Davita Cherry Hill Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 48966 Based on observation, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that the emergency code cart supplies are immediately available for use in the event of an emergency. Findings include: On 04/01/25 at 11:01 AM, the contents of the emergency code cart were reviewed and compared to the “Emergency Cart Checklist Log Sheet.” At 11:01 AM, surveyors attempted to open the first drawer of the emergency code cart, which contained emergency medications, and were unsuccessful. At 11:07 AM, Staff (S) 10, a Registered Nurse (RN), attempted to open the first drawer but was also unsuccessful. At 11:10 AM, S10 requested assistance from S7, a RN, who opened the drawer at 11:17 AM after considerable effort and difficulty. S7 opened the drawer and determined the issue was caused by a case of Dextrose 50% (medication used to treat low blood sugar) bottles that were too tall for the drawer. This caused the bottles to become lodged, which prevented the drawer from opening. During S7’s multiple attempts to open the drawer, 12 out of 25 blue caps on top of the Dextrose bottles came off, resulting in the bottles being unusable. During an interview on 04/01/25 at 11:18 AM, S13, the RN Facility Infection Control Manager, stated that the supplies are checked monthly in the emergency code cart. S13 was unsure when the back-ordered Dextrose 50% arrived or who placed it in the first drawer of the emergency code cart. During an interview on 04/01/25 at 11:20 AM, when asked if the first drawer should open easily, S10 stated there has never been any issues with the drawer before and that it should open without difficulty. Facility policy titled, “Emergency Equipment Checks,” revised October 2024, stated, “ ... Policy: ... 2. Recommended emergency medications to stock in the facility are medications to treat allergic reactions, anaphylactic reactions, hypoglycemia and chest pain ... 3. The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: ... Weekly: Emergency cart (crash cart) is clean, operational and supplies/medications have not expired ... “ N.J.A.C. 8:43A-15.1(d)”

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 51227 Based on one of one observation of staff acquiring an oxygen concentrator, staff interviews, and review of facility policies, it was determined that the facility failed to ensure equipment in an occupied patient station is cleaned and disinfected prior to being taken into another patient station for use on another patient. Findings include: On 04/01/25 at 11:15 AM, Staff (S) 10, a Registered Nurse (RN), was observed entering Station 15, which was occupied by a patient receiving dialysis, and obtained the oxygen concentrator located inside the station. S10 brought it into Station 19 and connected the patient’s oxygen tubing to the machine without the benefit of first cleaning and disinfecting it. During an interview at 11:20 AM, S10 stated that the oxygen concentrator was considered dirty because it was in a patient station and that he/she should have disinfected the concentrator before bringing it to a different station for patient use. During an interview at 12:00 PM, S16, the Manager of Clinical Services (MCS) stated anything brought from one station to another should be cleaned and disinfected before use. Facility policy titled, “Use of Oxygen Concentrators,” revised October 2023, stated, “ ... Policy: ... 5. The outside of the oxygen concentrator will be cleaned with an acceptable disinfectant solution between patients ... “ N.J.A.C 8:43A-24.8(b)”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 51227 Based on one of two observations of the cleaning and disinfection of a dialysis station, staff interview, and review of facility documents, it was determined that the facility failed to ensure that the patient has completely vacated the hemodialysis station and that all surfaces of the hemodialysis station are cleaned and disinfected. Findings include: On 04/01/25 at 10:08 AM, in Station 12, the patient completed hemodialysis treatment and ambulated to the patient scale, leaving his/her clothing on the patient recliner chair. Staff (S) 9, a Patient Care Technician (PCT), used a bleach-soaked cloth to clean and disinfect the dialysis machine while the patient’s belongings remained in the dialysis chair. After the patient returned to gather his/her belongings, S6 began to clean the dialysis chair. S6 did not wait until the dialysis station was completely vacated to begin cleaning and disinfecting. S6 proceeded to clean and disinfect the TV, blood pressure cuff, and remote control. S6 did not wipe the chase wall of the station. During an interview at 10:30 AM, S6 stated that he/she didn’t think he/she had to clean the back chase wall but would double check. Facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, stated, “ ... DISINFECTION ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. A. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by health care personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops) ... b. Dialysis station must be completely vacated by the previous patient before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station and set up for the next patient ...” N.J.A.C. 8:43A-24.8(b)”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 51040 Based on observation and staff interview, it was determined that the facility failed to ensure that: 1) an oxygen cylinder is properly secured; and 2) one of two chemical pumps in the Chemical Storage room are maintained properly. Findings include: 1. On 04/02/25 at 09:40 AM, during a tour of the Hemodialysis Treatment Floor in the presence of Staff (S) 25, the Biomedical Technician, it was observed that one type “E” oxygen cylinder, near the nurses station, was not properly secured in accordance with National Fire Protection Association Heath Care Facilities Code 99, 2012 Edition. This was confirmed at the time of observation by S25. Reference: National Fire Protection Association 11.6.2.3 (11) Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart. 2. On 04/02/25 at 9:54 AM, in the presence of S25, it was observed in the Acid Storage Tank area, located in the basement, that the one chemical pump had a large amount of white, crusted material around the top fitting of the unit. This was confirmed at the time of observation by S25.”

