Fkc - Robbinsdale Dialysis

“CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This Condition is not met as evidenced by: 38687 Based on interview and document review, the facility failed to ensure transplant status for 2 of 2 patients (P4 and P9) care plans were updated, ensure the social worker had a system to track transplantation status progress, that it was routinely discussed with the interdisciplinary team, and documented in the plan of care, and results were tracked. Findings include: P4 P4’s Patient Transfer data sheet identified P4 was admitted to the facility in January 2024 for hemodialysis treatment related to end stage kidney disease. P4 had a physician’s order for transplant referral for patient evaluation dated 1/30/24. P4’s current, undated, plan of care identified P4’s transplantation status as open on 4/16/24 with a goal to place P4 on the transplant list as indicated by the patient’s physician with a goal due date of 4/26/25. The status was listed as OPEN, patient referred, in evaluation process, also dated 4/16/24. There was no indication the facility had updated or checked P4’s transplant evaluation process since April 2024. P4’s current, undated, Transplant Assessment identified the facility noted a date of discussion of 12/31/24. P4 was not on the transplant list but was interested in transplantation. Under the section “Patient referred for transplantation” it was marked “No”. Comments noted were 4/2024 Mayo evaluation process. There was no indication staff had verified P4’s current place in the process, if an evaluation had taken place, or if P4 needed assistance with any measures to make sure she was able to pass the evaluation process if indicated. In the “Referral Process” section, the following information was left blank: 1) Date of referral. 2) Date transplant center was contacted. 3) Date of appointment. 4) If first appointment was missed, staff were to list the reason why. 5) If second appointment was missed, staff were to list the reason why. There was no indication the facility had checked to see P4’s status in her process for seeking transplantation, who attended the discussion, or what if anything, was discussed. Review of the 12/6/24, letter from Mayo Clinic addressed to P4 (obtained by the facility upon request), identified the transplant committee had met on 12/4/24 to discuss her kidney transplant evaluation. The committee noted they were unable to make a decision regarding her candidacy due to the following reasons and/or conditions. P4 was to: 1) Start Sertraline (anti-depressant medication) 25 milligrams (mg) per day for 2 weeks, then increase the dose to 50 mg per day. Further dosing optimization would occur on follow up. 2) Start hydroxyzine (anti-anxiety medication) 25 mg every 6 hours as needed for anxiety. 3) Establish care with a local therapist to provide more frequent and longitudinal follow-up and to consider cognitive behavioral therapy. 4) Follow up with transplant psychiatry in 1-2 months (end of December or January). Any requirements were noted to be expected to be completed within 3 months, at which time P4’s transplant candidacy was to be re-evaluated by the Multidisciplinary Transplant Selection Committee. The facility was noted as cc’ d on the letter. Interview on 1/29/25 at 1:15 p.m. with the facility administrator (FA) identified she felt P4 was on the transplant list but needed confirmation. She would reach out to the transplant clinic for an update. The FA agreed there was no indication P4’s care plan had been updated to show what her current progress was for transplant. There had been a lot of social worker (MSW) turnover within the last year, and the facility was currently unaware what P4’s status was. The FA noted P4’s home medications (medications not given at the facility) would be listed on her Patient Transfer sheet. Follow up interview on 1/29/25 at 2:30 p.m., with the FA identified the facility has not had a full time employed MSW for approximately 2.5 years. It is the MSW responsibility to follow up on transplant status. The FA does ensure whomever the MSW is at the time, discusses their findings in QAPI. The FA had not been following up to ensure the MSW had been bringing accurate data to QAPI as noted by the lack of follow up with transplant patient status’. Further review of P4’s current, undated Patient Transfer sheet identified her neither the Sertraline nor the hydroxyzine were listed as medications P4 was taking at home based off the recommendations by the transplant facility. Interview on 1/30/25 at 10:30 a.m., with the FA, MSW-A and interim MSW-B identified P4 was noted to have “higher acuity” able to be independent with most of the processes required by the transplant committee and was able to make decisions about her care known. MSW-A and MSW-B agreed they had not been following P4’s transplantation status, but as of that morning, they had spoken to P4 to identify if she had begun her medications as required by the transplant committee. To their knowledge, P4 had started the Sertraline, nut had not yet contacted any local therapists or followed up with transplant psychiatry as ordered. The facility leadership was to review the plan of care each month. P4’s current progress in transplant evaluation had been missed. MSW-A and MSW-B agreed it was the facility’s role to assist P4 with any barriers she may have in being able to achieve her goals and work closely with P4 to try and achieve those goals in order to be considered for transplant. Both stated the facilities failure to track and document her progress could cause P4 to be excluded from the evaluation process, therefore, removing her from consideration to be placed on the transplant waiting list. Interview on 1/30/25 at 2:05 p.m. with the medical director (MD)-A identified although he was not P4’s primary physician, her was aware of P4’s dialysis. He noted P4 did struggle with medical recommendations. He noted the facility was having a hard time retaining permanent social workers and that was likely what led to P4’s status not being documented or followed by the SW. The facility should maintain current transplant status and assisting patients to identify any barriers that could occur in efforts to get on the transplant list. MD-A thought the process would just be delayed and P4 would “constantly gain time on the list” but felt that should not preclude her from being removed from the evaluation process if she was unable to complete the items identified by the transplant committee. Call back received on 1/31/25 at 9:30 a.m. from the transplant committee (TC) identified P4’s evaluation began in October 2024. P4 was required to complete the above identified medications and care visits as indicated in the letter by March 5th, 2025. Prescriptions for the medications had been sent out, however TC could not verify if P4 had picked them up at the pharmacy as they did not show as filled. P4 was not dialysis compliant as she has missed treatments and has known psychosocial barriers to her treatment. the TC expectation was for the facility to follow P4’s progress in her transplant evaluation and assist P4 with any barriers such as potentially assisting in finding a local therapist, ensure she was reminded to pick up her meds, ask if she had started them, and identify any other barriers. If P4 made some progress (50% or more) by March 2025, the TC would likely delay her evaluation for another review in 3 months to give her time to complete the ordered medications and tasks. If P4 made little to no progress, P4 would be removed for consideration and would have to wait another year before referral to the TC for evaluation., thus removing her from potential eligibility to be placed on the waiting list to receive a kidney transplant. P9 P9’s facesheet indicated start of services was on 2/9/23. P9’s care plan dated 5/17/23 indicated transplantation status was open with a goal to get patient on transplant list as indicated by the provider by 5/30/24. On 5/17/23 the goal was still in progress with continue to monitor transplantation status as the plan. P9’s initial ESRD Comprehensive SW Assessment dated 2/16/23, indicated P9 had not been referred to a transplant center for review and the social worker (MSW) had not reviewed the transplant options with P9. P9’s 90-day ESRD Comprehensive SW Assessment dated 5/17/23, indicated P9 was not interested in transplantation, had not been referred for transplantation, and was not on a transplant list. During an interview on 1/29/25 at 3:11 p.m., the social worker (MSW)-B stated P9 was not one of her clients so she would need to review the medical record about the transplant status. After reviewing the medical record, MSW-B stated P9 had not been referred to any transplant program but would need to reach out to University of Minnesota (UoM) to verify if the record was correct. During a second interview on 1/29/25 at 3:48 p.m., MSW-B stated she reviewed P4’s medical record and saw the letter dated 12/6/24, with requested provider follow up orders that needed done in either December or January. MSW-B then stated there were no notes about a follow up appointment made that she could find and there were no notes that the patient had made the appointment themselves. During an interview on 1/29/25 at 4:47 p.m., the facility administrator (FA) and regional facility administrator (RFA) stated transplantation care plan conversations were started within the first week of services by the LSW. The transplantation conversations related to transplant list status and future goals would then be placed on the plan of care (POC) so all members of the dialysis team were aware of the patients transplant status. If the patient had been approved for a living donor transplant prior to admission to dialysis, then that information would be placed on the care plan so the IDT team was aware and the MSW could follow up on it with each IDT meeting. Review of the Comprehensive Interdisciplinary Assessment and Plan of Care policy dated 7/3/23, indicated the comprehensive patient assessment should include a conversation related to the patient’s wishes and status regarding transplantation. That conversation would occur within 30 days of the start of dialysis. The information obtained in the comprehensive patient assessment would be place in the care plan. The IDT must track the results of each kidney transplant referral. If not available by the transplant center, then reasonable efforts would be made by the facility to obtain this information. Monitoring the status of any facility patients on the transplant waiting list would also occur. Review of the 3/20/20, Kidney Selection Guidelines for Mayo Clinic-Rochester policy, provided by the facility, identified the purpose was to provide written guidance to facilities in their evaluating of patients in determining their suitability for kidney transplant. Some of the eligibility requirements were for the patient to have informed consent, have a psycho-social clearance, and obtain financial clearance. An absolute contraindication was for a patient who showed an inability to comply with transplant related management and medical follow up. Review of the 4/7/21, MSW job description identified the MSW, in collaboration with the interdisciplinary team (IDT) was to inform, educate, and support staff in understanding the emotional, psychological, and behavioral impact of chronic kidney disease on the patient and family to ensure comprehensive, quality care of patients. The MSW was to also provide educational, and goal directed counseling to patients who are seeing transplant, provide information, and assist the teams and patient with referral to community resources to facilitate optimal treatment outcomes, document interactions and interventions provided to patients, and facilitates in the transplant referral process and collaborates with the IDT on transplant wait-list management. The MSW was also to provide psychosocial support and/or social work focused interventions to address non-adherence, quality outcome, and quality of life concerns for all patients and document MSW interactions and interventions provided to the patient.”

