Fmc - Dundee

“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: 22050 Based on interview and record review, the facility failed to conduct Emergency Preparedness Testing exercises annually resulting in the increased likelihood for delayed emergency response and less than optimal outcomes for the 52 patients served by the facility. Findings include: On 09/25/24 at 11:50 A.M., record review of the facility Emergency Preparedness Plan revealed the following: The District 1 Regional Medical Response Coalition conducted a “Shelter From The Storm” Severe Weather Functional Exercise on March 22, 2023. The Dialysis Facility Incident After Action Review/Improvement Plan (AAR/IP) was completed on 8-2-23. On 09/25/24 at 01:00 P.M., an interview was conducted with Charge Nurse “C” regarding completion of a tabletop or other emergency preparedness exercise within the last 2 years. On 09/25/24 at 01:35 P.M., Charge Nurse “C” entered the conference room and stated: “We do not have a tabletop exercise.” Charge Nurse “C” also stated: “We are currently working on the fire event, referring to the (sister facility) fire event that occurred on 7-30-24. No further emergency preparedness documents were provided by survey exit.”

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) 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. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 29955 Based on observation, interview, and record review the facility failed to maintain the integrity of clean items resulting in the potential of the spread of infectious of disease amongst 13 patients receiving dialysis at the facility at the time of observation. Findings include: On 9/25/2024 at 0950 during initial tour of the facility, it was revealed that dialysis items (blue pads, dialyzer, clamps, and tubing, blood pressure cuffs, and machine bottles) were stored on the chase behind station #13 and station #11. On 9/25/2024 at 0955 during initial tour of the facility, it was revealed “patient packs (dialyzer, cannulation needles, gauze...)” were clipped with clamps holding gloves on the outside of the pack. On 9/25/2024 at 1000 during initial tour of the facility, it was revealed that a cardboard box labeled “twisters” was stored amongst clean items. On 9/25/2024 at 1015 during initial tour of the facility, it was revealed that patient wheelchairs and walkers were kept adjacent to trash cans and biohazard waste bins. On 9/25/2024 at 1100 an interview occurred with staff A, the facility administrator. Staff A was queried about the above stated observations. Staff A stated she would take care of the problems identified. On 9/26/2024 at 1325 a record review occurred of the policy titled, “General Cleanliness and Infection Control,” dated 07/01/2024, version 7, reference number 47685. The policy stated, “...Supplies or patient’s belongings should not be kept or stored behind the machine at the patient station...””

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 45246 Based on observation, interview, and record review, the facility failed to ensure treatments were delivered as prescribed for 2 (P-10 and 11) of 4 patients randomly selected for verification of dialysis prescription, resulting in the potential for inadequate dialysis treatment. Findings include: On 9/25/24 at approximately 1002 dialysis treatment orders were checked for 4 randomly selected patients with charge nurse, Staff C. P-10 was receiving his dialysis treatment at station #5. Patient’s DFR (dialysate flow rate) was programmed at 500. Order was checked and revealed DFR was ordered at 800. When asked for how long patient was running on 500 Staff C stated that the treatment started about 3 hours ago. P-11 was receiving his dialysis treatment at station #13. Dialysate composition was checked and revealed 2.0 K (potassium) and 2.5 Ca (calcium). Physician’s order was checked and indicated 3.0 K and 2.5 Ca. Staff C was asked for how long patient was receiving treatment with inaccurate dialysate composition, she stated for approximately 2 hours and 40 minutes. Staff C was also asked if the expectation was for nurses to check the machines’ settings after treatment initiation and confirm the correct (as ordered by provider) settings. She said yes, nurses check after technicians initiated the treatments. P-11’s treatment sheet for 9/25/24 was reviewed