Davita Summit Dialysis

“IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This Standard is not met as evidenced by: 48966 Based on observation, staff interviews, and review of facility policies and procedures, it was determined that the facility failed to ensure that clean areas are clearly designated from dirty areas in order to avoid possible cross contamination for one of two workstation areas. Findings include: On 1/14/25 at 11:10 AM, in the Hemodialysis Treatment Floor Side A area, a cabinet labeled “unopened jugs” was located next to the clean sink. Inspection of the cabinet revealed six 2.0 K (potassium) 3.0 Ca (calcium) acid concentrate jugs on the top shelf. Two of the 2.0 K 3.0 Ca acid concentrate jugs were previously opened. In addition, an unopened dialyzer, normal saline bag, and two hemodialysis treatment lines were present on the top shelf. The bottom shelf contained one unopened 1.0 K 2.5 Ca acid concentrate jug. During an interview at 11:12 AM, Staff (S) 3, a Registered Nurse (RN), stated that acid concentrate jugs are wiped down before being placed in the cabinet. S3 did not know of the policy for storage of used acid concentrate containers. During an interview at 11:27 AM, S5, a Patient Care Technician (PCT), confirmed that open, used acid concentrate jugs are wiped down and stored next to the clean, unopened acid containers in the cabinet. Facility policy titled, “Infection Control For Dialysis Facilities,” revised April 2023, stated, “... Facility Hygiene 16. Clean areas should be clearly designated for preparation, handling, and storage of medication and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled ...” Facility policy titled, “Acid Concentrate System, Incoming Acid Concentrate and Use Of Acid Concentrate Containers,” revised October 2024, stated, “... 9. Reusable acid concentrate jug(s) that will be placed in storage: Any remaining concentrate in jug(s) should be neutralized prior to disposal ...” 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: 39223 Based on observation, staff interview, and a review of facility documents, it was determined that the facility failed to ensure that: 1) all surfaces of clamps and hemostats are disinfected after use for two of two 1:100 bleach (one part bleach with 100 parts water) containers; and 2) the hemodialysis machine prime bucket is cleaned and disinfected in one of one observations of the cleaning and disinfection of the patient stations. Findings include: 1. On 1/14/25 starting at 10:30 AM, a tour of the Hemodialysis Treatment Room was conducted and the following was revealed: A 1:100 bleach solution container, located on a countertop across from Station 20, contained two vascular clamps and one hemostat soaking in the liquid. A blue rubber cover was present on the curved end of the each vascular clamp. This potentially prevented the bleach solution from making contact with and disinfecting all surfaces of the vascular clamps. During an interview at 10:36 AM, Staff (S) 8, a Patient Care Technician (PCT), stated that the blue rubber covers should not remain on the clamps while they are soaking in the bleach solution. S8 then removed the blue covers from the ends of the vascular clamps and returned the vascular clamps and blue rubber covers into the bleach solution. At 10:39 AM, on a countertop located across from Station 1, seven vascular clamps and three hemostats were soaking in a 1:100 bleach solution container. A blue rubber cover was present on the curved end of each vascular clamp. Additionally, one hemostat was soaking in a closed position. This potentially prevented the bleach from making contact with and disinfecting all surfaces of the vascular clamps. During an interview at 10:40 AM, S5, a PCT, stated that the blue rubber covers should not remain on the vascular clamps while soaking in the bleach solution. S5 also stated that the scissor clamps should be in an open position while soaking. Facility policy titled, “Infection Control for Dialysis Facilities,” revised April 2023, stated, “... DISINFECTION ... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. ... b. Hemostats (blood line clamps) should be in the open position and fully submerged in an appropriate disinfectant solution ...” 48966 2. On 1/14/25 at 10:21 AM, in Station 20, S8, a PCT, cleaned and disinfected the hemodialysis machine and chair with bleach-soaked cloths. S8 did not empty or wipe down the priming container, which contained a visible clear liquid, with a bleach-soaked cloth. During an interview at 10:25 AM, S8 stated, “I wiped down the priming container earlier.” When questioned what the visible clear liquid was in the priming container, S8 stated that he/she should empty the container of normal saline and clean it again. 