“Policies/Procedures-Volunteers and Staffing CFR(s): §403.748(b)(6), §416.54(b)(5), §418.113(b)(4), §441.184(b)(6), §460.84(b)(7), §482.15(b)(6), §483.73(b)(6), §483.475(b)(6), §484.102(b)(5), §485.68(b)(4), §485.542(b)(6), §485.625(b)(6), §485.727(b)(4), §485.920(b)(5), §491.12(b)(4), §494.62(b)(5). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This Standard is not met as evidenced by: 20794 Based on interview and document review, the facility failed to ensure their emergency preparedness policies and procedures addressed the use of volunteers in an emergency, or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. This had the potential to affect all 97 patients receiving treatment in the facility. Findings include: The facility’s emergency preparedness plan and policy and procedures were reviewed with the facility adminstrator (FA), stategic quality manager (SQM) and regional director (RD) on 1/29/25 at 3:00 p.m. The FA and SQM indicated volunteer use is not mentioned in the plan and confirmed the lack of a policy and procedure related to the use of volunteers as well as inclusion of the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.”

“Roles Under a Waiver Declared by Secretary CFR(s): §403.748(b)(8), §416.54(b)(6), §418.113(b)(6)(C)(iv), §441.184(b)(8), §460.84(b)(9), §482.15(b)(8), §483.73(b)(8), §483.475(b)(8), §485.542(b)(7), §485.625(b)(8), §485.920(b)(7), §494.62(b)(7). [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials. This Standard is not met as evidenced by: 20794 Based on interview and policy review, the facility failed to ensure their policies and procedures addressed the role of the facility under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. This had the potential to affect all 97 current patients being treated within the facility. Findings include: The facility’s emergency preparedness plan and policy and procedures (last updated 1/27/25) were reviewed and noted to have lacked evidence the facility had determined what their role would be, if a waiver was declared by the Secretary. There was a page within the manual directing the staff to place the 1135 Waiver there, however, no policy was found. During interview on 1/29/25 at 3:00 p.m., facility administrator (FA), strategic quality manager (SQM) and regional director (RD), after reviewing the facility’s emergency preparedness manual verified the manual lacked information on the 1135 Wavier.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 38687 Based on observation, interview, and document review, the facility failed to ensure a sanitary environment was maintained in 1 of 1 treatment room. This had the potential to affect all 97 patients dialyzed in the facility. Findings include: Observation on 1/28/25 at 11:40 a.m. through 11:45 p.m., in the treatment area identified numerous discarded gloves and syringe wrappers were lying on the floor by 2 of 2 garbage cans at the nurses station. Patient care dialysis tech (PCDT)-E had discarded gloves into the garbage can. Those gloves fell onto the floor. PCDT-E failed to pick up the contaminated gloves and place into the garbage bin. PCDT-D also walked by the numerous gloves and debris lying beside the garbage can to ensure a sanitary environment was achieved. Interview on 1/28/25 at 11:47 p.m., with registered nurse (RN)-A identified he was unaware of the debris beside the garbage’s as he had been facing the opposite side of the room. He agreed any removed gloves and/or garbage that missed the bin needed to be picked up to ensure proper infection control. Interview on 1/28/25 at 11:58 with the facility administrator, regional administrator, and the director of operations identified staff and patients walked directly by the nurses station routinely. They had not noticed the debris surrounding the garbage cans, but all agreed the treatment area needed to be maintained in a sanitary manner. 20794 In an telephone interview on 1/29/25 at 1:30 p.m., the medical director (MD) stated it was important to keep the treatment area free of clutter and items on the floor, especially for those patietns with balance issues while walking. MD stated he has seen where when staff pull gloves out of boxes, an extra will fallout. However, has never seen anything on the floor that contained bodily fluids. During interview on 1/29/25 at 2:30 p.m., facility administrator (FA) and strategic quality manager (SQM), stated the facility relies on all staff to monitor and remind team members to pick up dropped gloves, product wrappers and other care supplies up when dropped. SQM stated she has seen FA pick up items dropped by team members, and has addressed it with them. FA stated it was her expectation, all team members monitor each other for proper disposal of and storage of all patient care supplies, used or unused. There was no policy specific to the cleanliness of the treatment area provided by the end of survey.”

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 20794 Based on observation, interview and document review, the facility failed to ensure appropriate hand hygiene and glove changing was performed by facility staff after discontinuations for 5 of 5 patients (P10, P12, P13, P14, and P15) observed post dialysis treatment. Findings include: The following observations were observed. On: 1) 1/28/25 at 9:57 AM, P12 walked from station 4, after being assisted with patient’s supply bag by PCDT-C, to the floor scale after treatment. PCDT-C still wearing the gloves she was wearing post-treatment, grabbed hand held thermometer and took P12’s temperature, then set the thermometer back on the nurses station counter without disinfecting. PCDT-C then, while still wearing the gloved, zeroed out the floor scale, cueing P12 to step onto the scale for a post treatment weight. While still wearing the gloves donned at station 4, PCDT-C utilized a pen and pad of “Post-It” notes to document P12’s temp and weight. After handing P12 her supply bag and seeing patient to the lobby door, PCDT-C returned to station 4, entered P12’s post treatment temperature and weight on the station’s machine, then removed her gloves. 2) 1/28/25 at 10:00, P10 was finishing dialysis treatment. PCDT-A pushed in the foot pedal on P10’s chair with her gloved hands and assisted him to stand. PCDT-A then proceeded to check P10’s blood pressure (BP). PCDT-A assisted P10 to sit, touched the machine with her same gloved hands, and removed P10’s BP cuff. PCDT-A then clamped P10’s blood lines, and disconnected P10 from the machine. PCDT-A failed to remove her gloves and perform hand hygiene. With her same gloves, PCDT-A then flushed P10’s CVC ports. PCDT-A then touched the machine, then acuired an alcohol wipe, opened it, and procedded to scrub the hubs of P10’s CVC for 3 seconds and apply the caps. PCDT-A then applied a sterile dressing around the caps and secured them to P10’s chest. P10 was released from care and was not reminded to wash his hands before exiting the treatment area. 3) 1/28/25 at 10:25 a.m., P13 walked from station 8, after being assisted with patient’s supply bag by PCDT-A, to the floor scale after treatment. PCDT-A still wearing the gloves she was wearing post-treatment, grabbed hand held thermometer and took P13’s temperature, then set the thermometer back on the nurses station counter, without disinfecting. PCDT-C then, while still wearing the gloved, zeroed out the floor scale, cueing P13 to step onto the scale for a post treatment weight. While still wearing the gloves donned at station 8, PCDT-C utilized a pen and pad of “Post-It” notes to document P13’s temp and weight. After handing P13 her supply bag and seeing patient to the lobby door, PCDT-C returned to station 8, entered P13’s post treatment temperature and weight on the station’s machine, then removed her gloves. 4) 1/28/25 at 10:48 a.m. P14 walked from station BZ16, after being assisted with patient’s supply bag by registered nurse (RN)-B, to the floor scale after treatment. RN-B still wearing the gloves she was wearing post-treatment, grabbed hand held thermometer and took P14’s temperature, then set the thermometer back on the nurses station counter, without disinfecting. RN-B then, while still wearing the gloved, zeroed out the floor scale, cueing P14 to step onto the scale for a post treatment weight. While still wearing the gloves donned at station BZ16, RN-B utilized a pen and pad of “Post-It” notes to document P14’s temp and weight. After handing P14 her supply bag and seeing patient to the lobby door, PCDT-C returned to station BZ16, entered P14’s post treatment temperature and weight on the station’s machine, then removed her gloves. 