Davita Spencer Dialysis

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 35306 Based on policy and procedure review and staff interview, the facility staff failed to collaborate with local emergency preparedness officials to maintain and integrated response during a disaster or emergency for 1 of 1 facility sites surveyed (Facility A). Findings included: Review on 01/16/2025 of the facility Emergency Preparedness Plan revealed, “... Communication ... 11. The FA [Facility Administrator], or designee, shall have communication at least on an ANNUAL basis with the following local agencies regarding emergency preparedness, event collaboration and communication, needs of the dialysis patients and facility, and reviewing the agency’s emergency plan. ... NOTE: documentation of contact is important: a. Local Emergency Management agency i. Additional follow-up contact required to include: 1. Phone contact 2. Attending meeting 3. Participation in collaborative and cooperative planning efforts ...” Review of the facility’s Emergency Preparedness Plan failed to reveal evidence of communication with the local emergency management agency. Interview on 01/16/2025 at 1446 the Facility Administrator (FA) revealed evidence of communication with the local emergency management agency was not available for review. Interview revealed the FA (#2) assumed leadership/oversight of the facility on 12/05/2024 and that several opportunities for improvement had been identified. During the interview, the FA stated, “This is an opportunity for improvement for us. I have it on my list to be addressed.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was not aware evidence of communication with the local emergency management agency was not available for review and that his expectation going forward was that all policies and regulatory guidelines are met. During the interview the MD stated, “Given the recent change [newly appointed FA], I feel confident this will be addressed promptly and that all areas of improvement will be resolved.””

“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: 35306 Based on policy and procedure review and staff interviews, the dialysis clinic administrative staff failed to conduct drills, at least annually, to test the emergency preparedness plan’s effectiveness. Findings included: Review on 01/16/2025 of the facility’s Emergency Management Plan revealed, “... Emergency Drills 1. The FA, or designee, will maintain the emergency preparedness training and testing based on the facility EMP [Emergency Management Plan]. 2. EMP training exercises: ... e. Frequency: i. The facility will conduct and/or participate in one (1) exercise to test the facility EMP at least ANNUALLY ...” Review of the facility documentation on 01/16/2025 revealed no available documentation that the dialysis clinic administrative staff had conducted drills, at least annually, to test the plan’s effectiveness. Interview on 01/16/2025 at 1446 with the Facility Administrator (FA) revealed documented evidence of annual drills testing the EMP was not available for review. Interview revealed the current FA assumed leadership/oversight of the facility on 12/05/2024 and that several opportunities for improvement had been identified. During the interview, the FA stated, “This is an opportunity for improvement for us. I have it on my list to be addressed. Interview confirmed findings. Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was not aware annual drills were not available for review and that his expectation going forward was that all policies and regulatory guidelines are met. During the interview the MD stated, “Given the recent change [newly appointed FA], I feel confident this will be addressed promptly and that all areas of improvement will be resolved.””

“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: 35306 Based on facility policy review, medical record review and staff interview, the facility’s IDT and social worker failed to evaluate a patient’s psychosocial needs within 4 months of initiating treatment for 1 of 4 sampled patients from ICHD (Patient #2) and 1 of 3 sampled patients from home dialysis (Patient #6). Findings included: Review on 01/15/2025 of the policy titled, “Quality of Life Assessment Survey” (revised October 2023) revealed “ ... The Quality of Life (QOL) assessment survey is to be administered by the Social Worker to patients within four (4) months of initiating treatment, on an as needed basis, and repeated at least annually thereafter. ...” Review on 01/15/2025 of the policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” (Revised: October 2024) revealed, “ ... 4. A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines. ... 5. A follow up 90 day re-assessment will be completed to evaluate patient’s status and provide information to adjust the patient’s plan of care. ...9. The plan of care will address ... Psychosocial status which addresses necessary monitoring and social work interventions. ... as measured by a standardized Quality of Life tool. ...” 1. Medical record review on 01/14/2025 for patient #2 revealed the 84 year old patient was admitted to the facility on 07/19/2024 for ICHD. Review of the record revealed the Kidney Disease Quality of Life (KDQOL: Self-report measure developed for individuals on dialysis that includes 43 kidney disease targeted items, such as the effects of the disease on activities of daily living, work status, and social interaction, and 36 items that provide a measure of physical and mental health, and 1 overall health rating item) was completed 11/25/2024 (4 months, 9 days post-admission). Medical record review revealed the facility Social Worker (SW) failed to administer the KDQOL assessment to patient #2 within four (4) months of initiating treatment. Interview on 01/16/2025 at 1446 with the FA revealed late KDQOL assessments was identified during an October 2024 internal audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. Interview revealed there had been changes in social worker positions and that the assessment was missed. Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. 2. Medical record review on 01/14/2025 for patient #6 revealed the 70 year old was admitted to the facility on 04/30/2024 to the home training program for home dialysis. Review of the record revealed the KDQOL was completed 12/16/2024 (7 months, 16 days post-admission). Medical record review revealed the facility Social Worker (SW) failed to administer the KDQOL assessment to patient #6 within four (4) months of initiating treatment. Interview on 01/16/2025 at 1446 with the FA revealed late KDQOL assessments was identified during an October 2024 internal audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. Interview on 01/16/2025 at 1635 with the home training regional manager revealed the KDQOL was completed late. “This is an opportunity for improvement for us.””