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. ... ii. Priming containers are to be emptied prior to disinfection ...” N.J.A.C. 8:43A-24.8(b)”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 48966 Based on two of two observations of central venous catheter (CVC, a type of access used for hemodialysis) care, review of facility documents, and staff interview, it was determined the facility failed to ensure that: 1) the CVC hub including the sides, threads and the end of the hub are cleaned in accordance with the facility policy; and 2) the staff perform skin disinfection of the access site prior to initiating the dialysis treatment in accordance with facility policy. Findings include: 1. On 1/14/25 at 10:34 AM in Station 13, Staff (S) 7, a Registered Nurse, accessed the patient’s CVC. S7 placed a 4 X 4 (four inches by four inches) gauze under the catheter limbs and removed the red cap off the end of the CVC. S7 scrubbed the sides, threads and end of the hub for eight seconds with an alcohol prep pad before he/she attached a syringe to the red limb. S7 did not clean the sides and end of the hub for 15 seconds as required by facility policy. S7 then removed the blue cap off the end of the CVC, scrubbed the threads of the hub with an alcohol prep pad for three seconds. S7 attached a syringe on the end of the venous limb. S7 did not clean the sides and end of the hub for 15 seconds as required by facility policy. During an interview at 10:59 AM, S7 stated each CVC hub should be cleaned with an alcohol prep pad for 15 seconds and should include wiping the sides, threads and the end of the hub. S6’s personnel file was reviewed and indicated the “Annual Procedural Skills Verification Checklist” for CVC care was completed on 05/09/24. Facility policy titled, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure,” revised October 2024, stated, “... 16. Verify both catheter limbs are closed. Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue for example blood. Hold the limbs until the antiseptic has dried ...” 51227 2. On 1/14/25 at 10:30 AM, in Station 5, S3, a Registered Nurse (RN), was observed initiating hemodialysis through a CVC. S3 cleansed the CVC exit site with a prepackaged chlorhexidine swab for 20 seconds, this is 10 seconds less than required per facility policy. During an interview at 11:00 AM, S3 stated the site should be cleansed for 30 seconds. Facility policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure,” last revised October 2024, stated, “... 2% Chlorhexidine Gluconate ... Effective Contact Time ... 30 seconds back and forth motion ... Procedure ... 8. Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds, apply to the CVC exit site in a “back and forth” pattern using gentle friction progressing from the insertion site to the periphery using both sides of the swab ...” 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: 33557 Based on observation and interview, it was determined that the facility failed to ensure the building is maintained for the safety of the patients, the staff and the public. Findings include: On 1/14/25 beginning at 10:00 AM, a tour of the hemodialysis facility was conducted and the following was revealed: At 10:00 AM, the top hinge to the door to the men’s toilet, located in the Waiting Room, was separated from the door causing the door to not close fully. At 10:05 AM, an approximate 24 inch section of wall paper was peeling and separating from the wall under the counter next to the patient toilet located on the Treatment Floor. This has created a porous surface which cannot be properly cleaned. At 10:15 AM, exit sign number five was hanging from the ceiling by the wiring which supplies power to the sign. At 10:15 AM, the cabinet door labeled “16 H” at the Nurse’s Station, next to the medication refrigerator, was separated from the hinge and hanging in place. At 10:20 AM, clean sink number nine had a brown stain down the back side of the sink and around the drain. At 10:20 AM, the “3.0 K [potassium] 2.5 Ca [calcium]” line behind Station 13 was leaking causing a buildup of white particulate around the water line. During an interview on 1/14/25 at 1:30 PM with Staff (S) 2, the Biomedical Technician, he/she confirmed the above findings and stated he/she will be putting in a work order for the building maintenance contractor. N.J.A.C 8:43A-17.3(a)(e)(j) N.J.A.C 8:43A-17.4(15)”

“PR-PRIVACY & CONFIDENTIALITY-TREATMENT CFR(s): 494.70(a)(3) The patient has the right to- (3) Privacy and confidentiality in all aspects of treatment; This Standard is not met as evidenced by: 51227 Based on one of two Central Venous Catheter (CVC, a type of access used for hemodialysis) observations, and staff interview, it was determined that the facility failed to ensure each patient’s right to privacy. Findings include: On 1/14/25 at 10:30 AM in Station 5, a patient’s right chest CVC was accessed. During the procedure, the patient’s shirt was fully opened in the middle, exposing his/her chest. The curtain was not fully the extended in the front of Station 5, leaving an approximate two-foot opening. Additionally, the curtain in the back of the station remained open during the procedure. The patient’s exposed chest was visible to patients and staff walking past Station 5. This surveyor, who observed the procedure from inside Station 5, was able to visualize multiple staff members who walked past Station 5 as well as patients dialyzing behind the station. Facility policy titled, “Patient Rights” last revised October 2021, stated, “...Your Rights As A Patient: ... 4. The right to privacy and confidentiality in all aspects of treatment. The dialysis facility will make accommodations to provide for patient privacy when patients are examined or body exposure is required, for example privacy screens or curtains ...” N.J.A.C. 8:43A-16.2(a)10”