5) 1/28/25 at 11:25 a.m. P15 walked from station 11, after being assisted with patient’s supply bag by PCDT-B, to the floor scale after treatment. PCDT-B still wearing the gloves she was wearing post-treatment, grabbed hand held thermometer and took P15’s temperature, then set the thermometer back on the nurses station counter, without disinfecting. PCDT-B then, while still wearing the gloved, zeroed out the floor scale, cueing P15 to step onto the scale for a post treatment weight. While still wearing the gloves donned at station 11, PCDT-B utilized a pen and pad of “Post-It” notes to document P15’s temp and weight. After handing P15 her supply bag and seeing patient to the lobby door, PCDT-C returned to station 11, entered P15’s post treatment temperature and weight on the station’s machine, then removed her gloves. During a tepehone interview on 1/29/25 at 1:30 p.m., medical director (MD) stated it was very important all staff change gloves and wash hands between tasks for appropriate infection prevention. During interview on 1/29/25 at 2:30 p.m., facility administrator (FA) and strategic quality manager (SQM), stated staff are trained and monitored by their team mates and charge nurse to make sure gloving (both donning and doffing) and hand hygiene (washing or gelling) are performed between tasks. FA stated that the facility does infection control audits monthly on random staff to assure this process is being followed. FA supplied evidence of this auditing practice. FA and SQM stated it was their expectation that staff change gloves between tasks and disinfect commonly shared items, such as hand held thermometers, be disinfected if soiled gloved / hands are used. Review of the 11/6/23, Personal Protective Equipment policy identified a supply of clean, non-sterile gloves and waste container shall be near each dialysis station or treatment area. Staff shall remove gloves and wash their hands after patient care, exposure to blood and body fluid, and touching any surface within the patient station. If hands are not visably soilded, an alcohol-based hand sanitizer may be used. Always perform hand hygiene after glove removal.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 20794 Based on observation, interview, and document review, the facility failed to ensure personal protective equipment (PPE) was appropriately worn when 1 of 1 staff (administrative assistant (AA)-A) entered the treatment area and stood within 4 inches of a dialysis machine and blood lines during patient treatment. Findings include: Observation on 1/28/25 at 12:10 p.m., identified AA walked up to patient care dialysis tech (PCDT)-B and stood within the 6 foot safety zone without wearing and PPE. AA-A was observed to speak to PCDT-B for approximately 35 seconds, turn and walk away and enter the office area in the back corridor. Interview on 1/28/25 at 11:58 p.m., with the facility administrator (FA), regional administrator, and director of operations identified the AA was not to enter within 6 feet of a dialysis station without wearing appropriate PPE. The agreed AA was in the direct splash zone and could have contaminated herself or others with blood or body fluids. During telephone interview on 1/29/25 at 1:30 p.m., medical director (MD) stated all staff who enter an individual patient’s treatment area, while being actively treated are required to wear appropriate PPE, regardless of the amount of time he staff person is in the area. This is to protect both the patient as well as the staff member. During interview on 1/29/25 at 2:30 p.m., facility administrator (FA) and strategic quality manager (SQM), stated staff are trained to the appropriate personal protective (PPE) needs to be worn when entering the patient treatment station at all stages of the treatment process. FA stated “all staff”, including the facility’s dietitian, social worker, bio-med and administrative staff included. Review of the 11/6/23, Personal Protective Equipment policy identified employees shall use personal protective equipment in accordance with the type of patient contact expected and anticipated exposure.”

“PR-INFORMED OF RULES/EXPECTS-CONDUCT CFR(s): 494.70(a)(13) The patient has the right to- (13) Be informed of the rules and expectations of the facility regarding patient conduct and responsibilities; This Standard is not met as evidenced by: 20794 Based on observation, interview and document review, the facility failed to ensure patients entering the treatment area washed their hands and access sites, as well as after treatment during 4 of 4 patient (P12, P13, P14, and P15) observations, Pre and Post dialysis treatment. Findings include: The following observations were observed. On: 1) 1/28/25 at 9:57 AM, P12, after having PCDT-C weighting and taking P12’s temperature, left the treatment are to the lobby without washing her hands. PCDT-C was observed not to have cued P12 to do so. 2) 1/28/25 at 10:25 a.m., P13, after having PCDT-A weighting and taking P13’s temperature, left the treatment are to the lobby without washing her hands. PCDT-C was observed not to have cued P13 to do so. 3) 1/28/25 at 10:48 a.m. P14, after having RN-B weighting and taking P14’s temperature, left the treatment are to the lobby without washing her hands. PCDT-C was observed not to have cued P14 to do so. 4) 1/28/25 at 11:25 a.m. P15, after having PCDT-B weighting and taking P15’s temperature, left the treatment are to the lobby without washing her hands. PCDT-B was observed not to have cued P15 to do so. Interview on 1/28/25 at 11:47 p.m., with registered nurse (RN)-A identified al patients should wash or be reminded to wash their hands and/or access sites before and after dialysis to reduce the chance of infection. RN-A stated staff were to remind patients to do so. He was aware there was no signage placed to ensure this occurred upon entrance and exit of the treatment are, but that was a good idea to have that placed. Interview on 1/28/25 at 11:58 a.m., with the facility administrator, regional administrator, and director of operations identified all patients should be performing hand and access site hygiene upon entering the treatment area for dialysis and washing their hands prior to leaving. They agreed it placed patients at higher risk for infections as some patients held their access sites after dialysis and their access site before dialysis would not be cleansed prior to being disinfected, which may leave dirt and grime on the skin and lead to ineffective disinfection before dialysis, increasing chances of infection. During telephone interview on 1/29/25 at 1:30 p.m., medical director (MD) stated the facility staff, upon calling a patient in from the lobby, should be cueing patients to wash both their hands and their arterio-venous fistulas / graft access sites. And upon exiting the treatment area, post treatment, the staff should be cueing patients to wash their hands. These actions are all for infection prevention. During interview on 1/29/25 at 2:30 p.m., facility administrator (FA) and strategic quality manager (SQM), stated it is the facility’s expectation patients are cued by facility staff to wash their hands and access upon entering and washing their hands when they the treatment floor. FA stated the staff should be documenting in the treatment records if their are patients refusing to do so. Review of the 11/06/23, Hand Hygiene policy identified patients should perform hand hygiene if able, prior to and after each dialysis treatment. As needed, direct patient care staff will demonstrate how to operate the sinks, demonstrate hand washing to patients who are able to perform hand washing, and explain risk of contamination with regard to their vascular access and hands to all patients. Gloves must be provided to patients when performing procedures which risk exposure to blood or body fluids, such as self-cannulating or holding access sites post treatment to achieve hemostasis.To help ensure the prevention of cross contamination to their family members or other patients, hand hygiene must be performed.”