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 35306 Based on facility policy review, medical record review, and staff interview facility staff failed to conduct an initial comprehensive interdisciplinary assessment within 30 days of the first hemodialysis treatment for 3 of 4 ICHD sampled patients (Patient #1, #2, and #5) and 2 of 3 home training sampled patients (Patient #6, and #7). Findings included: Review on 01/15/2025 of the policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” dated October 2024 revealed the facility’s IDT consisting of the patient or personal representative, a registered nurse (RN), a physician (MD) or non-physician provider (NPP), “if allowed by state ESRD licensure regulations, treating the patient for ESRD, a social worker (SW), and qualified renal dietician. Further review of the policy revealed, “... 1. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment and documenting his/her needs. ... 4. A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines. ...” 1. Medical record review on 01/14/2025 for patient #1, an ICHD patient, revealed the 76 year old was admitted to the facility on 11/22/2024. Review of the medical record revealed the initial Comprehensive Assessment was completed by the RN on 01/08/2025 (47 calendar days post-admission). Medical record review revealed the facility IDT failed to ensure comprehensive assessments were completed within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis). Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The comprehensive assessments should have been completed within 30 days or 13 treatments per our policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. 2. Medical record review on 01/14/2025 for patient #2, an ICHD patient, revealed the 84 year old patient was admitted to the facility on 07/19/2024. Review of the medical record revealed the initial Comprehensive Assessment was completed by the RN on 08/22/2024 (34 calendar days post-admission) and RD on 09/25/2024 (68 calendar days post-admission). Medical record review revealed the facility IDT failed to ensure comprehensive assessments were completed within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis). Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The comprehensive assessments should have been completed within 30 days or 13 treatments per our policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. 3. Medical record review on 01/14/2025 for patient #5 revealed the 28 year old, an ICHD pt, was admitted to the facility on 02/17/2023. Review of the medical record revealed the initial Comprehensive Assessment was completed by the RD on 06/02/2023 (95 calendar days post-admission), MSW on 06/06/2023 (99 calendar days post-admission), and RN on 06/09/2023 (102 calendar days post-admission). Medical record review revealed the facility IDT failed to ensure comprehensive assessments were completed within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis). Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The comprehensive assessments should have been completed within 30 days or 13 treatments per our policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. Interview on 01/16/2025 at 1635 with the home training regional manager revealed comprehensive assessments were not completed within the required timeframes. “This is an opportunity for improvement for us and we are working on it.” 4. Medical record review on 01/14/2025 for patient #6 revealed the 70 year old, a PD patient, was admitted to the facility on 04/30/2024. Review of the medical record revealed initial Comprehensive Assessment was completed by the MSW on 07/06/2024 (67 calendar days post-admission). Medical record review revealed the facility IDT failed to ensure comprehensive assessments were completed within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis). Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The comprehensive assessments should have been completed within 30 days or 13 treatments per our policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. Interview on 01/16/2025 at 1635 with the home training regional manager revealed comprehensive assessments were not completed within the required timeframes. “This is an opportunity for improvement for us and we are working on it.” 5. Medical record review on 01/14/2025 for patient #6 revealed the 38 year old, a PD patient, transferred to the facility on 04/30/2024. Review of the medical record revealed the initial Comprehensive Assessment was completed by the MSW on 07/06/2024 (67 calendar days post-admission). Medical record review revealed the facility IDT failed to ensure comprehensive assessments were completed within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis). Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The comprehensive assessments should have been completed within 30 days or 13 treatments per our policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. Interview on 01/16/2025 at 1635 with the home training regional manager revealed comprehensive assessments were not completed within the required timeframes. “This is an opportunity for improvement for us and we are working on it.””

