2025 at 1440, Nurse Staff Q stated the meeting to discuss patient stability/instability was done by the nurse, social worker, and dietician and that they would “take input from the doctor.” On 3/18/2025 at 1531, Physician Staff M stated he was the only physician there currently and admitted difficulty in making it to the meetings; however, staff informed him of what occurred in the meeting. Facility policy #45283 titled “Comprehensive Interdisciplinary Assessment and Plan of Care” published 7/3/2023 states, “The Comprehensive Interdisciplinary Assessment and Plan of Care must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the patient or patient ’ s designee, a registered nurse, the patient ’ s attending physician (or physician extender where allowed by State regulations), qualified master ’ s degree level social worker and qualified registered dietitian...Patient stability must be reviewed monthly. The interdisciplinary team will offer input to the attending physician who will determine whether the patient is stable or unstable on the criteria included in this policy...The patient plan of care will be developed from the findings gathered in the CIA. The IDT members are expected to interact and share information from the comprehensive assessment to facilitate the development of the plan of care.””

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) 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- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 36887 Based in interview and record review, the facility failed to identify the need for continued instability of 1 (P-7) of 2 patients reviewed for instability resulting in the potential for unidentified, unmet patient needs and poor patient outcomes. Findings include: On 3/18/2025 at 0947, review of the medical record for P-7 revealed treatment sheets which indicated a start time of dialysis between 0600-0615 each treatment. Three plans of care were present, one from October 2024, November 2024, and December 2024. The plans of care from October 2024 and November 2024 revealed P-7 was unstable due to hospitalizations. Review of the December 4, 2024 plan of care revealed P-7 was made stable. On 3/18/2025 at 1005, review of the hospitalization log from October 2024 to present revealed P-7 was hospitalized 12/4/2024 for fluid overload. On 3/18/2025 at 1030, review of the “Missed or Shortened Treatment Report” for P-7 revealed he was hospitalized on 12/4/2024 and did not come for treatment. On 3/18/2025 at 1358, Dietician Staff N stated, “We were on the fence about his stability.” When queried as to why the interdisciplinary team (IDT) made P-7 stable when he was not present for treatment that day, she indicated P-7 had requested to meet with the nurse at a later time to discuss the plan of care so the IDT felt it was okay to proceed. On 3/18/2025 at 1440, Nurse Staff Q was queried as to what time the IDT started plans of care meetings with patients in general to which she replied they started approximately 0900. When shown the above information and queried as to why the IDT made P-7 stable, she stated, “I have no words. I don’t know what to say.” Facility policy #45283 titled “Comprehensive Interdisciplinary Assessment and Plan of Care” published 7/3/2023 states, “Unstable patients must be reassessed by the IDT monthly. Monthly reassessment and any POC updates related to the reason the patient is considered “unstable” must be documented until the issues have been resolved or the IDT (including the patient if possible) determines that the condition is chronic.””

“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: 48030 Based on observation, interview and record review, the medical director failed to ensure the facility adhered to policy and procedure regarding 1) dialysate flow rate and dialysate composition and ensure that treatment settings are as prescribed by the physician for 2 patients (P-11, P-12) , 2) signing the plan of care for 1 (P-5) of 5 incenter patients reviewed for plan of care, and 3) the timing of the initial nursing assessment for 1 (P-6) of 2 new patients resulting in the potential for adverse outcomes for the patients. Findings include: 1) On 3/18/2025 at approximately 0930 dialysis treatment orders were checked for 8 randomly selected patients with dialysis nurse, Staff Q. P-11 was receiving his dialysis treatment at station #7. Patient’s BFR (blood flow rate) was programmed at 400. Order was checked and revealed BFR was ordered at 350. Staff Q was asked how long P-11 was running at 400 and replied that the treatment started about 3 hours ago. When queried if there was a reason P-11’s BFR was running at a different rate than prescribed, Staff Q replied, “no, that was a mistake” and changed the BFR to 350. Review of the treatment sheet dated 3/18/2025 revealed dialysis treatment was started at 0608 and the BFR was 400 and the DFR was 600 and at 0937 the BFR was changed to 350 and DFR was 600. P-12 was receiving his dialysis treatment at Station #8. Patient’s BFR (blood flow rate) was programmed at 400 and the DFR (dialysate flow rate) was programmed at 500. The order was checked and revealed BFR was ordered at 450 and the DFR was ordered at 800. When queried the reason the BFR and DFR were running at a different rate than prescribed, Staff Q replied it was because the TMP (transmembrane pressure) was high because P-6’s “blood is thick” and added they often have to adjust the rates for the TMP pressure. Review of the treatment sheet date 3/18/2025 reveals P-6 was started on dialysis at 0654 and BFR was 300 was DFR was 300, at 0709 BFR was 400, DFR was 800, at 0736 BFR was 300 and DFR was 600, at 0833 BFR was 400 and DFR was 800, at 0902 BFR was 340 and DFR was 700, at 1000 BFR was 300 and DFR was 600, at 1101 BFR was 250 and DFR was 600, and at 1117 BFR was 200 and DFR was 400. When queried if the medical director was aware that the staff was adjusting the BFR and DFR due to the elevated TMP, Staff Q replied they did not notify him and they do not have an order to change the rates for the increased TMP pressure. On 3/18/2025 at 1536 during interview with facility’s Medical Director, Staff M, he stated that expectations are for all clinical and nursing staff to follow the facility’s policies and procedures. When asked if staff must follow physician’s orders for dialysis treatments he stated “yes”. Facility’s Patient Assessment and Monitoring Policy, dated 5/1/23, was reviewed on 3/18/2025 and revealed: The purpose of this policy is to provide guidance to [facility’s] direct patient care staff on assessment and monitoring patients before, during and after treatment. Data collection tasks as outlined in this policy may be delegated or assigned to non-licensed staff based on job description, licensure, certification, [facility’s] policies, and documented training and competency. Direct patient care staff may collect data such as weight, BP, pulse, respirations, temperature, general observations, access, and complaints reported by the patient. The Registered Nurse will assess/re-assess any findings addressed pre or during treatment as needed. During treatment. Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations. Machine Parameters and Extracorporeal Circuit. Check machine settings and measurements: -Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. -Check dialysate flow rate setting is correct, and the prescribed flow is being delivered. 36887 2) On 3/18/2025 at 0947, review of the medical record for P-5 revealed P-5 indicated they wanted to review the plan of care in a private setting with the team for the plan of care scheduled for 3/4/2025. A plan of care dated 3/4/2025 had signatures as follows: Physician oversight-3/9/2025, Nurse-3/4/2025, Social Worker 3/4/2025, Dietician-3/11/2025, Advanced Practice Provider-3/4/2025, and Patient-3/10/2025. It was noted the physician and the Dietician attended remotely. On 3/18/2025 at 1510, Clinic Manager Staff B were queried as to when the private meeting with the care team should take place to which Staff B stated it should take place on the date of the plan of care meeting. Staff B was shown the plan of care and was queried as to why the patient signed on 3/10/2025 to which he did not have an answer. On 3/19/2025 at 0845, Director of Operations Staff C stated he was investigating why the patient would sign the plan of care at a different time. He stated the patient did not show up for treatment on 3/4/2025 so the plan of care meeting was not held until 3/10/2025 and that was when the patient signed. Staff C was queried as to why the plan of care was dated 3/4/2025 instead of 3/10/2025 and why the nurse, social worker, and advanced practice provider signed the plan of care on 3/4/2025 and the physician provided oversight to the plan of care on 3/9/2025 prior to the plan of care being done to which Staff C stated he was unable to provide an “explanation for the varying dates of the IDT (interdisciplinary team) in the system.” In a meeting with the medical director, Staff M on 3/18/2025 at 1531, he indicated it was his expectation that the policies and procedures in the facility be followed by all staff. Facility policy #45283 titled “Comprehensive Interdisciplinary Assessment and Plan of Care” published 7/3/2023 states, “The Comprehensive Assessment and Plan of Care (adult patient) must be completed electronically in the patient ’ s medical record. The Plan of Care should be signed at the time of the interdisciplinary team meeting for those attending in person. If unable to sign at the time of the meeting or if attending remotely, the care plan must be signed by the IDP (sic) member within 30 days of the interdisciplinary team meeting.” 3) Review of the medical record of P-6 on 3/18/2025 at 0814 revealed he was a new patient that started dialysis on 1/16/2025 at 0720. Review of the initial nursing assessment which was documented at the end of the initial treatement sheet revealed the assessment was completed 1/16/2025 at 0804. On 3/18/2025 at 0903, Clinic Manager Staff B was queried as to why the initial nursing assessment had not been completed prior to start of the initial treatment to which he stated patients were not to be put on treatment until they were assessed. Facility policy #45283 titled “Comprehensive Interdisciplinary Assessment and Plan of Care” published 7/3/2025 states, “A registered nurse must perform an assessment on patients NEW to dialysis BEFORE initiation of their first treatment to determine immediate needs.The RN (registered nurse) must document the assessment. The assessment may be documented on the CIA (comprehensive interdisciplinary assessment) in eCC (e-cube documentation system), evaluation cascade in Chairside or multidisciplinary notes...””