“PA-MSW-PSYCHOSOCIAL NEEDS CFR(s): 494.80(a)(7) The patient’s comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker. This Standard is not met as evidenced by: 38687 Based on interview and document review, the facility failed to ensure continuity of care involving evaluation of psychosocial needs for 1 of 1 patient (P4) in addressing current transplantation status, barriers a patient may have to meaures required by the transplant organization, assist P4 in achieving requirements for transplantation, and identify thorough oversight was needed when a social worker was not maintained in regular employment with the facility. Findings include: P4 P4’s Patient Transfer data sheet identified P4 was admitted to the facility in January 2024 for hemodialysis treatment related to end stage kidney disease. P4 had a physician’s order for transplant referral for patient evaluation dated 1/30/24. P4’s current, undated, plan of care identified P4’s transplantation status as open on 4/16/24 with a goal to place P4 on the transplant list as indicated by the patient’s physician with a goal due date of 4/26/25. The status was listed as OPEN, patient referred, in evaluation process, also dated 4/16/24. There was no indication the facility had updated or checked P4’s transplant evaluation process since April 2024. P4’s current, undated, Transplant Assessment identified the facility noted a date of discussion of 12/31/24. P4 was not on the transplant list but was interested in transplantation. Under the section “Patient referred for transplantation” it was marked “No”. Comments noted were 4/2024 Mayo evaluation process. There was no indication staff had verified P4’s current place in the process, if an evaluation had taken place, or if P4 needed assistance with any measures to make sure she was able to pass the evaluation process if indicated. In the “Referral Process” section, the following information was left blank: 1) Date of referral. 2) Date transplant center was contacted. 3) Date of appointment. 4) If first appointment was missed, staff were to list the reason why. 5) If second appointment was missed, staff were to list the reason why. There was no indication the facility had checked to see P4’s status in her process for seeking transplantation, who attended the discussion, or what if anything, was discussed. Review of the 12/6/24, letter from Mayo Clinic addressed to P4 (obtained by the facility upon request), identified the transplant committee had met on 12/4/24 to discuss her kidney transplant evaluation. The committee noted they were unable to make a decision regarding her candidacy due to the following reasons and/or conditions. P4 was to: 1) Start sertraline (anti-depressant medication) 25 milligrams (mg) per day for 2 weeks, then increase the dose to 50 mg per day. Further dosing optimization would occur on follow up. 2) Start hydroxyzine (anti-anxiety medication) 25 mg every 6 hours as needed for anxiety. 3) Establish care with a local therapist to provide more frequent and longitudinal follow-up and to consider cognitive behavioral therapy. 4) Follow up with transplant psychiatry in 1-2 months (end of December or January). Any requirements were noted to be expected to be completed within 3 months, at which time P4’s transplant candidacy was to be re-evaluated by the Multidisciplinary Transplant Selection Committee. The facility was noted as cc’ d on the letter. Interview on 1/29/25 at 1:15 p.m. with the facility administrator (FA) identified she felt P4 was on the transplant list but needed confirmation. She would reach out to the transplant clinic for an update. The FA agreed there was no indication P4’s care plan had been updated to show what her current progress was for transplant. There had been a lot of social worker (MSW) turnover within the last year, and the facility was currently unaware what P4’s status was. The FA noted P4’s home medications (medications not given at the facility) would be listed on her Patient Transfer sheet. Follow up interview on 1/29/25 at 2:30 p.m., with the FA identified the facility has not had a full time employed MSW for approximately 2.5 years. It is the MSW responsibility to follow up on transplant status. The FA does ensure whomever the MSW is at the time, discusses their findings in QAPI, but the FA has not been following up to ensure the MSW had been bringing accurate data to QAPI as noted by the lack of follow up with transplant patient status’. Further review of P4’s current, undated Patient Transfer sheet identified her neither the sertraline nor the hydroxyzine were listed as medications P4 was taking at home based off the recommendations by the transplant facility. Interview on 1/30/25 at 10:30 a.m., with the FA, MSW-A and interim MSW-B identified P4 was noted to have “higher acuity” aka able to be independent with most of the processes required by the transplant committee and was able to make decisions about her care known. MSW-A and MSW-B agreed they had not been following P4’s transplantation status, but as of that morning, they had spoken to P4 to identify if she had begun her medications as required by the transplant committee. To their knowledge, P4 had started the sertraline, nut had not yet contacted any local therapists or followed up with transplant psychiatry as ordered. The facility leadership was to review the plan of care each month. P4’s current progress in transplant evaluation had been missed. MSW-A and MSW-B agreed it was the facility’s role to assist P4 with any barriers she may have in being able to achieve her goals and work closely with P4 to try and achieve those goals in order to be considered for transplant. Both stated the facilities failure to track and document her progress could cause P4 to be excluded from the evaluation process, therefore, removing her from consideration to be placed on the transplant waiting list. Interview on 1/30/25 at 2:05 p.m. with the medical director (MD)-A identified although he was not P4’s primary physician, her was aware of P4’s dialysis. He noted P4 did struggle with medical recommendations. He noted the facility was having a hard time retaining permanent social workers and that was likely what led to P4’s status not being documented or followed by the SW. The facility should maintain current transplant status and assisting patients to identify any barriers that could occur in efforts to get on the transplant list. MD-A thought the process would just be delayed and P4 would “constantly gain time on the list” but felt that should not preclude her from being removed from the evaluation process if she was unable to complete the items identified by the transplant committee. Call back received on 1/31/25 at 9:30 a.m. from the transplant committee (TC) identified P4’s evaluation began in October 2024. P4 was required to complete the above identified medications and care visits as indicated in the letter by March 5th, 2025. Prescriptions for the medications had been sent out, however TC could not verify if P4 had picked them up at the pharmacy as they did not show as filled. P4 was not dialysis compliant as she has missed treatments and has known psychosocial barriers to her treatment. the TC expectation was for the facility to follow P4’s progress in her transplant evaluation and assist P4 with any barriers such as potentially assisting in finding a local therapist, ensure she was reminded to pick up her meds, ask if she had started them, and identify any other barriers. If P4 made some progress (50% or more) by March 2025, the TC would likely delay her evaluation for another review in 3 months to give her time to complete the ordered medications and tasks. If P4 made little to no progress, P4 would be removed for consideration and would have to wait another year before referral to the TC for evaluation., thus removing her from potential eligibility to be placed on the waiting list to receive a kidney transplant. During interview on 1/29/25 at 3:48 p.m., MSW-B stated she reviewed P4’s medical record and saw the letter dated 12/6/24, with requested provider follow up orders that needed done in either December or January. MSW-B then stated there were no notes about a follow up appointment made that she could find and there were no notes that the patient had made the appointment themselves. During an interview on 1/29/25 at 4:47 p.m., the facility administrator (FA) and regional facility administrator (RFA) stated transplantation care plan conversations were started within the first week of services by the LSW. The transplantation conversations related to transplant list status and future goals would then be placed on the plan of care (POC) so all members of the dialysis team were aware of the patients transplant status. If the patient had been approved for a living donor transplant prior to admission to dialysis, then that information would be placed on the care plan so the IDT team was aware and the MSW could follow up on it with each IDT meeting. Review of the Comprehensive Interdisciplinary Assessment and Plan of Care policy dated 7/3/23, indicated the comprehensive patient assessment should include a conversation related to the patient’s wishes and status regarding transplantation. That conversation would occur within 30 days of the start of dialysis. The information obtained in the comprehensive patient assessment would be place in the care plan. The IDT must track the results of each kidney transplant referral. If not available by the transplant center, then reasonable efforts would be made by the facility to obtain this information. Monitoring the status of any facility patients on the transplant waiting list would also occur. Review of the 3/20/20, Kidney Selection Guidelines for Mayo Clinic-Rochester policy, provided by the facility, identified the purpose was to provide written guidance to facilities in their evaluating of patients in determining their suitability for kidney transplant. Some of the eligibility requirements were for the patient to have informed consent, have a psycho-social clearance, and obtain financial clearance. An absolute contraindication was for a patient who showed an inability to comply with transplant related management and medical follow up. Review of the 4/7/21, MSW job description identified the MSW, in collaboration with the interdisciplinary team (IDT) was to inform, educate, and support staff in understanding the emotional, psychological, and behavioral impact of chronic kidney disease on the patient and family to ensure comprehensive, quality care of patients. The MSW was to also provide educational, and goal directed counseling to patients who are seeing transplant, provide information, and assist the teams and patient with referral to community resources to facilitate optimal treatment outcomes, document interactions and interventions provided to patients, and facilitates in the transplant referral process and collaborates with the IDT on transplant wait-list management. The MSW was also to provide psychosocial support and/or social work focused interventions to address non-adherence, quality outcome, and quality of life concerns for all patients and document MSW interactions and interventions provided to the patient.