Dialysis Clinics, Inc. - Omaha

“CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This Condition is not met as evidenced by: 47269 V543 Based on review of facility policies and procedures, clinical records, and staff interviews, facility Registered Nurses (RN-C, RN-D, RN-G, and RN-H ) failed to implement physician orders and administer medication to 2 of 8 patients (Patient 2 and 3) for systolic blood pressure (SBP) and diastolic blood pressure (DBP) when above the physician ordered parameters during the provision of Hemodialysis (HD) treatment. The patient sample size was 8 and facility census was 83. This practice provided the opportunity for patients to experience adverse effects of hypertension (elevated blood pressure) during HD treatment. V638 Based on review of facility policies and procedures, review of the facility’s Quality Assessment and Performance Improvement (QAPI, a systematic, data-driven approach to improve the quality and safety of patient care by problem-solving and continuous improvement efforts) monthly meeting minutes, and staff interviews, the facility failed to conduct a root cause analysis and develop an action plan for intradialytic blood pressure monitoring and hypertensive (elevated blood pressure) medication administration. This failed practice prevented the Medical Director from being involved in adjusting the facility’s Plan of Correction to ensure ongoing correction of the deficient practice cited at V543 on 2/20/25 and had the potential to negatively impact all 83 patients on census. An Immediate Jeopardy (IJ) was identified, at V714, during the onsite survey and removed prior to survey exit. Cross reference to V714. V714 Based on review of facility policies and procedures, Medical Director agreement, and staff interviews, the facility policies failed to include a process for sequential administration of Clonidine (medication used to treat high blood pressure) and Hydralazine (medication used to treat high blood pressure) for hypertension (elevated blood Pressure) during dialysis treatments. Additionally, both policies failed to include a process to contact the provider prior to administering Clonidine and Hydralazine for hypertension when patients had less than an hour of dialysis treatment remaining. These failed practices had the potential to affect the health and safety of all 83 patients on census.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 47269 Condition-level noncompliance cited at V710. Cross reference to V710. An Immediate Jeopardy (IJ) was identified, at V714, during the onsite survey and removed prior to survey exit. Cross reference to V714. V752 Based on review of facility policies and procedures, job descriptions, and staff interviews, the facility failed to ensure management of the facility and of the provision of all dialysis services within the dialysis facility. This failed practice had the potential to negatively impact all 83 patients on census. V756 Based on review of facility policies and procedures, Quality Assessment and Performance Improvement (QAPI, a systematic, comprehensive, approach for improving and maintaining safety, and to identify areas of opportunity for the improvement in the provision of care, and testing of interventions) monthly meeting minutes, job descriptions, and staff interviews, the governing body failed to provide staff education, guidance, support and resources for the correction of deficient practice cited at V543 on 2/20/25. This failed practice had the potential to negatively impact all 83 patients on census.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 49530 Based on review of facility policies and procedures, review of the facility’s Quality Assessment and Performance Improvement (QAPI, a systematic, data-driven approach to improve the quality and safety of patient care by problem-solving and continuous improvement efforts) monthly meeting minutes, and staff interviews, the facility failed to conduct a root cause analysis and develop an action plan for intradialytic blood pressure monitoring and hypertensive (elevated blood pressure) medication administration. This failed practice prevented the Medical Director from being involved in adjusting the facility’s Plan of Correction to ensure ongoing correction of the deficient practice cited at V543 on 2/20/25 and had the potential to negatively impact all 83 patients on census. Findings are: A . Review of the facility policy and procedure titled Quality Assessment and Performance Improvement (QAPI) Program, dated 3/2020, revealed: 1. The facility must continuously monitor its performance by tracking and trending, analysis of root causes, development of improvement plans, implementation of those plans, evaluation of the success of the plan, and revision of the plan as indicated. 2. QAPI meeting minutes should be comprehensive to include action steps, status updates, and follow-up/plans. B. Review of facility’s monthly QAPI meeting minutes, for March 17, 2025, revealed the minutes failed to include trending of results being tracked daily, analysis of root causes, development, implementation, evaluation, and revisions of the improvement plan for the deficient practice cited at V543 on 2/20/25. C. During staff interview on 5/21/25 at 10:00 AM, the Nurse Manager (NM) confirmed medication audits for 100% of patients having orders for hypertensive medications were continuing to be monitored daily. The NM revealed the QAPI program failed to include trending of the results being tracked daily, analysis of root causes, development, implementation, evaluation, and revisions of the improvement plan for the deficient practice cited at V543 on 2/20/25. The NM also revealed the April 2025 QAPI minutes were not available because they had not been typed. D. During staff interview on 5/27/25 at 10:55 AM, the Area Operations Director (AOD) confirmed the QAPI program failed to include trending of the results being tracked daily, analysis of root causes, development, implementation, evaluation, and revisions of the improvement plan for the deficient practice cited at V543 on 2/20/25.”

