Davita Ozone Park Dialysis

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 36207 Based on document review and staff interview, the facility did not provide documented evidence of the of annual testing of the Emergency plan. Failure to test Emergency plan will delay the response of the facility during an emergency. Findings Include: During document review of facility’s Emergency preparedness binder dated 6/2025 on 06/12/2025 at 3:00pm, it was noted that the facility did not participate in a full-scale exercise that is community- based or individual facility based for the last two years. Upon interview Staff B (Facility Administrator) on 06/12/2025 at 3:15pm, acknowledge that the facility did not participate in a full-scale exercise that is community- based or individual facility based since she started as the Facility Administrator on 2/2/2023. During review of the personal file on 6/13/25 at 10:45am, it was confirmed that Staff B started as Facility Administrator on 2/2/2023. The above finding was brought to the attention of administration during the onsite exit conference on 6/13/2025.”

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 51000 Based on a review of the personnel files, policy review and staff interview the facility failed to ensure 7 out of 23 employees did not have an annual health assessment and tuberculosis (TB) screening to meet New York State Department of Health (NYSDOH) compliance for healthcare workers. This lack of compliance may compromise the health and safety of staff and patients. Findings include: Staff N ,O, P,Q,W, X, and Y’s personnel files did not have evidence of annual testing or TB individual Risk Assessment and Symptoms evaluation. During the interview with Staff B on June 11, 2025, at approximately 9:15 AM, a review of personal files revealed that seven staff members were missing evidence of PPD (Purified Protein Derivative) testing or Risk Assessment and Symptoms Evaluation per facility policy. On review of Policy 04-06-05 last reviewed on October 2024 it was revealed that “All teammates will complete the TB Individual Risk Assessment and Symptoms Evaluation”. During an interview on June 11, 2025 Staff B acknowledged that the facility had no documented evidence of TB (tuberculosis) testing or TB individual risk assessment and symptoms evaluation . When asked if this information was stored in another location, she responded that it was not. She also stated, “We will be testing them as we speak.””

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 51000 Based on observation, policy and procedure review, and interviews the facility did not ensure that staff followed standard infection control practices regarding glove changes and hand hygiene between glove changes. This places patients at risk for potential infection. Findings include: During an observation of a Staff L at 11:05 a.m. on June 10, 2025 at Station 15, the staff member was initiating dialysis. After evaluating the access and palpating the cannulation sites, Staff L removed his gloves and reapplied clean gloves without hand hygiene between the glove changes. The procedure of gloving without hand washing was repeated on station 14 while attending to the Alarm. PCT did not wash their hands after each patient. During an observation of Patient # 16 on 6/10/2025 at 10:01 AM, dialysis unit staff did not implement required infection control precautions. Specifically, the dialysis patient did not wear gloves or perform hand hygiene after holding their access site. These observation was conveyed to Staff J, and the findings were acknowledged. The facility Policy and Procedure titled, “Infection Control for Dialysis Facilities (Policy 1-05-01) revised in April 2023, states the following: “ All Teammates, Physicians, and Non-Physicians will perform hand Hygiene. (b) Before gloving and immediately after removal of gloves, “Even after glove use, hand hygiene is necessary after glove removal because hands become contaminated through small defects in gloves and from the outer surface of gloves during glove removal.””

“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: 43190 Based on observation, review of Policy and Procedure and staff interview, the facility failed to ensure that the dialysis equipment had been cleaned and disinfected before returning it to an area designated as clean or before being used on another patient. Items used on dialysis equipment and taken from station to station had the potential to serve as a vehicle for the transmission of infections. Deficient infection control practices have the potential to affect all patients. Findings: During Observation on 06/20/2025 of a Staff M at 10:30 AM at Station # 12, the temporal thermometer was taken from a clean cart and use to Patient #5 without cleaning after use, and returned to the clean cart. During the same observation, Staff M utilized a roll of tape for single use in the initiation of treatment for patient # 5 and place on computer cart, then use to another patient on station 15. During an observation on 6/11/2025 at 10:40 AM, Staff G auscultated Patient#17 lungs at station #23, then returned the stetescope to the pant leg pocket without cleaning. Staff G later proceded to Station# 18 and auscultated Patient # 19 lungs. Per Policy:1-05-01 Titled “Infection Control for Dialysis Facilities”, last reviewed on 4/2023, states, “Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 bleach solution...” In addition, the policy states, “non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. If item cannot be cleaned and disinfected it will be dedicated for use on a single patient”. This observation was conveyed to Staff J, and the findings were acknowledged.”

