Liberty Dialysis at Lakeland - Niles

“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 record review and interview, the facility failed to conduct exercises to test their emergency plan resulting in the potential for less than optimal outcomes for all patients in the event of an emergency. Findings include: Review of the facility’s emergency plan, dated August 2024, revealed in Section 7: Staff Preparedness, “...Conduct at least one Tabletop Mock drill annually with the entire Interdisciplinary Team (IDT) involvement. Participate in at least one community-based emergency drill sponsored by the Emergency Operations Center (EOC), Healthcare alliance or local hospital. If a community-based drill is not completed each year, the Director of Operations (DO) must document who they contact, what was the reason given on why the drill could not be completed. If no community-based drill the DO should conduct a mock drill with the area facilities and attempt to engage the local hospital and transportation companies, volunteer groups, etc...” On 10/15/24 at 1528, an interview with Facility Administrator “A” found they had no documentation for having performed a community based or tabletop exercise.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 36887 Based on observation, interview, and record review the facility failed to ensure staff remove personal protective equipment per facility policy, resulting in the potential for transmission of infectious agents to patients, staff, and the public. Findings include: On 10/15/2024 at 1130 during observations on the treatment floor, Patient Care Technician (PCT) Staff E was observed walking off the treatment floor wearing his cover gown, a shield that was pushed up on top of the head, and a mask under the chin. Staff E walked through the lobby and through the vestibule to the outside doorway and leaned out looking both ways before turning around and walking back onto the treatment floor and resuming patient care. It was observed that beside the door by the scale leading from the treatment floor to the lobby there was a sign posted that personal protective equipment (PPE) should not be worn past that point. On 10/16/2024 at 1345, Charge Nurse Staff G was queried as to if it were permissible to wear the PPE into the lobby and vestibule area to which she stated, “It should not be worn past the scale... There is a sign posted by the door.” On 10/17/2024 at 1035, Medical Director Staff D was queried as to if it were permissible to wear the PPE off the treatment floor to which he stated there was signage present as to where PPE was acceptable to wear and he expected that it be followed “strictly.” Facility policy #47663 titled “Personal Protective Equipment” published 11/6/2023 states, “PPE is used to protect employees who are occupationally exposed to blood or OPIM (other potentially infectious materials) when performing procedures during which spurting or spattering of blood might occur... All personal protective equipment shall be removed prior to leaving the treatment area.””

“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: 38905 Based on observation and interview the facility failed to maintain a safe and functional environment resulting in the potential for transmission of infectious agents to all patients. Findings Include: During a tour of the back water room hallway, on 10/15/24 at 1118, it was observed that the bottom sweep for the door leading outside was found with a ¼ to ½ inch gap at the bottom of the door. When bent down on one knee, daylight could be seen easily coming through the bottom of the door. During a tour of the water room, on 10/15/24 at 1121, it was observed that the Reverse Osmosis (RO) storage tank was leaking water at the top cap. The water was observed dripping down the side of the tank and creating a puddle and the bottom the tank. An accumulation of black debris was found around the perimeter legs of the RO storage tank, which was encompassed by a puddle of water. Further observation of the water room found an accumulation of dust, debris, and dead insects around the perimeter of the room and behind the carbon tanks. The bicarb tanks were found with excess accumulation of salt debris on the floor and around the bicarb tank areas. When asked who would clean this area, Facility Administrator (FA) “A” stated that staff must clean this area as the cleaning vendor does not come in here. Observation of the generator room, on 10/15/24 at 1130, observed two light shields were missing, no longer protecting the area from possible broken glass. During a tour of the back storage room with FA “A”, on 10/15/24 at 1132, it was observed that the perimeter of the room was found with an accumulation of dust and debris, specifically under open wire rack shelving. When asked who cleans this back area, FA “A” stated that a vendor comes in to clean the facility at night. Observation of the far corner found some clean and sanitary supplies on the floor, including a box of gauze sponge pads. During a tour of the dialyzer storage room, off the treatment floor, on 10/15/24 at 1137, found a metal rack with pressboard shelving used to store boxes of dialyzers. The press board shelving was found to not be smooth and easily cleanable, allowing the harborage of bacteria over time. Observation of the dirty room, off the treatment floor, on 10/15/24 at 1141, found the cabinet under the sink was starting to pit out and create holes in areas where old drips had occurred. Layers of old staining was found with as leaks and spills dried up over time. Further review found a cabinet under the far back countertop space labeled “Blood Culture Kits” and “Urine Specimen Cups”, with a board placed over the bottom of the storage space but covering up old staining and a dilapidated bottom shelf. Items were stored in this cabinet. Observation of the Biomed Office, on 10/15/24 at 1209, found that numerous items and large beakers stored underneath the wastewater drain of the sink. An interview with Bio-med “P” found that most of these items are not used and will be relocated. During an observation of the Janitors closet, on 10/15/24, at 1533, it was found that the faucets internal vacuum breaker was missing its top cap component that helps maintain the integrity of the unit. Further observation found that the sink was left on and connected to a pre-dispense chemical system for cleaning. This set up puts undue back pressure on the faucets internal vacuum breaker, of which it is not rated to handle.”

