Fresenius Kidney Care East Johnston

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 38766 Based on policy and procedure reviews, emergency drill reviews, and staff interviews, the facility administration failed to follow the policy in ensuring that fire drills were conducted quarterly according to the facility policy. Findings included: A review of the facility policy titled “Fire Drill,” published 08/02/2017, revealed “...Fire Drills *Quarterly, all [named] facilities shall perform a fire drill for each shift of patients and staff, including Home Therapies patients present in the facility... Documentation *Document patient participation in fire and disaster drills on the Patient Participation in Fire and Disaster Drills forms...” A review of emergency fire drills on 07/17/2025 revealed that the fire drills were documented in January 2025. The documentation review indicated that no fire drill has been conducted from February 2025 to the present, totaling six months. An interview conducted on 07/17/2025, at 1445 with the Administrative Assistant (AA) revealed that the AA was responsible for carrying out and documenting the fire drill exercise at the facility. The interview revealed that the AA believed that the fire drills were completed for the second quarter; however, the AA was uncertain about the whereabouts of the documentation. An interview on 07/17/2025, at 1500, with the Facility Administrator (FA) and the Area Team Lead (ATL) confirmed that a fire drill should occur quarterly; however, they were unable to locate documentation of a fire drill for the second quarter. The interview confirmed the findings.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 38766 Based on a review of policy and procedures, medical records review, and staff interviews, the facility staff failed to perform and/or document patient monitoring every 30-45-minute during dialysis treatments for four (4) of eight (8) in-patient records reviewed (Patient #5, #2, #7, and #4). Findings included: A review on 04/16/2025 of the facility’s policy and procedure, “Patient Assessment and Monitoring,” published 05/01/2023, revealed “...During Treatment: Obtaining blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 minutes or more often as needed, but not to exceed 45 minutes per state regulations...” 1. An open medical record review on 07/16/2025 for Patient #5 revealed that a 69-year-old female had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 10/02/2023. A review of the treatment flowsheet dated 07/04/2025 revealed the treatment started at 1115 and concluded at 1501 (lasting a total of 226 minutes). The treatment flowsheet revealed no documented vital signs from 1130 through 1235 (65 minutes). A review of the treatment flowsheet on 07/07/2025 revealed the treatment started at 1120 and ended at 1425 (lasting a total of 185 minutes). The treatment flowsheet revealed no documented vital signs from 1333 through 1425 (52 minutes). A review of the treatment flowsheet on 07/09/2025 revealed the treatment started at 1110 and ended at 1403 (lasting a total of 173 minutes). The treatment flowsheet revealed no documented vital signs from 1130 through 1243 (73 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment, as required by policy. An interview on 07/17/2025, at 1220 with PCT/CCHT #3, revealed that monitoring of the patient, including vital signs and safety checks, should be performed and documented every 30 minutes. The interview confirmed the findings. 2. An open medical record review on 07/16/2025 for Patient #2 revealed that a 50-year-old female had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 07/23/2021. A review of the treatment flowsheet dated 06/30/2025 revealed the treatment started at 0930 and concluded at 1343 (lasting a total of 253 minutes). The treatment flowsheet revealed no documented vital signs from 0932 through 1031 (a duration of 59 minutes) and from 1102 through 1231 (89 minutes). This review indicated that the staff failed to monitor the patient’s vital signs every 30 to 45 minutes during the hemodialysis treatment, as required by policy. An interview on 07/17/2025, at 1220 with PCT/CCHT #3, revealed that monitoring of the patient, including vital signs and safety checks, should be performed and documented every 30 minutes. The interview confirmed the findings. 3. An open medical record review on 07/17/2025 for Patient #7 revealed that a 58-year-old male had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 05/24/2022. A review of the treatment flowsheet dated 07/07/2025 revealed the treatment started at 0619 and concluded at 1004 (lasting a total of 225 minutes). The treatment flowsheet revealed no documented vital signs from 0901 through 1003 (62 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment, as required by policy. An interview on 07/17/2025, at 1220 with PCT/CCHT #3, revealed that monitoring of the patient, including vital signs and safety checks, should be performed and documented every 30 minutes. The interview confirmed the findings. 4. An open medical record review on 07/16/2025 for Patient #4 revealed that a 69-year-old female had been admitted to the facility for ICHD treatment on 11/04/2020. A review of the treatment flowsheet dated 07/07/2025 revealed the treatment started at 0609 and concluded at 0939 (lasting a total of 210 minutes). The treatment flowsheet revealed no documented vital signs from 0832 through 0932 (60 minutes). The review indicated the facility staff failed to monitor the patient every 30-45 minutes during hemodialysis treatment, as required by policy. An interview on 07/17/2025, at 1220 with PCT/CCHT #3, revealed that monitoring of the patient, including vital signs and safety checks, should be performed and documented every 30 minutes. The interview confirmed the findings.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 38766 Based on a policy review, medical records review, and staff interviews, the facility staff failed to follow the adequacy plan of care by not dialyzing 2 of 8 (Patients #2 and #5) in-center hemodialysis patients at the prescribed BFR/DFR and/or treatment duration. Findings included: A review on 04/16/2025 of the facility’s policy and procedure, “Patient Assessment and Monitoring,” published 05/01/2023, revealed “Purpose ...Responsibility ...Definitions ...Delegation ...Data Collection ...Pre-Treatment ...During Treatment ...Step 1 ...Step 3 [space] Machine Parameters and Extracorporeal Circuit [space] Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. ...” 1. An open medical record review on 07/16/2025 for Patient #2 revealed that a 50-year-old female had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 07/23/2021. A review of the Physician orders revealed Patient #2’s Blood Flow Rate (BFR) was ordered at 400 and Dialysate Flow Rate (DFR) at 800. Review of the Treatment Flowsheet dated 07/07/2025 revealed Patient #2’s hemodialysis treatment was initiated at 1012 and ended at 1333 (201 minutes). Review of the Flowsheet revealed that Patient #2’s BFR average was 300 with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. Review of the Treatment Flowsheet dated 07/09/2025 revealed Patient #2’s hemodialysis treatment was initiated at 0932 and ended at 1337 (241 minutes). Review of the Flowsheet revealed Patient #2’s BFR average was 300, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. An interview on 07/17/2025 at 1220 with PCT/CCHT #3 revealed that the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR, or if they were unable to achieve the ordered BFR/DFR. An interview on 07/17/2025 with the FA revealed that the nursing staff should have assessed and documented the reason for the decreased BFR during the patient treatments. 2. An open medical record review on 07/16/2025 for Patient #5 revealed that a 69-year-old female had been admitted to the facility for in-center hemodialysis (ICHD) treatment on 10/02/2023. A review of the Physician orders revealed Patient #5’s Blood Flow Rate (BFR) was ordered at 350, and Dialysate Flow Rate (DFR) at 1.5 times the BFR rate. Review of the Treatment Flowsheet dated 07/07/2025 revealed Patient #5’s hemodialysis treatment was initiated at 1120 and ended at 1425 (lasting a total of 185 minutes). Review of the Flowsheet revealed Patient #5’s BFR average was 300, with no documentation for the decreased BFR and no documentation of the Registered Nurse notification. An interview on 07/17/2025, at 1220 with PCT/CCHT #3 revealed that the facility’s patient care technicians should notify the nursing staff anytime they increased and/or decreased the patient’s BFR/DFR or were unable to achieve the ordered BFR/DFR. An interview on 07/17/2025, with the FA revealed that the nursing staff should have assessed and documented the reason for the decreased BFR during the patient treatments.”