“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: 51000 Based on observation and interview the facility failed to ensure that trays used to deliver medicaions to patients were cleaned between patients and that medications were stored in a secure manner. During observations on 6/10/2025 between 10 AM and 10:30 AM, Staff G carried pre-drawn heparin doses in multiple size syringes in a plastic basket, unsecure, and brought from station 22, where heparin was given to Patient # 18 and basket was not cleaned, then Staff G proceded to station 15 where the patient’s chart was checked but no medication was administered again the basket was not cleaned, then Staff G proceded to station 13 and Heparin was administered to Patient# 16 and the basket was not cleaned. After use the heparin basket was kept unsecure on the common desk in the patient area. During observations on 6/10/2025 at 1:51 PM, Staff L was removing bandages from the cabinet across from Station #15. The cabinet did not have a door to protect supplies from potential contamination. One unopened box of bandages fell onto the floor and was then placed back in the cabinet. This potentially contaminates all supplies in the cabinet. During an observation at 1:20 PM on 6/10/2025, an unsecure syringe of saline was noted on the side table at Station #16 where Patient #19 was being treated. These findings were discussed with Staff J on 6/10/2024 at 2:30PM”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [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- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 43190 Based on observation and interview, staff do not handle and/or dispose of potentially infectious waste properly. The failure of staff to properly dispose of potentially infectious waste places staff and patients at risk for exposure to infection. Findings Include: - On 6/12/2025 at 10:26 AM, Staff S, walked contaminated/use blood lines and dialyzer from Station #10 to biohazard bin located across from Stations #7 and #8. Staff did not bring the biohazard bin (on wheels) to the station. Review of policy “Infection Control for Dialysis Facilities” last revised 04/2023 does not specify limiting exposure to biohazard waste when disposing of used extrcoporeal blood lines and dialyzers. During an interview on 6/12/2025 at 10:35 with Staff S, it was confirmed that the contaminated blood lines should have been disposed of in a bin that was brought to the station but forgot. Interview on 6/13/2025, Staff A was made aware of this finding.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 36207 Based on the observation and staff interview the facility failed to provide a functional and safe environment for the provision of dialysis treatment. Each dialysis facility must be designed and equipped in a manner that protects the lives and assures the physical safety of all individuals in the area. These failures may place patients at risk for lack of care, falling, and allergy. Findings include: During the tour of the dialysis facility on 06/13/25 between 10:45am-11:30 am, 1) It was observed that the facility’s only examination room was used as a storage room. Review of FGI 2018 (Facility Guidelines Institute) 2.10-3.1 notes that at least one examination room shall be provided. This room is used for physical exams prior to dialysis or to perform any treatment. 2) It was observed that the floor trim was torn off the wall in the facility’s second exit. 3) The wall box in the home hemodialysis training room 2 was rusted These observations were done in the presence of Staff B , senior administrator and on interview she acknowledged the findings. These findings were shared with the facility’s administration during exit conference on 6/13/25.”