“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 on record review and interview, the facility failed to identify a patient with extended hospitalization as unstable for 1 (#9) of 2 patients reviewed for unstable status resulting in the potential for unrecognized and unmet patient needs and poor patient outcomes. Findings include During the patient selection process on 10/15/2024 at 1300, the hospital log was reviewed and it was noted P-9 had been hospitalized from 8/5/2024-9/10/2024 with interstitial pulmonary disease, abnormal blood chemistry, acute cystitis, altered mental status, encephalopathy, and atrial flutter. The unstable log was then reviewed and P-9’s name was absent from the unstable log. Review of P-9’s medical record on 10/16/2024 at 1300 revealed the most recent plan of care had been completed 5/29/2024 in which the patient had been put back into compliance following frequent hospitalizations. No other plans of care were present after 5/29/2024. On 10/16/2024 at 1345, Facility Administrator Staff A, Director of Operations Staff B, Charge Nurse Staff G, and Clinical Quality Director Staff N were together when Staff A confirmed there were no plans of care since 5/29/2024. Upon showing the hospitalization log, all four staff agreed P-9 should have been made unstable. Staff A was then queried as to who was responsible for notifying the interdisciplinary team (IDT) of lengthy or frequent hospitalizations to which she stated the nursing staff was responsible. On 10/16/2024 at 1353, Charge Nurse Staff G stated she was unaware a lengthy hospitalization would make the patient unstable. 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 (plan of care) 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. The following are unstable criteria: Extended or Frequent hospitalizations: a. Hospitalization of more than 15 days with discharge occurring within the last 30 days, or b. More than 3 admissions in the last 30 days...””

“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: 36887 Based on record review and interview the facility failed to ensure all members of the interdisciplinary team signed the plan of care for 4 (P-4, 5, 6, 8) of 4 patients reviewed resulting in the potential for poor patient outcomes. Findings include: Review of the medical record for P-4 on 10/16/2024 at 0930 revealed the POC dated 6/19/2024 was presented by the mid-level provider; however, there was no physician oversight signature present. Additionally, the POC dated 8/16/2024 was also presented by the mid-level provider and no physician oversight signature/date was present. Review of the medical record for P-8 on 10/16/2024 at 1020 revealed the POC dated 9/25/2024 was presented by the mid-level provider; however there was no physician oversight signature/date was present. On 10/17/2024 at 1035, Medical Director Staff D stated he was having computer issues and was unable to sign the oversight to the plans of care. Facility policy #45283 titled “Comprehensive Interdisciplinary Assessment and Plan of Care” published 7/3/2023 states, “ Physician extenders may participate in the development and implementation of the Plan of Care, including signing of the Comprehensive Assessment and Plan of Care, provided...The Attending Physician reviews CIA (comprehensive interdisciplinary assessment) and indicates with his/her signature on the POC their oversight of the patient’s Plan of Care within 30 days... The physician treating the patient is ultimately responsible for his/her patient’s Plan of Care...” 29955 On 10/16/2024 at 0945 document review of P-5’s plan of care dated 5/30/2024, revealed the signature page failed to include the signature of the patient and failed to include the signature of the physician as oversight of the physician extender (staff O). On 10/16/2024 at 1430 document review of P-6’s plan of care dated 7/16/2024, revealed the signature page failed to include the signature of the patient and failed to state the date and time of the physician’s approval of the patient’s plan of care as oversight of the physician extender (staff O). On 10/16/2024 at 1520 an interview was conducted with the Facility Administrator (staff A). Staff A was queried if patients were included in the plan of care meetings. Staff A stated that patients were included in the plan of care meetings if they decided they wanted to be included. Staff A was then asked why patients do not sign at the time of the plan of care meetings. Staff A stated with the new electronic system there was no way to have the patient sign that they attend the meetings.””

