Aurora Dialysis LLC

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 19410 Based on policy review, document review, record review, and patient and staff interview, the ESRD (end stage renal disease) facility failed to include 1 of 4 required members on the interdisciplinary team (licensed dietitian). Failure to have a licensed dietitian as part of the interdisciplinary team limited the facility’s ability to provide individualized and comprehensive assessments of the patients’ nutritional needs. Findings include: Review of the facility policy, “Multidisciplinary Re-Assessment,” dated March 2024, stated, “PURPOSE: To assure appropriate care based on the nature of the patient’s illness, the treatment prescribed and an ongoing assessment of the patient’s needs. . . . POLICY STATEMENTS: 1. The Multidisciplinary Re-assessment is individualized for each patient. It will address the psychosocial, dietary, medical and functional needs of the patient. 2. The Multidisciplinary Re-assessment is developed by a multi-disciplinary team including, but not limited to the attending physician, clinical manager an/or nursing designees, dietitian and social worker. . . . 5. The re-assessment for patients whose medical condition is stabilized is reviewed yearly. 6. The Multidisciplinary initial assessment will be completed within thirty (30) [days] of admission. . . .” Review of the facility’s current list of personnel occurred on 03/18/24. This list failed to include a licensed dietitian. Interviews with patients on March 18-19, 2024, identified the following: 03/18/24 at 2:12 p.m., Patient A stated he does not see a dietitian about his diet and the nurse, or the physician will give him the lab results. 03/18/24 at 2:20 p.m., Patient B stated the facility does not have a dietitian and the nurse talks to him about his labs and diet. 03/18/24 at 2:30 p.m., Patient C stated, “They don’t have a dietitian.” The patient stated she does not have any fluid restrictions and the nurse talks to her about her diet. 03/19/24 at 7:42 a.m., Patient D stated, “There is no dietitian here,” and the nurse will go over lab results each month. 03/19/23 at 7:48 a.m., Patient E stated “There was a dietitian when I first started on dialysis, but they don’t have one now.” - Review of patient medical records occurred on March 18-19, 2024. Review of the comprehensive assessments identified the following: Patient #1 - Annual Interdisciplinary Re-Assessment, dated 01/02/24 - Nutritional assessment lacked completion by a licensed dietitian. Patient #2 - Annual Interdisciplinary Re-Assessment, dated 01/03/24 - Nutritional assessment lacked completion by a licensed dietitian. Patient #3 - Initial Interdisciplinary Assessment, dated 12/13/24 - Nutritional assessment lacked completion by a licensed dietitian. Patient #4 - Annual Interdisciplinary Re-Assessment, dated 01/04/24 - Nutritional assessment lacked completion by a licensed dietitian. During interview on the morning of 03/19/24, an administrative staff member (#1) stated the facility has not had a dietitian on staff for “over six months,” and they have not been successful in hiring a new dietitian. The staff member (#1) stated the nursing staff provide dietary services to the patients.”

“PA-RD-NUTRITIONAL STATUS CFR(s): 494.80(a)(6) The patient’s comprehensive assessment must include, but is not limited to, the following: (6) Evaluation of nutritional status by a dietitian This Standard is not met as evidenced by: 19410 Based on record review, policy review, document review, and staff interview, the facility failed to ensure each patients’ comprehensive assessment included an evaluation of nutritional status by a registered dietitian for 4 of 4 patient initial and re-assessments reviewed (Patients #1, #2, #3, and #4). Failure to have a licensed dietitian on staff limited the facility’s ability to evaluate and meet the patients’ nutritional needs. Findings include: Review of the facility policy, “Multidisciplinary Re-Assessment,” dated March 2024, stated, “PURPOSE: To assure appropriate care based on the nature of the patient’s illness, the treatment prescribed and an ongoing assessment of the patient’s needs. . . . POLICY STATEMENTS: 1. The Multidisciplinary Re-assessment is individualized for each patient. It will address the psychosocial, dietary, medical and functional needs of the patient. 2. The Multidisciplinary Re-assessment is developed by a multi-disciplinary team including, but not limited to the attending physician, clinical manager an/or nursing designees, dietitian and social worker. . . . 5. The re-assessment for patients whose medical condition is stabilized is reviewed yearly. 6. The Multidisciplinary initial assessment will be completed within thirty (30) [days] of admission. . . .” Review of the facility’s current list of personnel occurred on 03/18/24. This list failed to include a licensed dietitian. - Review of patient medical records occurred on March 18-19, 2024. Review of the comprehensive assessments identified the following: Patient #1 - Annual Interdisciplinary Re-Assessment, dated 01/02/24 - Nutritional assessment lacked completion by a licensed dietitian. Patient #2 - Annual Interdisciplinary Re-Assessment, dated 01/03/24 - Nutritional assessment lacked completion by a licensed dietitian. Patient #3 - Initial Interdisciplinary Assessment, dated 12/23/23 - Nutritional assessment lacked completion by a licensed dietitian. Patient #4 - Annual Interdisciplinary Re-Assessment, dated 01/04/24 - Nutritional assessment lacked completion by a licensed dietitian. During interview on the morning of 03/19/24, an administrative staff member (#1) stated the facility has not had a dietitian on staff for over six months and they have not been successful in hiring a new dietitian. The staff member (#1) stated she and the nursing staff provide dietary services to the patients.”

“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: 19410 Based on record review, policy review, document review, and patient and staff interview, the governing body or designated responsible person failed to ensure 1 of 4 required members of the multidisciplinary team (licensed dietitian) was available to meet the patients’ clinical needs. Failure to have a licensed dietitian on staff limited the facility’s ability to meet the patients’ nutritional needs. Findings include: Review of the facility’s current list of personnel occurred on 03/18/24. This list failed to include a licensed dietitian. During an interview the morning of 03/19/24, an administrative staff member (#1) stated the facility has not had a dietitian on staff for “over six months.” Refer to V501 and V509.”