“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, review of facility policy, and staff interviews, it was determined that the facility failed to ensure that the Physician completes a comprehensive assessment prior to developing a patient Plan of Care for two of two patients (Patient (P)1 and P4). Findings include: Medical Record (MR) 1 was reviewed and revealed an initial Plan of Care (PoC), dated 12/10/24, that was signed by the Registered Nurse, the Registered Dietitian, the Social Worker and the Physician. The PoC lacked evidence that the Physician completed a comprehensive assessment prior to the meeting. MR4 was reviewed and revealed an initial PoC, dated 12/10/24, that was signed by the Registered Nurse, the Registered Dietitian, the Social Worker, and the Physician. The PoC lacked evidence that the Physician completed a comprehensive assessment prior to the meeting. During an interview on 1/15/25 at 12:21 PM, Staff (S) 1, the Facility Administrator, confirmed the comprehensive assessments by the Physician for P1 and P4 were not completed. During an interview on 1/16/25 at 9:55 AM, S10, the Medical Director, stated there is a strict comprehensive assessment done once a year by the Physician for the History and Physical of patients. S8 stated that comprehensive assessments need to be completed by the Physician. S8 explained, “It is a violation of our practice to have no progress notes or comprehensive assessments completed by the physician.” Facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment And Plan Of Care,” revised October 2024, stated, “... Assessment: ... 1. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’s treatment plan and expectations for care ... Plan Of Care: 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, and will include measurable and expected outcomes and estimated timetables to achieve these outcomes ...” N.J.A.C. 8.43A-24.13(c)”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must 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, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 51227 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that one of one patient experiencing an abnormal heart rate during hemodialysis treatment is reported to the Registered Nurse (RN), the Charge Nurse, or the Nephrologist. Findings include: A review of Patient (P) 2’s medical record was completed and revealed the following: Documentation from the 12/6/24 physician’s exam indicated that P2 had started a continuous intravenous infusion of Milrinone (a medication that makes the heart beat stronger and relaxes the blood vessels) as ordered by a cardiologist. The Nurse Practitioner’s comprehensive assessment dated 12/17/24 and cosigned by the nephrologist, documented evidence that P2 continued to have the Milrinone infusion. An interview with Staff (S) 6, the Director of Nursing, confirmed that P2 continued to have a Milrinone infusion while receiving hemodialysis treatments as of the day of survey, 1/16/25. Further review indicated a physician’s order, dated 12/05/24, that stated, “... do not initiate tx [treatment] and notify nurse for pre assessment if Heart Rate [HR] above 120 beats per minute [bpm] or HR below 50 bpm ...” Review of the Hemodialysis Flowsheets for 12/05/24 through 1/11/25 revealed that there was no documented evidence that a Milrinone drip was present on 12/5/24, 12/7/24, 12/10/24, 12/12/24, 12/17/24, 12/19/24, 12/21/24, 12/23/24, 12/26/24, 12/29/24, 12/31/24, 1/4/25, 1/7/25, and 1/11/25. Further review showed that the patient’s heart rate was above 120 bpm or below 50 bpm as follows: The hemodialysis flowsheet for 12/10/24 documented: 12:24 PM - HR 45 - documented by the Patient Care Technician (PCT) 12:26 PM - HR 40 - documented by the PCT There was no documented evidence that the PCT informed the RN or that the Nephrologist was made aware of the two times P2’s heart rate was below 50 bpm during hemodialysis treatment. The hemodialysis flowsheet for 12/19/24 documented the following heart rates by the PCT: 10:33 AM - HR 46 11:03 AM - HR 42 There was no documented evidence that the the RN or the Nephrologist were made aware of the two times P2’s heart rate was below 50 bpm during hemodialysis treatment. The hemodialysis flowsheet for 12/21/24 documented the following heart rates by the PCT: 10:30 AM - HR 30 11:17 AM - HR 44 There was no documented evidence that the RN or the Nephrologist were made aware of the two times P2’s heart rate was below 50 bpm during hemodialysis treatment. The hemodialysis flowsheet dated 1/4/25 at 9:56 AM documented the heart rate at 49 bpm, below the ordered parameter that was acceptable to start hemodialysis treatment. There was no evidence that the Nephrologist was made aware of the low heart rate at the initiation of the treatment. The hemodialysis flowsheet for 1/7/25 documented the following heart rates: 9:55 AM - HR 42 - treatment was initiated as documented by the PCT There was no documented evidence that the RN or the Nephrologist were aware of the low heart rate during the initiation of treatment. The hemodialysis flowsheet dated 1/11/25 at 1:28 PM documented a heart rate of 39 bpm by the PCT. There was no documented evidence that the RN or the Nephrologist were made aware of the low heart rate. During an interview on 1/15/25 at 2:00 PM, S6, verified the above findings and stated that if a PCT is initiating treatment and the HR is below 50 bpm, then he/she should notify the RN before initiating treatment. A nursing assessment should be documented. S6 also stated that if a the heart rate is below or higher than parameters, then a nurse should complete and document a manual heart rate check and notify the physician. S6 further explained that the nurses should document visualization of the working Milrinone infusion in his/her assessment. During an interview on 1/15/25 at 2:41 PM, S9, the Manager Clinical Services (MCS), stated that care for patients with a Milrinone infusion is individualized and that physician orders guide the care. S9 explained that the nurses should document the infusion in his/her assessments. During an interview on 1/16/25 at 9:55 AM, S10, the Medical Director (MD), stated that the nurse should call the attending nephrologist or him/herself for approval to start hemodialysis treatment if the patient’s heart rate is below 50 bpm. S10 clarified that if a PCT initiates treatment on a patient with a Milrinone infusion, an assessment by the RN should be done, “... within the early minutes of treatment.” Facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, stated, “... POLICY: ... 2. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN) ... PRE-TREATMENT DATA COLLECTION/ASSESSMENT 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse ... If any abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. ... ABNORMAL FINDINGS ... Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute and/or and irregular heart beat ...” N.J.A.C. 8:43A-24.13(b)”

“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 cannulation (the act of inserting a needle) of a vascular access, staff interview, and review of facility policy, it was determined that the facility failed to ensure that the staff perform skin disinfection in accordance with facility policy prior to cannulation of the vascular site. Findings include: On 1/14/25 at 10:00 AM, in Station 10, Staff (S) 5, a Patient Care Technician (PCT), cleaned both sites together with one iodine preparation (prep) pad in a circular motion for 35 seconds. S5 let the site dry for 45 seconds before inserting two fistula needles. S5 did not allow the site to dry for two minutes before inserting the fistula needles. During an interview at 10:45 AM, S5 stated that the site should be cleaned with iodine for two minutes with a dry time of 30 seconds before inserting the needles. On 1/14/25 at 11:35 AM in Station 18, S4, a PCT, cleaned a vascular access with an iodine prep pad for eight seconds. This was 22 seconds less than required per facility policy. S4 then proceeded to clean the second site with iodine for 10 seconds. This was 20 seconds less than required per facility policy. While the site was drying, the patients clothing touched the vascular access site, which possibly contaminated the area. S4 instructed the patient to hold still. Without the benefit of re-cleaning the access site, S4 then proceeded to insert a fistula needle into each access site. During an interview at 12:00 PM, S4 stated each site should be cleaned for 30 seconds with iodine. When S4 was questioned about the patient’s clothing touching the site, he/she stated they should have cleansed the site again. Facility policy titled, “AV Fistula or Graft Cannulation With Nipro Or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” revised October 2022, stated, “... Skin Antiseptic ... Povidone Iodine ... Effective Volume At least 1 prep pad per site or 1 saturated sterile gauze pad per site ... Effective Contact Time ... 30 seconds ... Air Drying Time ... 2 minutes ...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)”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 39223 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that a physician examines the patient and documents monthly progress notes for three of seven months reviewed (Patient 3). Findings include: A review of Patient (P) 3’s medical record for physician documentation completed from June 2024 through 1/14/25 lacked documented evidence of a physician’s monthly progress note for August, October, and November 2024. Further review of P3’s medical record revealed that the physician visits to the patient conducted on 6/30/24, 7/30/24, and 9/24/24 indicated that the visit was conducted virtually due to, “COVID” and no physical exam was completed. There was no documented evidence in the medical record that the patient tested positive for COVID-19 (coronavirus disease) or complained of symptoms consistent with a COVID-19 infection during the above listed virtual office visits. On 12/19/24, an office visit was conducted in person. On 1/16/25, during an interview starting at 9:54 AM, Staff (S) 10, the Medical Director, stated that physician rounding with patients in the facility has been an ongoing issue. S10 explained that he/she has reviewed a list of missing physician notes and he/she has followed up with each individual physician for correction informally, by telephone. Additionally, a letter was sent to all facility physicians that explained the expectation that all physicians round in the clinic, face-to-face with patients and document on a monthly basis. S10 also stated that if physicians are not able to meet face-to-face with the patient due to something like the patient does arrive for scheduled treatment, then he/she could examine the patient in the office. Review of the Medical Staff Bylaws, confirmed and adopted 8/01/21, stated, “... 2.2.2 Rounding and Documentation Requirements (a) Ensure patients are rounded on in compliance with DaVita, ESRD Network, state and federal requirements. At minimum, this includes the following requirements (unless state law or Public Health Emergency dictates otherwise) for: i. In-center and/or nocturnal patients: must be evaluated and examined by a nephrologist no less than once per month in-person in the facility while the patient is on dialysis; a. In the rare event that a monthly evaluation and examination cannot reasonably be conducted at the Facility, an evaluation and examination may take place at the patient’s home, in the physician’s office, at at another location that complies with DaVita policies, so long as record of care is promptly incorporated into the Facility medical record. ...” N.J.A.C. 8:43A 24.13(d)”