“PE-FIRE SAFETY-LIFE SAFETY CODE CFR(s): 494.60(e)(1) (1) Except as provided in paragraph (d)(2) of this section, dialysis facilities that do not provide one or more exits to the outside at grade level from the patient treatment area level must comply with provisions of the Life Safety Code (NFPA 101 and its Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4) applicable to Ambulatory Health Care Occupancies, regardless of the number of patients served. This Standard is not met as evidenced by: 36207 Based on observations and staff interview, the facility did not maintain the exit accordance with NFPA 101, 2012 edition. The means of egress is continuously maintained free of all obstructions to full instant use in case of emergency. Failure to maintain exit will significantly delay evacuation during emergency in case of fire or any emergency. Findings Include: During the tour of the facility on 06/12/25 at10:30 am, the facility’s second exit passageway / means of egress was used for storage. There were more than 10 cardboard boxes with dialysis supplies in the egress passageway, causing obstruction to safe evacuation through the emergency exit. When measured with Tape the clearance of the exit passageway was 41” inches instead of 44 inches between the steel shelf and the handwashing sink in the exit way. In addition, on 06/10/25 at 10:00 AM during the flash tour, the surveyors noted that the arrangement of egress from the water treatment room to an exit was through a storage room filled with metal racks and wooden pallets containing medical and non-medical supplies. A clear and continuous passageway of at least 36 inches was not maintained in the storage room thereby obstructing the exit access. These observations were done in the presence of Staff E , Senior administration. Upon interview this staff acknowledge the finding”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 43190 Findings include: Based on policy review, medical record review, and interview. Pretreatment and/or post treatment nursing assessments were not completed timely by a Registered Nurse (RN) for 5 of 15 patients (Patients #1, #3, #5, #6, and #7). Inadequate assessment may place a patient at risk for an adverse event. Findings: On 6/13/2025, a review of the treatment flowsheets for Patient #1, dated from 5/21/2025 through 6/10/2025, revealed the following: - On 6/10/2025, treatment was initiated at 8:32 AM, but the pre-assessment was not completed until 9:42 AM. - On 6/10/2025, treatment ended at 11:21 AM, but the post-assessment was not completed until 4:25 PM. A review on 6/12/2025 of the treatment flowsheets for patient #3 for the dates of 5/21/2025 through 06/10/2025 revealed the following: - On 5/21/2025, treatment was initiated at 9:02 AM, but the pre-assessment was not completed until 10:24 AM - On 5/26/2025, treatment was initiated at 9:03 AM, but the pre-assessment was not completed until 10:19 AM - On 5/30/2025, treatment was initiated at 8:31 AM, but the pre-assessment was not completed until 10:24 AM On 06/12/2025, a review of the treatment flowsheets for patient # 5 from 05/21/2025 through 06/10/2025 revealed the following discrepancies: - On 05/27/2025, treatment ended at 1:47 PM; however, the post-treatment assessment was not completed until 4:27 PM - On 05/29/2025, treatment was initiated at 9:59 AM; however, the pre-assessment was not completed until 11:01 AM. - Treatment was completed on 05/29/2025 at 1:39 PM, but the post-treatment assessment was not completed until 3:42 PM. - On 06/03/2025, treatment was initiated at 9:51 AM, but the pre-assessment was not completed until 10:50 AM. - Treatment ended on 06/03/2025 at 1:27 PM, yet the post-nursing assessment was not completed until 3:43 PM. - On 06/06/2025, treatment was initiated at 3:03 PM, and the pre-assessment was not completed until 4:19 PM. - Treatment concluded on 06/06/2025 at 6:02 PM, but the post-assessment was not documented. On 06/12/2025, a review of the treatment flowsheets for patient # 6 for dates from 05/21/2025 through 06/10/2025 revealed the following discrepancies: - On 06/05/2025, treatment was initiated at 1:58 PM; however, the pre-assessment was not completed until 3:00 PM. - On 06/06/2025, treatment began at 2:14 PM, but the pre-assessment was completed at 3:34 PM. - On 06/07/2025, treatment was initiated at 1:50 PM, yet the pre-assessment was not completed until 3:16 PM. A review conducted on 6/12/2025 of the treatment flowsheets for patient #7, dated from 5/21/2025 - 06/10/20252025 , revealed the following: - On 5/23/2025, treatment was initiated at 9:54 AM, but the pre-assessment was not completed until 11:09 AM. - On 5/30/2025, treatment was initiated at 9:40 AM, but the pre-assessment was not completed until 11:01 AM. Complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner, as required by state law. An interview on June 12, 2025, at 1:45 PM with Staff J revealed that the policy requires assessments to be completed within one hour of dialysis initiation. Staff J was informed that state regulations require stricter requirements if dialysis is initiated via a catheter.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 51000 Based on a record review, policy review, and staff interviews it was determined that the facility did not ensure that the required monthly reassessments and plan of care revisions were conducted for two (2) out of four (4) patients with an “unstable” status. A total of 15 Medical records were reviewed. Findings: A review of patient #5 revealed that the team classified this patient as unstable based on clinical outcomes from the last six months. The patient was categorized as unstable due to frequent hospitalizations and fluid overload, with a fluid management ultrafiltration rate (UFR) exceeding 13 ml/kg/hr. However, the team did not document the reasons for judging this patient’s condition as unstable during those two months. Additionally, specific dates of the patient’s hospitalizations were not provided, and there was no evidence that this patient had a Plan of Care for two months. Review of medical records for Patient#7 revealed the plan of care stated the patient was unstable on 10/09/2024. Patient unstable due to hospitalizations, fluid management, and diabetes management. There is no evidence of the plan of care being reviewed again until 5/27/2025 at which time the patient was noted to be stable. During an interview with Staff J, on 6/12/2025 at 4:05 PM when asked how often plans of care are to be reviewed on unstable patients, Staff J replied “monthly”. When asked to provide the plans of care for Patient #7 for 11/2024 through the time when the patient became stable, Staff J replied, “I can’t give you what we don’t have”. The review of Policy 1-14-01, Title: Interdisciplinary Team (IDT) Patient Assessment and Plan of Care revealed, “Re-assessment for hospitalized patients should be initiated on the day of the patient’s first treatment at the facility and should be completed within 30 days of hospital discharge”. These findings were discussed at exit conference on 6/13/2025.”