on 9/26/24 and revealed that machine setup was recorded as performed by patient care technician, Staff L, and reviewed by registered nurse, Staff I. On 9/26/24 at 0930 review of P-10 treatment sheets revealed the following documentation. Treatment flowsheet dated 9/25/24 had dialysis treatment documented as started at 0649 and completed at 1101. P-10’s treatment orders indicated: duration- 4 hours, BFR (blood flow rate)- 400, DFR (dialysate flow rate)- 800. At 0650 BFR was recorded 400 (as ordered) and DFR was 0 (zero). At 0659 BFR was recorded as 400, DFR- 500. DFR continued to be set at 500 untill 1006. At 1006 DFR was recorded as 0 (zero). No other recordings of DFR were noted untill patient treatment ended at 1101. Machine setup was recorded as performed by patient care technician, Staff J, and reviewed by registered nurse, Staff I. No nursing progress/treatment note was found with explanation of DFR being outside the provider’s order and no record of provider’s notification was found for that treatment day. On 9/26/24 at 1448 during interview with facility’s Medical Director, Staff D, he stated that expectations are for all clinical and nursing staff to follows facility’s policies and procedure. 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 9/26/24 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.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 47415 Based on record review and interview, the facility failed to ensure plans of care were signed by the patient for 6 (#2-7) of 13 patients, resulting in the potential for patients to be uninformed of their treatment plan. Findings include: On 9/25/2024 at 1400, record review of the plan of care document and signature page for P-2, dated 5/15/24, revealed the patient did not sign the plan of care indicating he/she participated in plan of care meeting, understood it, and agreed with actions or goals planned. On 9/25/24 at 1420, record review of the plan of care document and signature page for P-3, dated 4/23/24, revealed the patient did not sign the plan of care indicating he/she participated in plan of care meeting, understood it, and agreed with actions or goals planned. On 9/25/24 at 1445, record review of the plan of care document and signature page for P-4, dated 8/19/24, revealed the patient did not sign the plan of care indicating he/she participated in the plan of care meeting, understood it, and agreed with actions or goals planned. On 9/26/24 at 0930, record review of the plan of care document and signature page for P-5, dated 8/19/24, revealed the patient did not sign the plan of care indicating he/she participated in the plan of care meeting, understood it, and agreed with actions or goals planned. On 9/26/24 at 1000, record review of the plan of care document and signature page for P-6 dated 5/15/24, revealed the patient did not sign the plan of care indicating he/she participated in the plan of care meeting, understood it, and agreed with actions or goals planned. On 9/26/24 at 1015, record review of the unstable plan of care documents and signature pages for P-7, dated 7/19/24 and 8/19/24, revealed the patient did not sign the plans of care indicating he/she participated in the plan of care meeting, understood it, and agreed with actions or goals planned. On 9/26/2024 at 1030, Facility Administrator Staff A was queried as to when the patient should be signing the plan of care and she stated at the care plan meeting, or when the plan of care is reviewed with the patient, if they chose not to attend the meeting. Staff A also stated she looked at all the plans of care (2024) for the above listed patients and none of the plans of care were signed. On 9/26/24 at 1450, interview with Medical Director Staff D, revealed that it is his expectaion that staff follow policies and procedures of the facility. Facility policy #45283 titled “Comprehensive Interdisciplinary Assessment and Plan of Care” published 7/3/2023 states, “If the patient ...is unable or unwilling to attend the plan of care meeting or if the patient attends via telehealth ...the registered nurse may review the plan of care as developed by the IDT at the meeting with the patient and obtain the patient’s signature and any comments...The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for the refusal must be documented in the patient’s medical record.””