“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: 36887 Based on observation, interview, and record review, the medical director failed to (1) ensure the interdisciplinary team signed the plan of care at the time of the plan of care meeting for 4 (P-4, 7, 8, 9) of 4 patients reviewed, and (2) failed to ensure an initial nursing assessment was done prior to the start of the initial treatment for 1 (P-8) of 1 patients resulting in the potential for unrecognized, unmet patient needs with poor patient outcomes. Findings include: (1) Review of the medical record for P-4 on 10/16/2024 at 0930 revealed the plan of care (POC) dated 6/19/2024 was signed by the mid-level provider, the registered nurse (RN), the dietician (RD), and the social worker (SW) on 6/19/2024; however, was signed by the patient on 6/26/2024. Review of the invitation to the plan of care meeting revealed P-4 had requested to meet with the care team at chairside. Additionally, review of the plan of care for P-4 on 8/16/2024 revealed the POC was signed by the mid-level provider, the RN, RD, and SW on 8/16/2024; however, the patient signed the POC on 8/21/2024. Review of the invitation to the plan of care meeting revealed P-4 had requested to meet with the care team at chairside. Review of the medical record for P-7 on 10/16/2024 at 1110 revealed the POC dated 10/8/2024 had only the SW signature on 10/8/2024. The physician, mid-level provider, RN, and RD signatures were blank. The patient, who had requested to meet with the nurse privately after the care team meeting, signed the POC 10/10/2024. Review of the medical record for P-8 on 10/16/2024 at 1020 revealed the initial POC dated 9/25/2024 was signed by the mid-level provider, the RN, and the RD on 9/25. The SW who attended remotely signed the POC on 9/26/2024; however, the patient signed the POC on 9/30/2024. On 10/16/2024 at 1131, RD Staff I was queried as to why the patient was signing the plan of care several days after the plan of care meeting. She stated the interdisciplinary team (IDT) had been told they needed to sign it first and then the patient. The person signing last would then print the document and give to the nursing staff to have the patient sign within the next 7 days when they came in for treatment. Review of the medical record for P-9 on 10/16/2024 at 1300 revealed the POC dated 5/1/2024 was signed by the mid-level provider, RN, and RD on 5/1/2024. P-9 signed on 5/3/2024 and the SW signed 5/6/2024. On 10/17/2024 at 1035, Medical Director Staff D stated it was his expectation that all policies should be followed. 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... The Plan of Care should be signed at the time of the interdisciplinary team meeting for those attending in person...” (2) Review of the medical record for P-8 on 10/16/2024 at 1020 revealed she started dialysis for the first time on 9/6/2024. Treatment was initiated 9/6/2024 at 0717. Review of the initial nursing assessment revealed it was completed 9/6/2024 at 0741. On 10/16/2024 at 1445, Clinical Quality Director Staff N stated it was a “hard stop in the system” that the nursing assessment was completed prior to the initiation of treatment “because so many were missed... I am very surprised. I wouldn’t have believed it if I didn’t see it myself. I am going to escalate this in our system because this shouldn’t have happened.” On 10/17/2024 at 1035, Medical Director Staff D stated it was his expectation that all policies be followed. Facility policy #45283 titled “Comprehensive Interdisciplinary Assessment and Plan of Care” published 7/3/2023 states, “A registered nurse must perform an assessment on patients NEW to dialysis BEFORE initiation of their first treatment to determine immediate needs.””