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 35306 Based on facility policy review, medical record review, and staff interview facility staff failed to conduct a 90 day comprehensive reassessment within 3 months after completion of the initial assessment for 1 of 5 ICHD sampled patients (Patient #2) and 1 of 3 home training sampled patients (Patient #5 and #6). Findings included: Review on 01/15/2025 of the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” (Revised: October 2024) revealed, “ ... 5. A follow up 90 day re-assessment will be completed to evaluate patient’s status and provide information to adjust the patient’s plan of care. ...” 1. Medical record review on 01/14/2025 for patient #2 revealed the 84 year old patient was admitted to the facility on 07/19/2024 for ICHD. On Review of the medical record revealed the RN initial comprehensive assessment was completed 08/22/204. The RN follow-up 90-day reassessment was completed on 11/26/2024 (107 calendar days post-initial comprehensive assessment). Medical record review revealed the facility IDT failed to ensure 90-day follow-up assessments were completed. Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The comprehensive assessments should have been completed within 30 days or 13 treatments per our policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. 2. Medical record review on 01/14/2025 for patient #6 revealed the 70 year old, a PD patient, was admitted to the facility on 04/30/2024. Review of the medical record revealed the initial Comprehensive Assessment was completed by the MSW on 07/06/2024. The MSW follow-up 90-day reassessment was completed 10/22/2024 (108 calendar days post-initial comprehensive assessment). Medical record review revealed the facility IDT failed to ensure 90-day follow-up assessments were completed. Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The comprehensive reassessments should have been completed within 90 days of the 30-day initial comprehensive assessment per our policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. Interview on 01/16/2025 at 1635 with the home training regional manager revealed comprehensive assessments were not completed within the required timeframes. “This is an opportunity for improvement for us and we are working on it.””

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) 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- (1) At least annually for stable patients; This Standard is not met as evidenced by: 35306 Based on facility policy review, medical record review, and staff interview facility staff failed to complete an annual comprehensive re-assessment of a stable patient for 1 of 4 ICHD sampled patients (Patient #4) and 1 of 3 home training sampled patients (Patient #5). Findings included: Review on 01/15/2025 of the policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” dated October 2024 revealed the facility’s IDT consisting of the patient or personal representative, a registered nurse (RN), a physician (MD) or non-physician provider (NPP), “if allowed by state ESRD licensure regulations, treating the patient for ESRD, a social worker (SW), and qualified renal dietician. Further review of the policy revealed, “... 1. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment and documenting his/her needs. ... 7. A comprehensive re-assessment of each patient .... will be conducted: *At least annually for stable patients ....” 1. Medical record review on 01/14/2025 for patient #4 revealed the 64 year old, an ICHD was admitted to the facility on 12/26/2019. Review of the medical record revealed the annual comprehensive re-assessment was due 05/09/2024. The SW comprehensive re-assessment was completed on 05/16/2024 (7 calendar days after the due date). Medical record review revealed the facility IDT failed to ensure a comprehensive re-assessment was completed annually for stable patients. Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement with completion of annual comprehensive re-assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. Comprehensive re-assessments should have been completed annually for stable patients, per policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. 2. Medical record review on 01/14/2025 for patient #5 revealed the 28 year old, an ICHD patient, was admitted to the facility on 02/17/2023 and transferred to Home PD on 07/27/2023. Review of the medical record revealed the annual comprehensive re-assessment was due 09/03/2024. Further review revealed the annual comprehensive assessment was completed by the RN on 09/04/2024 (1 day after the due date) and the MSW on 10/22/2024 (34 days after the due date). Medical record review revealed the facility IDT failed to ensure a comprehensive re-assessment was completed annually for stable patients. Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement with completion of annual comprehensive re-assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. Comprehensive re-assessments should have been completed annually for stable patients, per policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. Interview on 01/16/2025 at 1635 with the home training regional manager revealed comprehensive assessments were not completed within the required timeframes. “This is an opportunity for improvement for us and we are working on it.””