“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: 48966 Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that the interdisciplinary team (IDT) completed a comprehensive assessment prior to developing a patient Plan of Care for two of seven hemodialysis patients reviewed (Patients (P) 7 and P8). Findings include: A review of P7’s medical record revealed that the Plan of Care meeting occurred on 01/24/25. The comprehensive assessment by the Registered Dietician (RD) had a documented finalized date of 01/30/25, after the Plan of Care meeting. During an interview on 04/02/25 at 11:22 AM, Staff (S) 26, the RD, stated he/she was on a leave of absence and returned to work on 01/14/25. S26 explained there were several dieticians that filled in during his/her absence and they continued to document until the end of January. S26 confirmed the comprehensive assessment for P7 was completed by the covering RD on 01/30/25 but was unsure why it was finalized after the Plan of Care meeting held on 01/24/25. A review of Patient 8’s medical record revealed that the Plan of Care meeting occurred on 01/14/25. The comprehensive assessment by the Registered Dietician (RD) had a documented finalized date of 01/27/25, after the Plan of Care meeting. During an interview on 04/02/25 at 1:02 PM, S26, confirmed the comprehensive assessment for P8 was finalized by the covering RD on 01/27/25 after the Plan of Care meeting held on 01/14/25. During an interview on 04/02/25 at 1:09 PM, S4, the Social Worker (SW) and Alternate Facility Manager, stated the comprehensive assessment was completed by the Plan of Care meeting on 01/14/25 but was not finalized until 01/27/25. Facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment And Plan Of Care,” revised October 2024, stated, “ ... Assessment: ... 7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: At least annually for stable patients or semiannually when required by State Regulation ... Plan Of Care: 22. Implementation of assessments and plans of care are detailed in table below: In the states of ... New Jersey ... Assessment 6 months after the 90 day reassessment or unstable reassessment. Ongoing semi-annual re-assessments will be completed 6 months after the semi-annual re-assessment or unstable reassessment. Plan of Care Complete patient plan of care and patient plan of care meeting within 15 days of the completion of the reassessment ... “ N.J.A.C. 8.43A-24.13(c)”

“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: 51227 Based on medical record review, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that abnormal blood pressures (BP) occurring during eight of nine hemodialysis treatments for Patient (P) 4 are assessed by the Registered Nurse (RN) in accordance with facility policy and procedure. Findings include: A review of P4’s Plan of Care, dated 11/21/24, stated, “ ... Fluid/BP Maintain post weight compared to target weight. Blood pressure within range ... “ A review of P4’s Treatment Detail Reports were reviewed from 03/06/25 through 03/31/25 and revealed the following: On 03/06/25 the following was documented by a Patient Care Technician (PCT): 06:05 [6:05 AM]: BP 155/109; “ ... Treatment started without complications ... “ 06:35 [6:35 AM]: BP 148/101 07:05 [7:05 AM]: BP 157/112 07:35 [7:35 AM]: BP 150/102 08:05 [8:05 AM]: BP 157/111 08:36 [8:36 AM]: BP 148/101 09:01 [9:01 AM]: BP 156/113; “ ... Treatment terminated ... “ There was no documented evidence that the PCT alerted the RN of P4’s elevated blood pressures (hypertension) at the start of the treatment or throughout the duration of hemodialysis treatment. Additionally, there was no documented evidence that the RN acknowledged the abnormal blood pressure and assessed P4 for symptoms of hypertension in accordance with facility policy. On 03/08/25 