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 38687 Based on interview and document review, the facility failed to ensure the facility interdisciplinary team (IDT) had a system to ensure transplantation status was monitored, routinely discussed, followed-up on, and documented in the plan of care for 2 of 3 patients reviewed (P4 and P9) transplant status. Findings include: P4 P4’s Patient Transfer data sheet identified P4 was admitted to the facility in January 2024 for hemodialysis treatment related to end stage kidney disease. P4 had a physician’s order for transplant referral for patient evaluation dated 1/30/24. P4’s current, undated, plan of care identified P4’s transplantation status as open on 4/16/24 with a goal to place P4 on the transplant list as indicated by the patient’s physician with a goal due date of 4/26/25. The status was listed as OPEN, patient referred, in evaluation process, also dated 4/16/24. There was no indication the IDT had updated or checked P4’s transplant evaluation process since April 2024. P4’s current, undated, Transplant Assessment identified the facility noted a date of discussion of 12/31/24. P4 was not on the transplant list but was interested in transplantation. Under the section “Patient referred for transplantation” it was marked “No”. Comments noted were 4/2024 Mayo evaluation process. There was no indication staff had verified P4’s current place in the process, if an evaluation had taken place, or if P4 needed assistance with any measures to make sure she was able to pass the evaluation process if indicated. In the “Referral Process” section, the following information was left blank: 1) Date of referral. 2) Date transplant center was contacted. 3) Date of appointment. 4) If first appointment was missed, staff were to list the reason why. 5) If second appointment was missed, staff were to list the reason why. There was no indication the facility had checked to see P4’s status in her process for seeking transplantation, who attended the discussion, or what if anything, was discussed. Review of the 12/6/24, letter from Mayo Clinic addressed to P4 (obtained by the facility upon request), identified the transplant committee had met on 12/4/24 to discuss her kidney transplant evaluation. The committee noted they were unable to make a decision regarding her candidacy due to the following reasons and/or conditions. P4 was to: 1) Start sertraline (anti-depressant medication) 25 milligrams (mg) per day for 2 weeks, then increase the dose to 50 mg per day. Further dosing optimization would occur on follow up. 2) Start hydroxyzine (anti-anxiety medication) 25 mg every 6 hours as needed for anxiety. 3) Establish care with a local therapist to provide more frequent and longitudinal follow-up and to consider cognitive behavioral therapy. 4) Follow up with transplant psychiatry in 1-2 months (end of December or January). Any requirements were noted to be expected to be completed within 3 months, at which time P4’s transplant candidacy was to be re-evaluated by the Multidisciplinary Transplant Selection Committee. The facility was noted as cc’ d on the letter. Interview on 1/29/25 at 1:15 p.m. with the facility administrator (FA) identified she felt P4 was on the transplant list but needed confirmation. She would reach out to the transplant clinic for an update. The FA agreed there was no indication P4’s care plan had been updated to show what her current progress was for transplant. There had been a lot of social worker (MSW) turnover within the last year, and the facility was currently unaware what P4’s status was. The FA noted P4’s home medications (medications not given at the facility) would be listed on her Patient Transfer sheet. Further review of P4’s current, undated Patient Transfer sheet identified her neither the sertraline nor the hydroxyzine were listed as medications P4 was taking at home based off the recommendations by the transplant facility. Interview on 1/30/25 at 10:30 a.m., with the FA, MSW-A and interim MSW-B identified P4 was noted to have “higher acuity” aka able to be independent with most of the processes required by the transplant committee and was able to make decisions about her care known. MSW-A and MSW-B agreed they had not been following P4’s transplantation status, but as of that morning, they had spoken to P4 to identify if she had begun her medications as required by the transplant committee. To their knowledge, P4 had started the sertraline, nut had not yet contacted any local therapists or followed up with transplant psychiatry as ordered. The facility leadership was to review the plan of care each month. P4’s current progress in transplant evaluation had been missed. MSW-A and MSW-B agreed it was the facility’s role to assist P4 with any barriers she may have in being able to achieve her goals and work closely with P4 to try and achieve those goals in order to be considered for transplant. Both stated the facilities failure to track and document her progress could cause P4 to be excluded from the evaluation process, therefore, removing her from consideration to be placed on the transplant waiting list. The IDT was to discuss findings related to transplant status on a routine basis. Interview on 1/30/25 at 2:05 p.m. with the medical director (MD)-A identified although he was not P4’s primary physician, her was aware of P4’s dialysis. He noted P4 did struggle with medical recommendations. He noted the facility was having a hard time retaining permanent social workers and that was likely what led to P4’s status not being documented or followed by the SW. The facility should maintain current transplant status and assisting patients to identify any barriers that could occur in efforts to get on the transplant list. MD-A thought the process would just be delayed and P4 would “constantly gain time on the list” but felt that should not preclude her from being removed from the evaluation process if she was unable to complete the items identified by the transplant committee. Call back received on 1/31/25 at 9:30 a.m. from the transplant committee (TC) identified P4’s evaluation began in October 2024. P4 was required to complete the above identified medications and care visits as indicated in the letter by March 5th, 2025. Prescriptions for the medications had been sent out, however TC could not verify if P4 had picked them up at the pharmacy as they did not show as filled. P4 was not dialysis compliant as she has missed treatments and has known psychosocial barriers to her treatment. the TC expectation was for the facility to follow P4’s progress in her transplant evaluation and assist P4 with any barriers such as potentially assisting in finding a local therapist, ensure she was reminded to pick up her meds, ask if she had started them, and identify any other barriers. If P4 made some progress (50% or more) by March 2025, the TC would likely delay her evaluation for another review in 3 months to give her time to complete the ordered medications and tasks. If P4 made little to no progress, P4 would be removed for consideration and would have to wait another year before referral to the TC for evaluation., thus removing her from potential eligibility to be placed on the waiting list to receive a kidney transplant. P9 P9’s facesheet indicated start of services was on 2/9/23. P9’s care plan dated 5/17/23 indicated transplantation status was open with a goal to get patient on transplant list as indicated by the provider by 5/30/24. On 5/17/23 the goal was still in progress with continue to monitor transplantation status as the plan. P9’s initial ESRD Comprehensive SW Assessment dated 2/16/23, indicated P9 had not been referred to a transplant center for review and the social worker (MSW) had not reviewed the transplant options with P9. P9’s 90-day ESRD Comprehensive SW Assessment dated 5/17/23, indicated P9 was not interested in transplantation, had not been referred for transplantation, and was not on a transplant list. During an interview on 1/29/25 at 3:11 p.m., the social worker (MSW)-B stated P9 was not one of her clients so she would need to review the medical record about the transplant status. After reviewing the medical record, MSW-B stated P9 had not been referred to any transplant program but would need to reach out to University of Minnesota (UoM) to verify if the record was correct. During a second interview on 1/29/25 at 3:48 p.m., MSW-B stated she reviewed P4’s medical record and saw the letter dated 12/6/24, with requested provider follow up orders that needed done in either December or January. MSW-B then stated there were no notes about a follow up appointment made that she could find and there were no notes that the patient had made the appointment themselves. During an interview on 1/29/25 at 4:47 p.m., the facility administrator (FA) and regional facility administrator (RFA) stated transplantation care plan conversations were started within the first week of services by the LSW. The transplantation conversations related to transplant list status and future goals would then be placed on the plan of care (POC) so all members of the dialysis team were aware of the patients transplant status. If the patient had been approved for a living donor transplant prior to admission to dialysis, then that information would be placed on the care plan so the IDT team was aware and the MSW could follow up on it with each IDT meeting. Review of the Comprehensive Interdisciplinary Assessment and Plan of Care policy dated 7/3/23, indicated the comprehensive patient assessment should include a conversation related to the patient’s wishes and status regarding transplantation. That conversation would occur within 30 days of the start of dialysis. The information obtained in the comprehensive patient assessment would be place in the care plan. The IDT must track the results of each kidney transplant referral. If not available by the transplant center, then reasonable efforts would be made by the facility to obtain this information. Monitoring the status of any facility patients on the transplant waiting list would also occur.”

“POC-TRANSPLANT STATUS PLAN OR WHY NOT CFR(s): 494.90(a)(7)(ii) When the patient is a transplant referral candidate, the interdisciplinary team must develop plans for pursuing transplantation. The patient’s plan of care must include documentation of the- (A) Plan for transplantation, if the patient accepts the transplantation referral; (B) Patient’s decision, if the patient is a transplantation referral candidate but declines the transplantation referral; or (C) Reason(s) for the patient’s nonreferral as a transplantation candidate as documented in accordance with §494.80(a)(10). This Standard is not met as evidenced by: 38687 Based on interview and document review, the facility failed to be aware and document in the plan of care 2 of 2 patients (P4 and P9) current transplant status progress and and include interventions that may be required while patients are in process of transplant evaluation. Findings include: P4 P4’s Patient Transfer data sheet identified P4 was admitted to the facility in January 2024 for hemodialysis treatment related to end stage kidney disease. P4 had a physician’s order for transplant referral for patient evaluation dated 1/30/24. P4’s current, undated, plan of care identified P4’s transplantation status as open on 4/16/24 with a goal to place P4 on the transplant list as indicated by the patient’s physician with a goal due date of 4/26/25. The status was listed as OPEN, patient referred, in evaluation process, also dated 4/16/24. There was no indication the facility had updated or checked P4’s transplant evaluation process since April 2024. P4’s current, undated, Transplant Assessment identified the facility noted a date of discussion of 12/31/24. P4 was not on the transplant list but was interested in transplantation. Under the section “Patient referred for transplantation” it was marked “No”. Comments noted were 4/2024 Mayo evaluation process. There was no indication staff had verified P4’s current place in the process, if an evaluation had taken place, or if P4 needed assistance with any measures to make sure she was able to pass the evaluation process if indicated. In the “Referral Process” section, the following information was left blank: 1) Date of referral. 