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 35306 Based on facility policy review, medical record review, and staff interview facility staff failed to conduct an initial comprehensive interdisciplinary assessment within 30 days of the first hemodialysis treatment for 3 of 4 ICHD sampled patients (Patient #1, #2, and #5) and 2 of 3 home training sampled patients (Patient #6, and #7). Findings included: Review on 01/15/2025 of the policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” dated October 2024 revealed the facility’s IDT consisting of the patient or personal representative, a registered nurse (RN), a physician (MD) or non-physician provider (NPP), “if allowed by state ESRD licensure regulations, treating the patient for ESRD, a social worker (SW), and qualified renal dietician. Further review of the policy revealed, “... 8. The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition ... 10. An initial Plan of Care, based on findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment ... 11. After completion of the 90 Day [sic] re-assessment, the Interdisciplinary Team will conduct an IDT meeting to make adjustments to the Plan of Care. ... 12. ... The Plan of Care following re-assessment must be completed within 15 days of completing the re-assessment. This process would occur .... annually for stable patients. ...” 1. Medical record review on 01/14/2025 for patient #1 revealed the 76 year old, an ICHD patient, was admitted to the facility on 11/22/2024. Review of the medical record revealed the 30-day, initial Plan of Care (POC) was due 12/23/2024; however, it was not finalized until 01/13/2025 (52 calendar days post-admission). Medical record review revealed facility IDT failed to ensure initial POCs were completed within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis). Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The initial plan of care should have been completed within 30 days or 13 treatments per policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. 2. Medical record review on 01/14/2025 for patient #2 revealed the 84 year old patient, an ICHD patient, was admitted to the facility on 07/19/2024. Review of the medical record revealed the 30 day, initial POC was due 08/19/2024; however, it was not finalized until 11/26/2024 (99 calendar days post-due date). Medical record review revealed facility IDT failed to ensure initial POCs were completed within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis). Medical record review revealed facility IDT failed to ensure initial POCs were completed within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis). Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The initial plan of care should have been completed within 30 days or 13 treatments per policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. 3. Medical record review on 01/14/2025 for patient #3 revealed the 38 year old, an ICHD patient, transferred to the facility on 08/30/2023. Review of the medical record revealed the annual plan of care was due 07/11/2024; however, it was not finalized until 11/26/2024 (138 calendar days post-due date). Further review revealed the RD re-assessment and POC was completed 09/25/2024 (76 calendar days past the due date). Medical record review revealed the IDT failed to ensure comprehensive re-assessments and POCs were completed annually. Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The annual comprehensive re-assessment and Plan of Care should have been completed per policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. 4. Medical record review on 01/14/2025 for patient #4 revealed the 64 year old, an ICHD patient, was admitted to the facility on 12/26/2019. Review of the medical record revealed the annual POC was due 05/24/2024; however, it was not finalized until 05/30/2024 (6 calendar days post-due date). Further review revealed the RN POC was not completed until 05/30/2024. Medical record review revealed the IDT failed to ensure comprehensive re-assessments and POCs were completed annually. Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The annual comprehensive re-assessment and Plan of Care should have been completed per policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. 5. Medical record review on 01/14/2025 for patient #5 revealed the 28 year old was admitted to the facility on 02/17/2023 for ICHD, who transferred to home PD on 07/27/2023. Review of the medical record revealed the annual POC was due 09/18/2024; however, it was not finalized until 10/29/2024 (41 calendar days post-due date). Further review revealed to RN POC was completed on 09/25/2024 (7 calendar day post-due date) and the MSW POC was completed on 10/22/2024 (34 calendar days post-due date). Medical record review revealed the IDT failed to ensure comprehensive re-assessments and POCs were completed annually. Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The annual comprehensive re-assessment and Plan of Care should have been completed per policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. Interview on 01/16/2025 at 1635 with the home training regional manager revealed comprehensive assessments, re-assessments and plans of care were not completed within the required timeframes. “This is an opportunity for improvement for us and we are working on it.” 6. Medical record review on 01/14/2025 for patient #6 revealed the 70 year old, a PD patient, transferred to the facility on 04/30/2024. Review of the medical record revealed the initial 30 day, POC was due 05/30/2024; however, it was not finalized until 07/17/2024 (48 days post-due date). Further review revealed the 90 day POC was due 10/19/2024; however it was finalized until 10/29/2024. Medical record review revealed the IDT failed to ensure comprehensive re-assessments and POCs were completed annually. Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The initial plan of care should have been completed within 30 days or 13 treatments and 90 day re-assessment and Plan of Care should have been completed per policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. Interview on 01/16/2025 at 1635 with the home training regional manager revealed comprehensive assessments, re-assessments and plans of care were not completed within the required timeframes. “This is an opportunity for improvement for us and we are working on it.” 7. Medical record review on 01/14/2025 for patient #7 revealed the 38 year old, a PD patient, was admitted to the facility on 09/09/2024. Review of the medical record revealed the initial 30 day POC was due 10/09/2024; however, it was not finalized until 10/28/2024 (19 day post-due date). Further review revealed the MSW POC was completed 10/22/2024 (13 calendar days post-due date). Interview on 01/16/2025 at 1446 with the FA revealed an opportunity for improvement was identified with late comprehensive assessments and care plans was identified during an October 2024 audit and that “nothing was done about it. When I assumed the FA role 12/5/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. The initial plan of care should have been completed within 30 days or 13 treatments per policy.” Interview on 01/16/2025 at 1459 with the facility Medical Director (MD) revealed he was aware of the above improvement opportunities and that an Action Plan had been developed with the intention of improving the identified deficiencies. Interview revealed, “I believe with the recent change in the FA position, we will see improvement, overall. Interview on 01/16/2025 at 1635 with the home training regional manager revealed comprehensive assessments, re-assessments and plans of care were not completed within the required timeframes. “This is an opportunity for improvement for us and we are working on it.””