hemodialysis treatment was as follows: 05:45 [5:45 AM]: BP 195/127; “ ... Treatment started without complications ... “ documented by a PCT. 06:05 [6:05 AM]: BP 178/137 06:35 [6:35 AM]: BP 176/131 07:05 [7:05 AM]: BP 175/126 07:35 [7:35 AM]: BP 170/122; “ ... Patient awake; alert; and states no complaints at this time; pt bp remains high RN aware ... “ documented by a PCT. 08:06 [8:06 AM]: BP 179/140 “ ... BP remains elevated; Pt [patient] states no complaints ... “ documented by a RN. 08:35 [8:35 AM]: BP 179/134 09:05 [9:05 AM]: BP 176/134 09:11 [9:11 AM]: BP 178/135 “ ... treatment terminated ... “ documented by a PCT. There was no documented evidence that the PCT alerted the RN of P4’s hypertension until 07:35 AM, one hour and 50 minutes into the hemodialysis treatment. On 03/11/25 treatment was documented as follows: 05:47 [5:47 AM]: BP 181/126; “ ... Treatment started without complications ... “ documented by a PCT. 06:31 [6:31 AM]: BP 196/98 07:02 [7:02 AM]: BP 182/167 07:32 [7:32 AM]: BP 179/130 08:02 [8:02 AM]: BP 186/136 08:32 [8:32 AM]: BP 185/129 09:02 [9:02 AM]: BP 191/140 09:03 [9:03 AM]: BP 189/126; “ ... bp closer to baseline ... “ documented by a PCT. 09:12 [9:03 AM]: BP 176/123; “ ... Treatment terminated ... “ documented by a PCT. There was no documented evidence that the PCT alerted the RN of P4’s hypertension at the start of the treatment. Additionally, there was no documented evidence that the RN was aware of the abnormal blood pressures and assessed P4 for symptoms of hypertension in accordance with facility policy. On 03/13/25 treatment was documented as follows: 06:32 [6:32 AM]: BP 216/135; “ ... Patient states no complaints at this time; BP high ... “ documented by a PCT. 07:02 [7:02 AM]: BP 214/143; “ ... BP remains high; RN aware ... “ documented by a PCT. 07:33 [7:33 AM]: BP 221/141; “ ... pt resting b/p elevated will continue to monitor RN aware ... “ documented by a PCT. 08:03 [8:03 AM]: BP 160/137 08:35 [8:35 AM]: BP 218/127 09:03 [9:03 AM]: BP 223/134; “ ... BP still running high: asymptomatic; seen by MD [medical doctor]. No complaints. ... “ documented by a RN. 09:32 [9:32 AM]: BP 221/152: “ ... treatment terminated ... “ documented by a RN. There was no documented evidence that the RN assessed P4 for symptoms of hypertension from 06:32 [6:32 AM] until 09:03 [9:03 AM]. This was two hours and 31 minutes that P4 remained hypertensive without an RN assessment in accordance with facility policy. On 03/22/25 treatment was documented as follows: 05:49 [5:49 AM]: BP 172/120; “ ... Treatment started without complications; BP high; RN aware ... “ documented by a PCT. 05:59 [5:59 AM]: BP 178/129 06:30 [6:30 AM]: BP 177/109 07:00 [7:00 AM]: BP 172/122 07:29 [7:29 AM]: BP 174/126; “ ... BP elevated; Pt states no complaints ... “ documented by RN. 07:59 [7:59 AM]: BP 174/126 08:30 [8:30 AM]: BP 120/104 08:39 [8:39 AM]: BP 169/131 09:00 [9:00 AM]: BP 182/130 09:10 [9:10 AM]: BP 178/128; “ ... treatment terminated ... “ documented by a RN. There was no documented evidence that the RN assessed P4 for symptoms of hypertension from 05:49 [5:49 AM] until 07:29 [7:29 AM]. This was one hour and 40 minutes that P4 remained hypertensive without an RN assessment in accordance with facility policy. On 03/25/25 treatment was documented as follows: 05:43 [5:43 AM] BP 156/116; “ ... Treatment started without complications; lines secure no kinks; no pod membrane rupture ... “ documented by a PCT. 06:02 [6:02 AM] BP: 147/102 06:32 [6:32 AM] BP: 155/112 07:02 [7:02 AM] BP: 148/110 07:32 [7:32 AM] BP: 148/102 08:02 [8:02 AM] BP: 149/102 08:32 [8:32 AM] BP: 157/109 09:03 [9:03 AM]: BP 158/109; “ ... Treatment terminated ... “ documented by a PCT. There was no documented evidence that the PCT alerted the RN that P4 was hypertensive throughout the entire