2) Date transplant center was contacted. 3) Date of appointment. 4) If first appointment was missed, staff were to list the reason why. 5) If second appointment was missed, staff were to list the reason why. There was no indication the facility had checked to see P4’s status in her process for seeking transplantation, who attended the discussion, or what if anything, was discussed. Review of the 12/6/24, letter from Mayo Clinic addressed to P4 (obtained by the facility upon request), identified the transplant committee had met on 12/4/24 to discuss her kidney transplant evaluation. The committee noted they were unable to make a decision regarding her candidacy due to the following reasons and/or conditions. P4 was to: 1) Start sertraline (anti-depressant medication) 25 milligrams (mg) per day for 2 weeks, then increase the dose to 50 mg per day. Further dosing optimization would occur on follow up. 2) Start hydroxyzine (anti-anxiety medication) 25 mg every 6 hours as needed for anxiety. 3) Establish care with a local therapist to provide more frequent and longitudinal follow-up and to consider cognitive behavioral therapy. 4) Follow up with transplant psychiatry in 1-2 months (end of December or January). Any requirements were noted to be expected to be completed within 3 months, at which time P4’s transplant candidacy was to be re-evaluated by the Multidisciplinary Transplant Selection Committee. The facility was noted as cc’ d on the letter. Interview on 1/29/25 at 1:15 p.m. with the facility administrator (FA) identified she felt P4 was on the transplant list but needed confirmation. She would reach out to the transplant clinic for an update. The FA agreed there was no indication P4’s care plan had been updated to show what her current progress was for transplant. There had been a lot of social worker (MSW) turnover within the last year, and the facility was currently unaware what P4’s status was. The FA noted P4’s home medications (medications not given at the facility) would be listed on her Patient Transfer sheet. Further review of P4’s current, undated Patient Transfer sheet identified her neither the sertraline nor the hydroxyzine were listed as medications P4 was taking at home based off the recommendations by the transplant facility. Interview on 1/30/25 at 10:30 a.m., with the FA, MSW-A and interim MSW-B identified P4 was noted to have “higher acuity” aka able to be independent with most of the processes required by the transplant committee and was able to make decisions about her care known. MSW-A and MSW-B agreed they had not been following P4’s transplantation status, but as of that morning, they had spoken to P4 to identify if she had begun her medications as required by the transplant committee. To their knowledge, P4 had started the sertraline, nut had not yet contacted any local therapists or followed up with transplant psychiatry as ordered. The facility leadership was to review the plan of care each month. P4’s current progress in transplant evaluation had been missed. MSW-A and MSW-B agreed it was the facility’s role to assist P4 with any barriers she may have in being able to achieve her goals and work closely with P4 to try and achieve those goals in order to be considered for transplant. Both stated the facilities failure to track and document her progress could cause P4 to be excluded from the evaluation process, therefore, removing her from consideration to be placed on the transplant waiting list. Interview on 1/30/25 at 2:05 p.m. with the medical director (MD)-A identified although he was not P4’s primary physician, her was aware of P4’s dialysis. He noted P4 did struggle with medical recommendations. He noted the facility was having a hard time retaining permanent social workers and that was likely what led to P4’s status not being documented or followed by the SW. The facility should maintain current transplant status and assisting patients to identify any barriers that could occur in efforts to get on the transplant list. MD-A thought the process would just be delayed and P4 would “constantly gain time on the list” but felt that should not preclude her from being removed from the evaluation process if she was unable to complete the items identified by the transplant committee. Call back received on 1/31/25 at 9:30 a.m. from the transplant committee (TC) identified P4’s evaluation began in October 2024. P4 was required to complete the above identified medications and care visits as indicated in the letter by March 5th, 2025. Prescriptions for the medications had been sent out, however TC could not verify if P4 had picked them up at the pharmacy as they did not show as filled. P4 was not dialysis compliant as she has missed treatments and has known psychosocial barriers to her treatment. the TC expectation was for the facility to follow P4’s progress in her transplant evaluation and assist P4 with any barriers such as potentially assisting in finding a local therapist, ensure she was reminded to pick up her meds, ask if she had started them, and identify any other barriers. If P4 made some progress (50% or more) by March 2025, the TC would likely delay her evaluation for another review in 3 months to give her time to complete the ordered medications and tasks. If P4 made little to no progress, P4 would be removed for consideration and would have to wait another year before referral to the TC for evaluation., thus removing her from potential eligibility to be placed on the waiting list to receive a kidney transplant. P9 P9’s facesheet indicated start of services was on 2/9/23. P9’s care plan dated 5/17/23 indicated transplantation status was open with a goal to get patient on transplant list as indicated by the provider by 5/30/24. On 5/17/23 the goal was still in progress with continue to monitor transplantation status as the plan. P9’s initial ESRD Comprehensive SW Assessment dated 2/16/23, indicated P9 had not been referred to a transplant center for review and the social worker (MSW) had not reviewed the transplant options with P9. P9’s 90-day ESRD Comprehensive SW Assessment dated 5/17/23, indicated P9 was not interested in transplantation, had not been referred for transplantation, and was not on a transplant list. During an interview on 1/29/25 at 3:11 p.m., the social worker (MSW)-B stated P9 was not one of her clients so she would need to review the medical record about the transplant status. After reviewing the medical record, MSW-B stated P9 had not been referred to any transplant program but would need to reach out to University of Minnesota (UoM) to verify if the record was correct. During a second interview on 1/29/25 at 3:48 p.m., MSW-B stated she reviewed P4’s medical record and saw the letter dated 12/6/24, with requested provider follow up orders that needed done in either December or January. MSW-B then stated there were no notes about a follow up appointment made that she could find and there were no notes that the patient had made the appointment themselves. During an interview on 1/29/25 at 4:47 p.m., the facility administrator (FA) and regional facility administrator (RFA) stated transplantation care plan conversations were started within the first week of services by the LSW. The transplantation conversations related to transplant list status and future goals would then be placed on the plan of care (POC) so all members of the dialysis team were aware of the patients transplant status. If the patient had been approved for a living donor transplant prior to admission to dialysis, then that information would be placed on the care plan so the IDT team was aware and the MSW could follow up on it with each IDT meeting. Review of the Comprehensive Interdisciplinary Assessment and Plan of Care policy dated 7/3/23, indicated the comprehensive patient assessment should include a conversation related to the patient’s wishes and status regarding transplantation. That conversation would occur within 30 days of the start of dialysis. The information obtained in the comprehensive patient assessment would be place in the care plan. The IDT must track the results of each kidney transplant referral. If not available by the transplant center, then reasonable efforts would be made by the facility to obtain this information. Monitoring the status of any facility patients on the transplant waiting list would also occur. 45842 P9 P9’s facesheet indicated start of services was on 2/9/23. P9’s care plan dated 5/17/23 indicated transplantation status was open with a goal to get patient on transplant list as indicated by the provider by 5/30/24. On 5/17/23 the goal was still in progress with continue to monitor transplantation status as the plan. P9’s initial ESRD Comprehensive SW Assessment dated 2/16/23, indicated P9 had not been referred to a transplant center for review and the social worker (MSW) had not reviewed the transplant options with P9. P9’s 90 day ESRD Comprehensive SW Assessment dated 5/17/23, indicated P9 was not interested in transplantation, had not been referred for transplantation, and was not on a transplant list. During an interview on 1/29/25 at 3:11 p.m., the social worker (MSW)-B stated P9 was not one of her clients so she would need to review the medical record about the transplant status. After reviewing the medical record, MSW-B stated P9 had not been referred to any transplant program, but would need to reach out to University of Minnesota (UoM) to verify if the record was correct. During a second interview on 1/29/25 at 3:48 p.m., MSW-B stated she reviewed P4’s medical record and saw the letter dated 12/6/24, with requested provider follow up orders that needed done in either December or January. MSW-B then stated there were no notes about a follow up appointment made that she could find and there were no notes that the patient had made the appointment themselves. During an interview on 1/29/25 at 4:47 p.m., the facility administrator (FA) and regional facility administrator (RFA) stated transplantation care plan conversations were started within the first week of services by the LSW. The transplantation conversations related to transplant list status and future goals would then be placed on the plan of care (POC) so all members of the dialysis team were aware of the patients transplant status. If the patient had been approved for a living donor transplant prior to admission to dialysis then that information would be placed on the care plan so the IDT team was aware and the MSW could follow up on it with each IDT meeting. Review of the Comprehensive Interdisciplinary Assessment and Plan of Care policy dated 7/3/23, indicated the comprehensive patient assessment should include a conversation related to the patient’s wishes and status regarding transplantation. That conversation would occur within 30 days of the start of dialysis. The information obtained in the comprehensive patient assessment would be place in the care plan. The IDT must track the results of each kidney transplant referral. If not available by the transpant center then reasonable efforts would be made by the facility to obtain this information. Monitoring the status of any facility patients on the transplant waiting list would also occur.”