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 35306 Based in review of the facility’s “Governing Body Meeting Minutes”, facility policies and procedures, action plans, and staff interviews, the facility staff failed to ensure effective monitoring, tracking, and evaluation of corrective action plans implemented for treatment documentation, timely completion of assessments, care plans, and quarterly notes. Findings included: 1. Review on 01/15/2025 of “Governing Body Meeting Minutes”, dated 12/06/2024 revealed, “... Discussion Notes: On 12/05/2024, a review of the Plan of Correction/GB [Governing Body] from October 2024 for areas of improvement on treatment documentation, it was found that follow up audits were not completed. ... Further review of the meeting minutes revealed Action Plan for improvement was “Reviewed, discussed, and approved” by the facility administrator (FA #2), regional operations director (ROD), facility medical director (MD), and nurse manager (NM). Interview on 01/16/2025 at 1446 with the FA revealed areas for improvement were identified with treatment documentation during an internal quality compliance audit in October 2024 and that “nothing was done about it. When I assumed the role on 12/05/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. Flow sheet audits were initiated and we continue to work on educating staff when opportunities are identified. The Action Plan should have been implemented in October when the opportunity for improvement was identified and unfortunately, it was not.” 2. Review on 01/15/2025 of” Governing Body Meeting Minutes”, dated 10/17/2024 revealed, “... Discussion Notes: Completion of Assessments, care plans, and quarterly notes were discussed. ... In-Center Hemo, PD Services ... A. Discussion Topic: Assessments, Care Plans, and Social Worker monthly notes. Discussion Points/Action Plan: Audit was completed on Assessments and Care Plans and due to transition of new social worker, there are 20 Assessment/Care plans that have not been completed by social worker. Social worker notes for patient that are due monthly have not been completed since July 2024. Moving forward, Assessments and Care plans will be completed by new social worker and previous care plans will be updated and corrected by Regional social worker or new social worker. Quarterly notes for October, assessments, and Care plans will be corrected and updated by December 1, 2024.” Further review of the meeting minutes revealed audit findings and the Action Plan for improvement were “Reviewed, discussed, and approved” by the facility administrator (FA #1), regional operations director (ROD), and facility Medical Director (MD). Interview on 01/16/2025 at 1446 with the FA revealed areas for improvement were identified with completion of SW assessments, care plans, and quarterly notes during an internal quality compliance audit in October 2024 and that “nothing was done about it. When I assumed the role on 12/05/2024, I began implementing Action Plans and we are working on improving compliance with our documentation. Audits have been initiated and we continue to work on educating staff when opportunities are identified. The Action Plan should have been implemented in October when the opportunity for improvement was identified and unfortunately, it was not.” 3. Review on 01/15/2025 of “Governing Body Meeting Minutes”, dated 01/13/2025 revealed, “... Discussion Notes: Care Plan completion. ... Discussion Points/Action Plan: On January 9th, 2025, Care Plans were reviewed. Due to the POC [Plan of Correction] written in October of 2024 not being followed up on, a new plan was conducted. ... Care plans will be caught up by January 31st, 2025. Moving forward, the social worker is responsible for timely closure and completion.” Further review of the meeting minutes revealed audit findings and the Action Plan for improvement were “Reviewed, discussed, and approved” by the new facility administrator (FA #2), regional operations director (ROD), and facility Medical Director (MD). Interview on 01/16/2025 at 1446 with the FA revealed areas for improvement were identified with treatment documentation during an internal quality compliance audit and that “nothing was done about it. When I assumed the role on 12/05/2024, I began implementing Action Plans and we are working on improving compliance with timely completion of Care Plans. Audits have been initiated and we continue to work on educating staff when opportunities are identified. The Action Plan should have been implemented in October when the opportunity for improvement was identified and unfortunately, it was not.””