“MD RESP-DEVELOP, REVIEW & APPROVE P&P CFR(s): 494.150(c)(1) The medical director must- (1) Participate in the development, periodic review and approval of a “patient care policies and procedures manual” for the facility; This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, Medical Director agreement, and staff interviews, the facility policies failed to include a process for sequential administration of Clonidine (medication used to treat high blood pressure) and Hydralazine (medication used to treat high blood pressure) for hypertension (elevated blood Pressure) during dialysis treatments. Additionally, both policies failed to include a process to contact the provider prior to administering Clonidine and Hydralazine for hypertension when patients had less than an hour of dialysis treatment remaining. These failed practices had the potential to affect the health and safety of all 83 patients on census. Findings include: A. Review of the facility policy titled Clonidine (oral) Administration dated 2/2013, failed to include a process for the sequential administration of Clonidine first when patient parameters are met, and Hydralazine is also prescribed for hypertension. Additionally, the policy failed to include a process for contacting the provider prior to administering Clonidine when patients had less than an hour of dialysis treatment. B. Review of the facility policy titled Hydralazine (oral) Administration dated 10/2010, failed to have a process for the sequential administration of Hydralazine second when patient parameters are met, and Clonidine is also prescribed for hypertension. Additionally, the policy failed to include a process for contacting the provider prior to administering Hydralazine when patients had less than an hour of dialysis treatment remaining. C. Review of the Medical Director agreement, signed 1/26/18, revealed the Medical Director is responsible for the participation in the development of policies and procedures. D. During staff interviews conducted in the dialysis treatment area on 5/22/25, Registered Nurses (RN-D, RN-G, RN-C, RN-H, and RN-E) revealed they had been educated by the Nurse Manager (NM) on the medication administration policies for Clonidine and Hydralazine. All RNs interviewed were not aware of a sequential order to administer Clonidine and Hydralazine when a patient has been prescribed both medications and parameters for administering both Clonidine and Hydralazine had been met. Additionally, 4 of the 5 RNs (RN-D, RN-G, RN-C, and RN-H) revealed the Medical Director and Nurse Practitioner (NP) have advised the RNs not to administer Clonidine or Hydralazine if a patient has less than an hour of treatment remaining. RN-H, a traveling nurse, was not aware this was the expectation. These interviews were conducted at: 1. 8:45 AM with RN-D 2. 8:50 AM with RN-G 3. 8:55 AM with RN-H 4. 9:00 AM with RN-C 5. 9:10 AM with RN-E E. During staff interview on 5/22/25 at 9:30 AM, the NM confirmed they had educated all nurses on the policies for both Clonidine and Hydralazine. The NM revealed they were not aware the facility policy for Hydralazine gave instructions for administering Clonidine, not instructions for administering Hydralazine. The NM was not aware the RNs had been instructed by the Medical Director or the NP not to administer Clonidine or Hydralazine if a patient has less than an hour of dialysis treatment remaining. The NM comfirmed the facility policies for Clonidine and Hydralazine failed to include this process. The NM was not aware the policies for administering Clonidine and Hydralazine failed to include a sequential order to administer Clonidine and Hydralazine when a patient has been prescribed both medications and parameters for administering both Clonidine and Hydralazine have been met. F. During staff interview on 5/27/25 at 10:00 AM, the Medical Director revealed it is the expectation that Clonidine is the first medication to administer when a patient has both Clonidine and Hydralazine prescribed for intradialytic hypertension when the patient parameters for Clonidine has been met. The Medical Director confirmed the facility policies for Clonidine and Hydralazine failed to include a sequential order for the administration of either medication. The Medical Director revealed it is the expectation that nurses will contact the prescribing provider for directions on administering Clonidine or Hydralazine when a patient has less than an hour remaining on dialysis treatment. The Medical Director confirmed the policies for Clonidine and Hydralazine failed to include a process for contacting the provider prior to administering either medication when a patient had less than an hour of dialysis treatment remaining. The Medical Director confirmed they are responsible for the participation and development of facility policies and procedures. G. During staff interview on 5/27/25 at 10:21 AM, The NP confirmed the facility policies for Clonidine and Hydralazine failed to include a sequential order for the administration of either medication. The NP confirmed it is the expectation that nurses will contact the prescribing provider for directions on administering Clonidine or Hydralazine when a patient has less than an hour remaining on dialysis treatment. The NP confirmed the policies for Clonidine and Hydralazine failed to include a process for contacting the provider prior to administering either medication when a patient had less than an hour of dialysis treatment remaining. H. During staff interview on 5/27/25 at 11:00 AM, the Area Operations Director (AOD) confirmed the facility policies for Clonidine and Hydralazine failed to include a sequential order