“QAPI-INDICATOR-PT SATIS & GRIEVANCES CFR(s): 494.110(a)(2)(viii) The program must include, but not be limited to, the following: (viii) Patient satisfaction and grievances. This Standard is not met as evidenced by: 15195 Based on document review and interview, the facility failed to monitor and track patient complaints and/or grievances for six (3/2024 - 8/2024) of six months reviewed in the Quality Assessment and Performance Improvement meetings, resulting in the potential for patient dissatisfaction and unresolved grievances for the 52 in-center and 6 home dialysis patients seen at this facility. Findings include: Review of Quality Assessment and Performance Improvement (QAPI) documentation for the past six months (3/2024 - 8/2024) revealed that the facility failed to log and track patient complaints and grievances. On 9/26/24 at approximately 0900, interview with the Facility Administrator A revealed that patients had complained recently about the changes in their dialysis times, but this had not been logged. Other complaints included cold temperatures, televisions not working, and other patient concerns which had not been logged. Further interview with Facility Administrator A, on 9/26/24 at approximately 1330, verified that there were no complaints or grievances addressed in the QAPI information provided. Review of the facility policy titled “Quality Assessment and Performance Improvement Program, dated 5/2/22” documented, “Elements to be reviewed... Patient satisfaction and grievances.””

“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: 45246 Based on observation, interview and record review, the facility failed to ensure that staff adhered to policy and procedure regarding dialysate flow rate and dialysate composition and assure that treatment settings are as prescribed by the physician for 2 patients (P-10 and 11), resulting in the potential for adverse outcomes for the patients. Findings include: On 9/25/24 at approximately 1002 dialysis treatment orders were checked for 4 randomly selected patients with charge nurse, Staff C. P-10 was receiving his dialysis treatment at station #5. Patient’s DFR (dialysate flow rate) was programmed at 500. Order was checked and revealed DFR was ordered at 800. When asked for how long patient was running on 500 Staff C stated that the treatment started about 3 hours ago. P-11 was receiving his dialysis treatment at station #13. Dialysate composition was checked and revealed 2.0 K (potassium) and 2.5 Ca (calcium). Physician’s order was checked and indicated 3.0 K and 2.5 Ca. Staff C was asked for how long patient was receiving treatment with inaccurate dialysate composition, she stated for approximately 2 hours and 40 minutes. Staff C was also asked if the expectation was for nurses to check the machines’ settings after treatment initiation and confirm the correct (as ordered by provider) settings. She said yes, nurses check after technicians initiated the treatments. P-11’s treatment sheet for 9/25/24 was reviewed on 9/26/24 and revealed that machine setup was recorded as performed by patient care technician, Staff L, and reviewed by registered nurse, Staff I. On 9/26/24 at 0930 review of P-10 treatment sheets revealed the following documentation. Treatment flowsheet dated 9/25/24 had dialysis treatment documented as started at 0649 and completed at 1101. P-10’s treatment orders indicated: duration- 4 hours, BFR (blood flow rate)- 400, DFR (dialysate flow rate)- 800. At 0650 BFR was recorded 400 (as ordered) and DFR was 0 (zero). At 0659 BFR was recorded as 400, DFR- 500. DFR continued to be set at 500 untill 1006. At 1006 DFR was recorded as 0 (zero). No other recordings of DFR were noted untill patient treatment ended at 1101. Machine setup was recorded as performed by patient care technician, Staff J, and reviewed by registered nurse, Staff I. No nursing progress/treatment note was found with explanation of DFR being outside the provider’s order and no record of provider’s notification was found for that treatment day. On 9/26/24 at 1448 during interview with facility’s Medical Director, Staff D, he stated that expectations are for all clinical and nursing staff to follows facility’s policies and procedure. 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 9/26/24 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.”

“GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility’s internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient’s designated representative will be informed of steps taken to resolve the grievance. This Standard is not met as evidenced by: 29955 Based on interview and record review the facility failed to acknowledge, investigate, and respond to 3 of 4 patients (P-5, P-6, P-10) complaints resulting in the loss of a patient’s right to file a complaint. Findings include: On 9/25/2024 at 1015 an interview occurred with P-5. P-5 was queried if he was happy with his care at the facility. P-5 stated, “The only complaint I have is that they have changed my on time.” P-5 was asked to further explain. P-5 continued, “I recently was diagnosed with cancer...it’s in my liver and I am getting treatments. With that being said my on time was changed from 0545 to 0715 because of the patient’s that are coming from the unit that burnt. They were going to change my time again to 0750 and I (P-5) told them no because I have scheduled all my other appointments around my dialysis...Why should I have to change my time because of the other clinic’s patients being bussed in?” P-5 was then asked if he had made anyone aware that he was unhappy with the changes. P-5 responded, “Yeah, but they didn’t change my time to 0750...I’m still upset that I don’t get on (treatment) until 0715...that’s an hour and a half after when I used to run...I’ve been a patient here for 11 years...I’ve only missed one treatment in that entire time...You should go ask other patients that are being moved around with times. It is only to fit in the patients that are being bussed here.” On 9/25/2024 at 1040 an interview occurred with P-6. P-6 was queried if he was happy with his care at the facility. P-6 stated he was happy with his care. P-6 was then asked if he had his time changed recently. P-6 stated, “Yes...I would really like to be the first patient on (treatment) because I’m self-employed and I’m my own bread winner.” P-6 stated, “I used to start treatment at 0600 and now it is 0750...that means I’m later to work which means I am behind on the days I run.” P-6 was queried if he had expressed his concern with anyone at the facility. P-6 stated, “Yes, could you please help me? Again it impacts my livelihood.” On 9/25/2024 at 1057 an interview was conducted with P-10. P-10 was loud and complaining about late starts, broken machines, and that staff did not care to help or listen to his complaints. P-10 was queried if he had made his complaints known to management and filed a complaint. P-10 stated, “nothing gets done by you people.” Record review of P-5 occurred on 9/26/2024. P-5 was confirmed to have liver cancer, and was confirmed to be receiving chemotherapy treatment. Record review of P-6 occurred on 9/26/2024. P-6 was confirmed to be self-employed, and revealed to have multiple-myeloma. On 9/26/2024 at 1345 a record review was conducted of the complaints/grievances log. The log contained one complaint received 9/13/24 concerning televisions not being operational and failed to contain any complaints from P-5, P-6, and P-10. On 9/26/2024 at 1420 staff A, the facility administrator confirmed that complaints regarding chair times had not been recorded because the existing patients at the facility were told that, “if our facility was involved in a fire wouldn’t you want the other facility to accommodate our patients?” On 9/26/2024 at 1500 an interview occurred with staff D, the medical director of the facility. Staff D was queried if complaints and grievances were reviewed at Quality Assurance Performance Improvement (QAPI) meetings. Staff D stated, “Yes.” Staff D was then queried if he was aware that patients were unhappy about their chair times being moved, and that patients had made appointments around their dialysis treatment times. Staff D stated, “I have had several conversations with (P-5) and I have told him that I didn’t start the fire at the other clinic and he needed to be flexible.” Staff D then stated, “We have worked with (P-5) around his oncology appointments.” On 9/26/2024 at 1445 a record review occurred of the policy titled, “Patient Grievance,” version 3, dated 01/02/2014. According to the policy it states: “Receiving and Documenting Grievances” it states, “Any patient treated at an FMCNA dialysis facility has the right to file a grievance at any time. · Grievances may be filed written or verbally, by the patient or patient ’ s designated representative. · Any grievance that involves a situation or practice that may place patients or staff members in immediate danger must be resolved immediately. · Timeframes outlined in the procedure for acknowledging, investigating, and addressing grievances shall be followed.” and, “Reviewing and Documenting,” it states, “All patient grievances received at the facility must be reported to the QAI Committee and to the Governing Body: · The intent of QAI review is to use patient grievances and trends as a means to identify opportunities to improve care. Written documentation of the grievances and the actions taken to resolve it must be available in the QAI minutes. · The intent of the Governing Body review is to ensure that: - An effective internal grievance process is established and followed. - Major problems with care and safety of patients or patients ’ rights are addressed and resolved. - Description of patient grievance and the resolution offered to the patient is documented within the Governing Body meeting minutes.” On 9/26/2024 at 1520 staff A, the facility administrator confirmed complaints/grievances concerning changes in “on times” had not been documented. Staff A stated, “I told the patients that if our clinic had and emergency wouldn’t they like to be treated the same (as the displaced patients).””