“POC-TRACK TP REFER/STATUS;CONTACT TP CTR YRLY CFR(s): 494.90(c) The interdisciplinary team must- (1) Track the results of each kidney transplant center referral; (2) Monitor the status of any facility patients who are on the transplant wait list; and (3) Communicate with the transplant center regarding patient transplant status at least annually, and when there is a change in transplant candidate status. This Standard is not met as evidenced by: 38687 Based on interview and docuement review, the facility failed to track the results of 2 of 2 patients (P4 and P9) transplantation referral and status. Findings include: P4 P4’s Patient Transfer data sheet identified P4 was admitted to the facility in January 2024 for hemodialysis treatment related to end stage kidney disease. P4 had a physician’s order for transplant referral for patient evaluation dated 1/30/24. P4’s current, undated, plan of care identified P4’s transplantation status as open on 4/16/24 with a goal to place P4 on the transplant list as indicated by the patient’s physician with a goal due date of 4/26/25. The status was listed as OPEN, patient referred, in evaluation process, also dated 4/16/24. There was no indication the facility had updated or checked P4’s transplant evaluation process since April 2024. P4’s current, undated, Transplant Assessment identified the facility noted a date of discussion of 12/31/24. P4 was not on the transplant list but was interested in transplantation. Under the section “Patient referred for transplantation” it was marked “No”. Comments noted were 4/2024 Mayo evaluation process. There was no indication staff had verified P4’s current place in the process, if an evaluation had taken place, or if P4 needed assistance with any measures to make sure she was able to pass the evaluation process if indicated. In the “Referral Process” section, the following information was left blank: 1) Date of referral. 2) Date transplant center was contacted. 3) Date of appointment. 4) If first appointment was missed, staff were to list the reason why. 5) If second appointment was missed, staff were to list the reason why. There was no indication the facility had checked to see P4’s status in her process for seeking transplantation, who attended the discussion, or what if anything, was discussed. Review of the 12/6/24, letter from Mayo Clinic addressed to P4 (obtained by the facility upon request), identified the transplant committee had met on 12/4/24 to discuss her kidney transplant evaluation. The committee noted they were unable to make a decision regarding her candidacy due to the following reasons and/or conditions. P4 was to: 1) Start sertraline (anti-depressant medication) 25 milligrams (mg) per day for 2 weeks, then increase the dose to 50 mg per day. Further dosing optimization would occur on follow up. 2) Start hydroxyzine (anti-anxiety medication) 25 mg every 6 hours as needed for anxiety. 3) Establish care with a local therapist to provide more frequent and longitudinal follow-up and to consider cognitive behavioral therapy. 4) Follow up with transplant psychiatry in 1-2 months (end of December or January). Any requirements were noted to be expected to be completed within 3 months, at which time P4’s transplant candidacy was to be re-evaluated by the Multidisciplinary Transplant Selection Committee. The facility was noted as cc’ d on the letter. Interview on 1/29/25 at 1:15 p.m. with the facility administrator (FA) identified she felt P4 was on the transplant list but needed confirmation. She would reach out to the transplant clinic for an update. The FA agreed there was no indication P4’s care plan had been updated to show what her current progress was for transplant. There had been a lot of social worker (MSW) turnover within the last year, and the facility was currently unaware what P4’s status was. The FA noted P4’s home medications (medications not given at the facility) would be listed on her Patient Transfer sheet. Further review of P4’s current, undated Patient Transfer sheet identified her neither the sertraline nor the hydroxyzine were listed as medications P4 was taking at home based off the recommendations by the transplant facility. Interview on 1/30/25 at 10:30 a.m., with the FA, MSW-A and interim MSW-B identified P4 was noted to have “higher acuity” aka able to be independent with most of the processes required by the transplant committee and was able to make decisions about her care known. MSW-A and MSW-B agreed they had not been following P4’s transplantation status, but as of that morning, they had spoken to P4 to identify if she had begun her medications as required by the transplant committee. To their knowledge, P4 had started the sertraline, nut had not yet contacted any local therapists or followed up with transplant psychiatry as ordered. The facility leadership was to review the plan of care each month. P4’s current progress in transplant evaluation had been missed. MSW-A and MSW-B agreed it was the facility’s role to assist P4 with any barriers she may have in being able to achieve her goals and work closely with P4 to try and achieve those goals in order to be considered for transplant. Both stated the facilities failure to track and document her progress could cause P4 to be excluded from the evaluation process, therefore, removing her from consideration to be placed on the transplant waiting list. Interview on 1/30/25 at 2:05 p.m. with the medical director (MD)-A identified although he was not P4’s primary physician, her was aware of P4’s dialysis. He noted P4 did struggle with medical recommendations. He noted the facility was having a hard time retaining permanent social workers and that was likely what led to P4’s status not being documented or followed by the SW. The facility should maintain current transplant status and assisting patients to identify any barriers that could occur in efforts to get on the transplant list. MD-A thought the process would just be delayed and P4 would “constantly gain time on the list” but felt that should not preclude her from being removed from the evaluation process if she was unable to complete the items identified by the transplant committee. Call back received on 1/31/25 at 9:30 a.m. from the transplant committee (TC) identified P4’s evaluation began in October 2024. P4 was required to complete the above identified medications and care visits as indicated in the letter by March 5th, 2025. Prescriptions for the medications had been sent out, however TC could not verify if P4 had picked them up at the pharmacy as they did not show as filled. P4 was not dialysis compliant as she has missed treatments and has known psychosocial barriers to her treatment. The TC expectation was for the facility to follow P4’s progress in her transplant evaluation and assist P4 with any barriers such as potentially assisting in finding a local therapist, ensure she was reminded to pick up her meds, ask if she had started them, and identify any other barriers. If P4 made some progress (50% or more) by March 2025, the TC would likely delay her evaluation for another review in 3 months to give her time to complete the ordered medications and tasks. If P4 made little to no progress, P4 would be removed for consideration and would have to wait another year before referral to the TC for evaluation., thus removing her from potential eligibility to be placed on the waiting list to receive a kidney transplant. P9 P9’s facesheet indicated start of services was on 2/9/23. P9’s care plan dated 5/17/23 indicated transplantation status was open with a goal to get patient on transplant list as indicated by the provider by 5/30/24. On 5/17/23 the goal was still in progress with continue to monitor transplantation status as the plan. P9’s initial ESRD Comprehensive SW Assessment dated 2/16/23, indicated P9 had not been referred to a transplant center for review and the social worker (MSW) had not reviewed the transplant options with P9. P9’s 90-day ESRD Comprehensive SW Assessment dated 5/17/23, indicated P9 was not interested in transplantation, had not been referred for transplantation, and was not on a transplant list. During an interview on 1/29/25 at 3:11 p.m., the social worker (MSW)-B stated P9 was not one of her clients so she would need to review the medical record about the transplant status. After reviewing the medical record, MSW-B stated P9 had not been referred to any transplant program but would need to reach out to University of Minnesota (UoM) to verify if the record was correct. During a second interview on 1/29/25 at 3:48 p.m., MSW-B stated she reviewed P4’s medical record and saw the letter dated 12/6/24, with requested provider follow up orders that needed done in either December or January. MSW-B then stated there were no notes about a follow up appointment made that she could find and there were no notes that the patient had made the appointment themselves. During an interview on 1/29/25 at 4:47 p.m., the facility administrator (FA) and regional facility administrator (RFA) stated transplantation care plan conversations were started within the first week of services by the LSW. The transplantation conversations related to transplant list status and future goals would then be placed on the plan of care (POC) so all members of the dialysis team were aware of the patients transplant status. If the patient had been approved for a living donor transplant prior to admission to dialysis, then that information would be placed on the care plan so the IDT team was aware and the MSW could follow up on it with each IDT meeting. Review of the Comprehensive Interdisciplinary Assessment and Plan of Care policy dated 7/3/23, indicated the comprehensive patient assessment should include a conversation related to the patient’s wishes and status regarding transplantation. That conversation would occur within 30 days of the start of dialysis. The information obtained in the comprehensive patient assessment would be place in the care plan. The IDT must track the results of each kidney transplant referral. If not available by the transplant center, then reasonable efforts would be made by the facility to obtain this information. Monitoring the status of any facility patients on the transplant waiting list would also occur.”