for the administration for either medication. The AOD confirmed the facility policies for Clonidine and Hydralazine failed to include a sequential order for the administration of either medication. The AOD revealed it is the expectation that nurses will contact the prescribing provider for directions on administering Clonidine or Hydralazine when a patient has less than an hour remaining on dialysis treatment. I. The State Agency (SA) survey team’s discussion of facility noncompliance with the State Agency (SA) supervisor occurred on 5/28/25 at 11:34 AM. Review of the three components of Immediate Jeopardy occurred, the identified noncompliance created the likelihood of an adverse outcome that could result in patient harm, and immediate action to correct the facility’s noncompliance was identified. On 5/28/25 at 12:25 PM, the AOD was advised, by the SA surveyor, that an Immediate Jeopardy had been identified and a copy of the completed Immediate Jeopardy template was provided to the AOD with a request for a written Immediate Jeopardy removal plan to address the noncompliance. On 5/28/25 at 3:40 PM, the AOD provided the facility’s written Immediate Jeopardy removal plan identifing the following actions taken by the facility to remove the Immediate Jeopardy: 1. The Medical Director identified confusion when both Clonidine and Hydralazine were listed as options in the standing orders. The Medical Director directed that only Clonidine be retained as the first-line medication for managing hypertension. If an alternative medication such as Hydralazine is preferred, a separate order will be issued, and Clonidine will be discontinued. The facility policy titled Admission Standing orders, revised 5/28/25, revealed Hydralazine had been removed. 2. The facility policy titled Clonidine (oral) Administration, revised 5/28/25, revealed if less than one hour of treatment is remaining, notify Nephrology Provider for direction before administering and document. 3. The facility policy titled Hydralazine (oral) Administration, revised 5/28/25, revealed if less than one hour of treatment is remaining, notify Nephrology Provider for direction before administering and document. 4. The NM provided education to all nurses regarding the above policies as evidenced by an attached attendance roster. 5. Observations of the facility treatment area and medication room on 5/28/25 at 3:50 PM revealed updated policies posted at the two nurse stations and in the medication room, with an additional placard for both Clonidine and Hydralazine, reminding nurses if less than one hour of treatment is remaining, to notify Nephrology Provider for direction before administering and document. 6. Interview with Registered Nurse (RN)-C on 5/28/25 at 3:55 PM in the dialysis treatment area confirmed RN-C received education on the revised facility policies titled Admission Standing orders, Clonidine (oral) Administration, and Hydralazine (oral) Administration. During this interview, RN-C showed the SA surveyor the medication orders for Patient 3, as printed off and located in the medication room, had been updated to remove Hydralazine and to reflect Clonidine order only for the treatment of intradialytic hypertension. 7. Interview with RN-H on 5/28/25 at 4:00 PM in the dialysis treatment area confirmed RN-H received education on the revised facility policies titled Admission Standing orders, Clonidine (oral) Administration, and Hydralazine (oral) Administration. J. The SA survey team confirmed the facility staff’s compliance with the facility’s Immediate Jeopardy removal plan. The Immediate Jeopardy was removed, by the SA survey team, at the facility on 5/28/25 at 4:05 PM, prior to the SA survey team exiting the facility.”

“GOV-APPOINT CEO/ADMINISTRATOR CFR(s): 494.180(a) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, job descriptions, and staff interviews, the facility failed to ensure management of the facility and of the provision of all dialysis services within the dialysis facility. This failed practice had the potential to negatively impact all 83 patients on census. Findings are: A. Review of the facility policy titled Quality Assessment and Performance Improvement (QAPI) Program (QAPI, a systematic, comprehensive, approach for improving and maintaining safety, and to identify areas of opportunity for the improvement in the provision of care, and testing of interventions), dated 3/2020, revealed the dialysis facility must set priorities for improvements that affect patient safety, analyze and track indicators to identify the prevalence, commonalities and causes of occurrences. B. Review of the facility job description titled Area Operations Director (AOD), dated 8/2022, revealed the AOD is responsible for the overall management and operations of the dialysis facility. C. Review of the facility job description titled Nurse Manager (NM), dated 8/2022, revealed the Nurse Manager is responsible for the oversight of the dialysis facility, including compliance with policies and procedures. The Nurse Manager reports to the AOD. D. During staff interview on 5/27/25 at 11:00 AM, the AOD confirmed the Nurse Manager was responsible for tracking and trending of results to identify the prevalence, commonalities and causes of occurrences related to the deficient practice cited at V543 on 2/20/25. The AOD confirmed the NM reports to the AOD and also confirmed the AOD was not aware that tracking and trending for root cause analysis and further investigation was not occurring related to the deficient practice cited at V543 on 2/20/25. The AOD also confirmed they are responsible for the overall management and operations of the dialysis facility.”