treatment. Additionally, there was no documented evidence that the RN acknowledged the abnormal blood pressure and assessed P4 for symptoms of hypertension in accordance with facility policy. On 03/29/25 treatment was documented as follows: 05:46 [5:46 AM]: BP 177/124; “ ... Treatment started without complications; RN aware of high BP; Patient asymptomatic ... “ documented by a PCT. 06:16 [6:16 AM]: BP 171/124 06:46 [6:46 AM]: BP 178/128 07:16 [7:16 AM]: BP 187/138 07:17 [7:17 AM]: BP 177/127 07:30 [7:30 AM]: BP 177/126 08:00 [8:00 AM]: BP 178/129; “ ... Patient states no complaints at this time; BP still remains high; RN aware ... “ documented by a PCT. 08:30 [8:30 AM]: BP 181/125 09:01 [9:01 AM]: BP 181/121 09:06 [9:06 AM]: BP 179/120; “ ... Treatment terminated; Patient blood returned without complications; patient request to come off early; RN aware ... “ documented by a PCT. There was no documented evidence that the RN assessed P4 for symptoms of hypertension throughout the treatment from 05:46 [5:49 AM] to 09:06 [9:06 AM]. This was three hours and 20 minutes that P4 remained hypertensive without an RN assessment in accordance with facility policy. On 03/31/25 treatment was documented as follows: 15:25 [3:25 PM]: BP 178/128; “ ... Treatment started without complications; Patient awake; alert; and states no complaints at this time ... “ documented by a PCT. 15:55 [3:55 PM] BP 178/137; “ ... PT bp high; no c/o; RN aware ... “ documented by a PCT. 16:24 [4:24 PM] BP: 188/137 16:27 [4:27 PM] BP: 177/125 16:55 [4:55 PM]: BP 181/139; “ ... BP still remains high; patient asymptomatic; RN aware ... “ documented by a PCT. 17:24 [5:24 PM]: BP 178/134; “ ... Patient blood pressure is elevated; Treatment terminated; Patient blood returned without complications; RN aware ... “ documented by a PCT. There was no documented evidence that the RN assessed P4 for symptoms of hypertension throughout the treatment from 15:25 [3:55 PM] to 17:24 [5:24 PM]. This was two hours that P4 remained hypertensive without an RN assessment in accordance with facility policy. During an interview on 04/02/25 at 01:35 PM, Staff (S)18, a RN, confirmed the above treatment sheets lacked documentation of P4’s elevated BP. S18 explained when a PCT documents a high BP they should inform the RN and document it. S18 also stated that they would expect a RN to assess the patient’s BP within 30 minutes of notification. Facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring And Nursing Assessment,” revised April 2024, stated, “ ... Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record ... Blood Pressure-Intradialytic: ... Diastolic greater than or equal to 100 mm/Hg [millimeters of mercury] or less than 50 mm/Hg ... “ N.J.A.C. 8:43A-24.4(a)”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 51227 Based on two of two observations of the initiation of hemodialysis through an arteriovenous fistula (AVF, a type of vascular access used for hemodialysis), staff interview, and a review of facility documents, it was determined that the facility failed to ensure that the staff perform skin disinfection of the access site prior to initiating the dialysis treatment in accordance with facility policy. Findings include: On 04/01/25 at 9:55 AM, Staff (S) 6, a Licensed Practical Nurse (LPN), was observed entering Station 18 to initiate hemodialysis through an AVF. S6 rubbed the first site of the AVF with a gauze saturated with ExSept in a circular motion for five seconds. This was 55 seconds less than required by facility policy. S6 proceeded to rub the second site with a second gauze saturated with ExSept for 3 seconds. This was 57 seconds less than required by facility policy. During an interview at 10:35 AM, S6 stated, he/she should clean the site with ExSept for 30 seconds. When asked if he/she cleansed