“GOV-RN, MSW, & RD AVAIL TO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs; This Standard is not met as evidenced by: 38687 Based on interview and document review, the governing body failed to ensure consistent regular social workers were employed or provide enhanced monitoring of social worker duties when regular employment status could not be achieved when 2 of 2 patients (P4 and P9) who were in the transplantation evaluation phase, were not monitored by the interim social workers for current transplantation status, assessed and monitored for potential barriers during evaluation, updating the care plans, and reporting accurate transplant status to the Quality Assurance Performance Improvement Committee, when high social worker staff turnover patterns occurred. This had the potential to affect all 97 patients currently recieving care requiring social services. Findings include: P4 P4’s Patient Transfer data sheet identified P4 was admitted to the facility in January 2024 for hemodialysis treatment related to end stage kidney disease. P4 had a physician’s order for transplant referral for patient evaluation dated 1/30/24. P4’s current, undated, plan of care identified P4’s transplantation status as open on 4/16/24 with a goal to place P4 on the transplant list as indicated by the patient’s physician with a goal due date of 4/26/25. The status was listed as OPEN, patient referred, in evaluation process, also dated 4/16/24. There was no indication the facility had updated or checked P4’s transplant evaluation process since April 2024. P4’s current, undated, Transplant Assessment identified the facility noted a date of discussion of 12/31/24. P4 was not on the transplant list but was interested in transplantation. Under the section “Patient referred for transplantation” it was marked “No”. Comments noted were 4/2024 Mayo evaluation process. There was no indication staff had verified P4’s current place in the process, if an evaluation had taken place, or if P4 needed assistance with any measures to make sure she was able to pass the evaluation process if indicated. In the “Referral Process” section, the following information was left blank: 1) Date of referral. 2) Date transplant center was contacted. 3) Date of appointment. 4) If first appointment was missed, staff were to list the reason why. 5) If second appointment was missed, staff were to list the reason why. There was no indication the facility had checked to see P4’s status in her process for seeking transplantation, who attended the discussion, or what if anything, was discussed. Review of the 12/6/24, letter from Mayo Clinic addressed to P4 (obtained by the facility upon request), identified the transplant committee had met on 12/4/24 to discuss her kidney transplant evaluation. The committee noted they were unable to make a decision regarding her candidacy due to the following reasons and/or conditions. P4 was to: 1) Start sertraline (anti-depressant medication) 25 milligrams (mg) per day for 2 weeks, then increase the dose to 50 mg per day. Further dosing optimization would occur on follow up. 2) Start hydroxyzine (anti-anxiety medication) 25 mg every 6 hours as needed for anxiety. 3) Establish care with a local therapist to provide more frequent and longitudinal follow-up and to consider cognitive behavioral therapy. 4) Follow up with transplant psychiatry in 1-2 months (end of December or January). Any requirements were noted to be expected to be completed within 3 months, at which time P4’s transplant candidacy was to be re-evaluated by the Multidisciplinary Transplant Selection Committee. The facility was noted as cc’ d on the letter. Interview on 1/29/25 at 1:15 p.m. with the facility administrator (FA) identified she felt P4 was on the transplant list but needed confirmation. She would reach out to the transplant clinic for an update. The FA agreed there was no indication P4’s care plan had been updated to show what her current progress was for transplant. There had been a lot of social worker (MSW) turnover within the last year, and the facility was currently unaware what P4’s status was. The FA noted P4’s home medications (medications not given at the facility) would be listed on her Patient Transfer sheet. Follow up interview on 1/29/25 at 2:30 p.m., with the FA identified the facility has not had a full time employed MSW for approximately 2.5 years. It is the MSW responsibility to follow up on transplant status. The FA does ensure whomever the MSW is at the time, discusses their findings in QAPI. The FA had not been following up to ensure the MSW had been bringing accurate data to QAPI as noted by the lack of follow up with transplant patient status’. Further review of P4’s current, undated Patient Transfer sheet identified her neither the sertraline nor the hydroxyzine were listed as medications P4 was taking at home based off the recommendations by the transplant facility. Interview on 1/30/25 at 10:30 a.m., with the FA, MSW-A and interim MSW-B identified P4 was noted to have “higher acuity” aka able to be independent with most of the processes required by the transplant committee and was able to make decisions about her care known. MSW-A and MSW-B agreed they had not been following P4’s transplantation status, but as of that morning, they had spoken to P4 to identify if she had begun her medications as required by the transplant committee. To their knowledge, P4 had started the sertraline, nut had not yet contacted any local therapists or followed up with transplant psychiatry as ordered. The facility leadership was to review the plan of care each month. P4’s current progress in transplant evaluation had been missed. MSW-A and MSW-B agreed it was the facility’s role to assist P4 with any barriers she may have in being able to achieve her goals and work closely with P4 to try and achieve those goals in order to be considered for transplant. Both stated the facilities failure to track and document her progress could cause P4 to be excluded from the evaluation process, therefore, removing her from consideration to be placed on the transplant waiting list. Interview on 1/30/25 at 2:05 p.m. with the medical director (MD)-A identified although he was not P4’s primary physician, her was aware of P4’s dialysis. He noted P4 did struggle with medical recommendations. He noted the facility was having a hard time retaining permanent social workers and that was likely what led to P4’s status not being documented or followed by the SW. The MD agreed, the facility needed to have appropriate oversight to ensure stability of regularly employed social workers to ensure continuity. The facility should maintain current transplant status, discuss and document findings in IDT and and assist patients to identify any barriers that could occur in efforts to get on the transplant list. Call back received on 1/31/25 at 9:30 a.m. from the transplant committee (TC) identified P4’s evaluation began in October 2024. P4 was required to complete the above identified medications and care visits as indicated in the letter by March 5th, 2025. Prescriptions for the medications had been sent out, however TC could not verify if P4 had picked them up at the pharmacy as they did not show as filled. P4 was not dialysis compliant as she has missed treatments and has known psychosocial barriers to her treatment. the TC expectation was for the facility to follow P4’s progress in her transplant evaluation and assist P4 with any barriers such as potentially assisting in finding a local therapist, ensure she was reminded to pick up her meds, ask if she had started them, and identify any other barriers. If P4 made some progress (50% or more) by March 2025, the TC would likely delay her evaluation for another review in 3 months to give her time to complete the ordered medications and tasks. If P4 made little to no progress, P4 would be removed for consideration and would have to wait another year before referral to the TC for evaluation., thus removing her from potential eligibility to be placed on the waiting list to receive a kidney transplant. P9 P9’s facesheet indicated start of services was on 2/9/23. P9’s care plan dated 5/17/23 indicated transplantation status was open with a goal to get patient on transplant list as indicated by the provider by 5/30/24. On 5/17/23 the goal was still in progress with continue to monitor transplantation status as the plan. P9’s initial ESRD Comprehensive SW Assessment dated 2/16/23, indicated P9 had not been referred to a transplant center for review and the social worker (MSW) had not reviewed the transplant options with P9. P9’s 90-day ESRD Comprehensive SW Assessment dated 5/17/23, indicated P9 was not interested in transplantation, had not been referred for transplantation, and was not on a transplant list. During an interview on 1/29/25 at 3:11 p.m., the social worker (MSW)-B stated P9 was not one of her clients so she would need to review the medical record about the transplant status. After reviewing the medical record, MSW-B stated P9 had not been referred to any transplant program but would need to reach out to University of Minnesota (UoM) to verify if the record was correct. During a second interview on 1/29/25 at 3:48 p.m., MSW-B stated she reviewed P4’s medical record and saw the letter dated 12/6/24, with requested provider follow up orders that needed done in either December or January. MSW-B then stated there were no notes about a follow up appointment made that she could find and there were no notes that the patient had made the appointment themselves. During an interview on 1/29/25 at 4:47 p.m., the facility administrator (FA) and regional facility administrator (RFA) stated transplantation care plan conversations were started within the first week of services by the LSW. The transplantation conversations related to transplant list status and future goals would then be placed on the plan of care (POC) so all members of the dialysis team were aware of the patients transplant status. If the patient had been approved for a living donor transplant prior to admission to dialysis, then that information would be placed on the care plan so the IDT team was aware and the MSW could follow up on it with each IDT meeting. Review of the Comprehensive Interdisciplinary Assessment and Plan of Care policy dated 7/3/23, indicated the comprehensive patient assessment should include a conversation related to the patient’s wishes and status regarding transplantation. That conversation would occur within 30 days of the start of dialysis. The information obtained in the comprehensive patient assessment would be place in the care plan. The IDT must track the results of each kidney transplant referral. If not available by the transplant center, then reasonable efforts would be made by the facility to obtain this information. Monitoring the status of any facility patients on the transplant waiting list would also occur. Review of the 3/20/20, Kidney Selection Guidelines for Mayo Clinic-Rochester policy, provided by the facility, identified the purpose was to provide written guidance to facilities in their evaluating of patients in determining their suitability for kidney transplant. Some of the eligibility requirements were for the patient to have informed consent, have a psycho-social clearance, and obtain financial clearance. An absolute contraindication was for a patient who showed an inability to comply with transplant related management and medical follow up. Review of the 4/7/21, MSW job description identified the MSW, in collaboration with the interdisciplinary team (IDT) was to inform, educate, and support staff in understanding the emotional, psychological, and behavioral impact of chronic kidney disease on the patient and family to ensure comprehensive, quality care of patients. The MSW was to also provide educational, and goal directed counseling to patients who are seeing transplant, provide information, and assist the teams and patient with referral to community resources to facilitate optimal treatment outcomes, document interactions and interventions provided to patients, and facilitates in the transplant referral process and collaborates with the IDT on transplant wait-list management. The MSW was also to provide psychosocial support and/or social work focused interventions to address non-adherence, quality outcome, and quality of life concerns for all patients and document MSW interactions and interventions provided to the patient.”