“GOV-ADM RESP FOR RESOURCES FOR QAPI CFR(s): 494.180(a)(4) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to- (4) Allocation of necessary staff and other resources for the facility’s quality assessment and performance improvement program as described in §494.110. This Standard is not met as evidenced by: 49530 Based on review of facility policies and procedures, Quality Assessment and Performance Improvement (QAPI, a systematic, comprehensive, approach for improving and maintaining safety, and to identify areas of opportunity for the improvement in the provision of care, and testing of interventions) monthly meeting minutes, job descriptions, and staff interviews, the governing body failed to provide staff education, guidance, support and resources for the correction of deficient practice cited at V543 on 2/20/25. This failed practice had the potential to negatively impact all 83 patients on census. Findings are: A. Review of the facility policy and procedure titled Quality Assessment and Performance Improvement (QAPI) Program, dated 3/2020, revealed the dialysis facility must set priorities for improvements that affect patient safety, analyze and track indicators to identify the prevalence, commonalities and causes of occurrences. B. Review of the Medical Director (MD) agreement, signed by the Medical Director on 1/26/18, revealed the MD is responsible for the delivery of patient care, quality, utilization and outcomes. The Medical Director actively participates in the facility’s QAPI process and meetings by reviewing the quality data and outcomes, formulation and follow up on corrective action plans, and accordingly provide feedback to the Nurse Manager (NM) and Area Operations Director (AOD) related to patients’ quality of care, patient outcomes and clinical standards of care. C. Review of the facility job description titled Area Operations Director, dated 8/2022, revealed the AOD is responsible for the overall management and operations of the dialysis facility. D. Review of the facility job description titled Nurse Manager, dated 8/2022, revealed the NM is responsible for the oversight of the dialysis facility, including compliance with the policies and procedures, supports and participates in continuous improvement looking for ways to improve processes. Identifies and communicates quality improvement measures to others. The NM reports to the AOD. E. Review of the facility’s QAPI meeting minutes, dated 2/27/25 and 3/17/25, revealed the meeting minutes failed to include communication for trends, analysis, cause for occurrences and to implement a corrective action plan with expected outcomes for the deficient practice cited at V543 on 2/20/25. F. During an interview on 5/27/25 at 10:06 AM, the Medical Director confirmed the facility’s QAPI program failed to identify trends, formulate a process to determine the root cause for occurrences, and implement a corrective action plan with expected outcomes for the deficient practice cited at V543 on 2/20/25. G. During an interview on 5/28/25 at 3:30 PM, the AOD revealed the NM completes the reports and minutes for the monthly QAPI meetings, and confirmed the facility’s QAPI program failed to identify trends, formulate a process to determine the root cause for occurrences, and implement a corrective action plan with expected outcomes for the deficient practice cited at V543 on 2/20/25. H. During staff interview on 5/28/25 at 4:10 PM, the NM revealed they received QAPI training from the previous NM when assuming the position as NM, and did not have the necessary forms to follow a process to complete a root cause analysis of the identified problem. Additionally, the NM confirmed the QAPI program failed to identify trends, formulate a process to determine the root cause for occurrences, and implement a corrective action plan with expected outcomes for the deficient practice cited at V543 on 2/20/25.”