the site for 30 seconds, S6 said, “I did not.” On 04/01/25 at 10:15 AM, S9, a Patient Care Technician (PCT), was observed entering Station 14 to initiate hemodialysis through an AVF. S9 rubbed both access sites with one gauze saturated with ExSept in a circular motion for 10 seconds. S9 did not use one gauze saturated with ExSept for each site and did not cleanse both sites for 60 seconds each, as required by facility policy. During an interview at 10:25 AM, S9 stated, he/she should clean the site for 30 seconds using ExSept. When asked if he/she should have used one gauze for each site, S9 stated, “I’m not sure.” Facility policy titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised April 2025, stated, “ ... Skin Antiseptic ... Hypochlorite (ExSept Plus) ... Effective Volume ... If using sterile 2x2 gauze, saturate with 3-5 ml [milliliter] or 5-8 sprays; Use at least two (2) sterile gauze for each site ... Effective Contact Time ... 60 seconds ... Procedure: ...11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. (For contact and dry time refer to table above) ... “ N.J.A.C. 8:43A-24.8(b)”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 49828 Based on observation, staff interview, and a review of facility documents, it was determined that the Medical Director failed to ensure: 1) implementation of the policy and procedure for the labeling of medications for three of three opened medication syringes observed and; 2) that heparin is administered in accordance with facility policy for one of one medication administration observed. Findings include: 1. On 04/01/25 at 09:50 AM, a locked drawer, located at the nurse’s station across from the isolation room, contained three syringes filled with a clear liquid, labeled as heparin (blood thinning medication). Upon inspection, all three medication labels lacked the initials of the preparer, and the time the medications were prepared. During an interview at 09:55 AM, Staff (S) 10, a Registered Nurse, stated that he/she was assigned to the patients designated to receive the heparin. S10 stated that the medication label should contain the preparer’s initials and time it was drawn. He/she confirmed that the labels did not contain initials or a time, that he/she did not draw the medication, and was not sure what time it was drawn. During an interview at 10:05 AM, S7, a Registered Nurse, stated that he/she prepared the heparin “around 9:00 AM.” S7 confirmed he/she did not initial or add the time the medication was prepared, as per facility policy. Facility policy titled, “Medication Policy,” revised October 2023 stated, “ ... Policy: ... 20. ... If the medication is not immediately administered or to be administered by another teammate, the medication must be labeled with ... time prepared, ... and initials of teammate preparing the medication ... “ N.J.A.C. 8:43A-9.3(a) 51227 2. On 04/01/25 at 09:55 AM, in Station 3, Staff (S) 6, a Licensed Practical Nurse (LPN) initiated hemodialysis through an AVF. The following was observed: S6 attached a pre-filled heparin syringe to the venous access line and slowly injected the heparin with a back-and-forth motion. After waiting 30 seconds, S6 then initiated the hemodialysis treatment. This was two minutes and 30 seconds less than required by facility policy. During an interview at 10:15 AM, S6 stated that after the administration of heparin, he/she should wait three to five minutes before initiating the hemodialysis treatment. When asked if he/she waited for the appropriate amount of time S6 stated, “I did not.” Facility policy titled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised April 2025 stated, “... Procedure ... Do not initiate dialysis for a minimum if three (3) to five (5) minutes after administering heparin loading dose ...” N.J.A.C. 8:43A-9.3(a)”