“IC-O-SIGHT-MONITOR ACTIVITY/IMPLEMENT P&P CFR(s): 494.30(b)(1) The facility must- (1) Monitor and implement biohazard and infection control policies and activities within the dialysis unit; This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, observations and staff interviews, the facility failed to have a procedure to ensure expired supplies were identified and removed from the first-floor Hemodialysis (HD) patient supply closet. This failed practice had the potential to expose all 86 patients on census to expired supplies. Findings are: A. Review of facility policy titled Expiration Dates of Meds and Supplies, dated 5/24, revealed the purpose of the policy was to provide guidelines for expiration dates for supplies used in dialysis for the prevention of infection and other complications caused by using expired supplies. The policy identified that the acid dialysate expiration date was the manufacture expiration date. The policy failed to list a procedure for staff monitoring of supplies for expiration dates and failed to identify a procedure for the disposal of identified expired supplies. B. Observation of the first-floor HD patient supply closet on 2/12/25 at 3:00 PM with the Nurse Manager (NM), revealed the following expired supplies, as confirmed by the NM: 1. Three out of five expired 4 K, 2.5 Ca acid dialysate gallons (the fluid used to remove impurities during HD patient treatments), with expiration date of 6/24. C. During staff interview on 2/12/25 at 3:00 PM, the NM confirmed the facility policy failed to list a procedure for staff monitoring of supplies for expiration dates and failed to identify a procedure for the disposal of identified expired supplies.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 47269 Based on review of facility policies and procedures, clinical records, and staff interviews, the facility Registered Nurses (RN-C and RN-H) failed to implement physician orders and administer medication to 1 of 7 patients (Patient 5) for systolic blood pressure (SBP) above the physician ordered parameter greater than 190 millimeters (mm) of Mercury (Hg) and the diastolic blood pressure (DBP) above the physician ordered parameter greater than 100 mm/Hg during the provision of Hemodialysis (HD) treatment. The patient sample size was 7 and facility census was 86. This practice provided the opportunity for patients to experience adverse effects of hypertension (elevated blood pressure) during HD treatment. Findings are A. Review of the facility policy titled Registered Nurse (RN), Outpatient Hemodialysis, dated 9/17, revealed the responsibilities of the RN include implementation of physician orders. B. Review of the facility policy titled Clonidine (oral) Administration, dated 4/23, revealed Clonidine will be administered by the licensed nurse per physician order parameters. (Clonidine is an antihypertensive medication. Administration of this medication results in a reduced SBP and reduced DBP. C. Review of Patient 5’s clinical record revealed a physician’s order for Clonidine 0.1 milligrams (mg) for SBP parameter greater than 190 mm/Hg or DPB parameter greater than 100 mm/Hg, dated 9/4/24. D. Review of Patient 5’s HD flowsheet forms, completed during hemodialysis treatment, revealed the following entries: 1. 1/20/25 HD flowsheet blood pressure (BP) readings during the provision of HD treatment: 12:19 PM 170/127 12:34 PM 175/122 1:04 PM 170/122 1:37 PM 173/172 2:04 PM 175/127 2:34 PM 182/135 2:58 PM 173/122 3:07 PM 182/127 3:08 PM 199/120 End of HD treatment, RN-C documented Medication: Clonidine. Reason not given: Parameter not met. 2. 1/24/25 HD flowsheet BP readings during the provision of HD treatment: 12:01 PM 164/118 12:04 PM 164/117 12:34 PM 165/115 1:04 PM 175/116 1:34 PM 166/117 2:04 PM 186/123 2:35 PM 170/119 2:44 PM 176/120 2:47 PM 174/128 End of HD treatment, RN-C documented Medication: Clonidine. Reason not given: Parameter not met. 3. 1/27/25 HD flowsheet BP readings during the provision of HD treatment: 12:05 PM 178/133 12:34 PM 186/136 1:01 PM 171/121 1:31 PM 183/121 2:01 PM 179/124 2:31 PM 189/133 3:01 PM 185/137 3:09 PM 177/119 3:22 PM 196/122 End of HD treatment, RN-C documented, Medication: Clonidine. Reason not given: Parameter not met. 4. 2/7/25 HD flowsheet BP readings during the provision of HD treatment: 12:01 PM 182/128 12:03 PM 177/130 12:31 PM 184/128 1:01 PM 181/129 1:31 PM 177/130 2:01 PM 174/121 2:31 PM 184/128 3:00 PM 176/123 3:02 PM 183/118 3:09 PM 175/116 End of HD treatment, RN-C documented Medication: Clonidine. Reason not given: Parameter not met. 5. 2/10/25 HD flowsheet BP readings during the provision of HD treatment: 12:09 PM 196/136 12:31 PM 197/140 12:36 PM 197/134 1:01 PM 199/132 1:31 PM 194/130 2:04 PM 186/129 2:31 PM 187/130 2:59 PM 182/131 3:01 PM 182/125 3:03 PM 181/124 End of HD treatment, RN-H documented, Medication: Clonidine. Reason not given: Parameter not met. E. During staff interview on 2/19/25 at 10:30 AM, the Facility Nurse Manager (NM) confirmed Patient 5’s physician order for Clonidine was 0.1 mg for SBP parameter greater than 190 mm/Hg or DPB parameter greater than 100 mm/Hg. The NM confirmed the facility RNs (RN-C and RN-H) failed to implement the physician order for the administration of Clonidine per the above parameters throughout Patient 5’s HD treatments on 1/20/25, 1/24/25, 1/27/25, 2/7/25, and 2/10/25.”