Fmcna - Muskogee

“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: 34689 Based on observation, record review, and interview, the facility failed to ensure that emergency equipment was readily available to manage medical and non-medical emergencies that are likely to threaten the health and safety of patients, citing two of two emergency evacuation boxes (In-center hemodialysis Emergency Evacuation Boxes) included expired supplies and medications available for use during an emergency in the facility. Findings included: A review of the facility’s Emergency Medications, Equipment and Supplies Policy dated 02/03/2025, included, “Emergency Evacuation Box...must be available to grab in case of fire or the immediate need to evacuate the clinic...contain all patient and staff emergency contact information...be checked monthly or after use for contents, expiration dates and cleanliness...complete the monthly check in the approved electronic documentation...” A review of the facility’s Expiration Dates Sterile Supplies Policy dated 07/04/2012, included, “Policy...sterile items will be checked before use to ensure that they have not expired...” On 04/15/2025 at 3:00 PM, the surveyor and charge nurse II (Personnel #1) opened 2 of the in-center hemodialysis (ICHD) emergency evacuation boxes and observed expired medications and supplies, as follows: - 20 3 milliliter (ml) syringes expiration date 2/28/2025. - 5 infusion sets expiration date 9/14/23. - 6 4 X 4 Island dressings expiration date 2023-4-16. - 20 povidone/iodine swabsticks expiration date 2023-4. - 20 chloraprep swabsticks expiration date 2023-12. - 20 infusion sets 5/20/24. - 20 10 ml Normal Saline (NS) flush syringes expiration date 2023-03-31. - 20 10 ml NS flush syringes expiration date 1-31-25. - 20 10 ml syringes expiration date 1-31-25. - 5 Volumat line infusion set expiration date 2024-5-20. On 04/15/2025 at 3:25 PM, the charge nurse II (Personnel #1) confirmed the above findings.”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 34689 Based on observation, record review, and interview, the facility failed to ensure two of two facility areas (In-center hemodialysis treatment area and home therapy area) provided and monitored a sanitary environment to minimize the transmission of infectious agents within and between the units or other public areas. Findings included: A review of the facility’s General Cleanliness and Infection Control Guidance Policy dated 11/04/2024, included, “Purpose...this policy is to provide guidance for...staff on preventing the spread of infectious disease and maintaining a clean, safe...environment...Policy...All Areas must be kept clean and organized...facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff...clean supplies may not be kept under dirty sinks...” 1. In-center Hemodialysis (ICHD) treatment area: On 04/15/2025 at 1:15 PM, the surveyor and charge nurse II (Personnel #1) observed the cabinets under the sinks in the treatment area were dirty, as follows: - The cabinet under the labeled “clean” sink #1 across dialysis stations #11 and #10, was dirty with yellowish brownish stain on the wooden base. There was a plastic container approximately the size of a shoe box, filled with wet disposable wipes soaking in approximately 800 milliliters (ml) of yellowish amber colored liquid. When the charge nurse II (Personnel #1) was asked what the liquid was and how long had the plastic container stored in this cabinet, she stated that it looked like they had a leak and that she had not seen the inside of the cabinet before. - The cabinet under the labeled “clean” sink #2 across dialysis stations #13, #14, and #15 stored 2 corrugated boxes of syringes. - The cabinet under the labeled “dirty” sink #3 across dialysis stations #19 and #20, was dirty, stained with a bright greenish colored gel substance at the back of the cabinet and reddish stain on the cracks of the wooden base. - The cabinet under the labeled “dirty” sink #4 across dialysis stations #6 and #7 was dirty with reddish stain on the wooden base. On 04/15/2025 at 1:30 PM, the charge nurse II (Personnel #1) confirmed the above findings. 2. Home Therapy area: On 04/15/2025 at 2:40 PM, the surveyor and the home therapy Registered Nurse (RN) (Personnel #3) conducted a tour of the facility’s home therapy area and observed the following: - Home dialysis room #1, training room for both cycler and NxStage room wall had grayish black approximately 12 inches in length 4 - 5 smudges on the wall and labeled “dirty” sink was stained with brownish reddish crusted stain. On 04/15/2025 at 2:45 PM, the home therapy RN (Personnel #3) confirmed the above findings. When asked what the smudges were, he stated that those must be from the recliner handles. On 04/15/2025 at 2:45 PM, the surveyor and the area technical operations manager (ATOM) (Personnel #8) observed room #2 designated as the mixed training room had a strong foul smelling odor by the counter with the sink. On 04/15/2025 at 2:46 PM, Personnel #8 confirmed the above findings.”

“IC-TRANSDUCER PROTECTORS-NOT WETTED/CHANGED CFR(s): 494.30(a)(1)(i) Use external venous and arterial pressure transducer filters/protectors for each patient treatment to prevent blood contamination of the dialysis machines’ pressure monitors. If the external transducer protector becomes wet, replace immediately and inspect the protector. If fluid is visible on the side of the transducer protector that faces the machine, have qualified personnel open the machine after the treatment is completed and check for contamination. This includes inspection for possible blood contamination of the internal pressure tubing set and pressure sensing port. If contamination has occurred, the machine must be taken out of service and disinfected using either 1:100 dilution of bleach (300-600 mg/L free chlorine) or a commercially available, EPA-registered tuberculocidal germicide before reuse. Change filters/protectors between each patient treatment, and do not reuse them. Internal transducer filters do not need to be changed routinely between patients. This Standard is not met as evidenced by: 34689 Based on observation, record review, and interview, the facility failed to ensure two of two facility staff (Personnel #1 and #6) changed transducer protector when wetted. This practice placed patients at risk for cross contamination and venous chamber clotting and blood loss. Findings included: A review of the facility’s Maintenance of Transducer Protectors Procedure Policy dated 11/01/2021, included, “Purpose...this policy is to ensure accurate measurement of arterial and venous pressures by maintaining clean, dry, transducer protectors and to prevent cross transmission of bloodborne pathogens due to a contaminated internal transducer protector...Policy...external transducer protectors must be changed immediately when they become wet with blood or other fluid...wet external transducer protectors must be thoroughly examined to determine if any blood or other fluid contamination is visible on the machine side (back) of the transducer protector prior to replacement...internal transducer checks...when inspection of the internal transducer finds evidence of contamination the following steps should be taken...pull the machine from use after completion of the current treatment...sequester the machine...facility nursing staff (are responsible for notifying Technical Services that the machine has been removed...and requires replacement of contaminated parts and disinfection...” 1. On 04/15/2025 at 1:50 PM, the surveyor and charge nurse II (Personnel #1) observed Patient #4’s dialysis machine #899 with the venous transducer filled with blood. When Personnel #1 was asked who was the facility staff who took care of Patient #4 and if there was anything that needed to be done with the dialysis machine, she stated the patient care technician (PCT) (Personnel #6) was the assigned staff to Patient #4. Personnel #6 stood by the nursing station counter across dialysis station #14 and when asked if there was anything that needed to be done with the dialysis machine of Patient #4, she stated that she needed to change that (transducer). On 04/15/2025 at 1:53 PM, the charge nurse II (Personnel #1) confirmed the above findings. 2. On 04/15/2025 at 1:54 PM, the surveyor and charge nurse II (Personnel #1) observed Patient #5 at dialysis station #14 during his dialysis treatment on dialysis machine #888 alarmed. Patient #5’s dialysis machine showed 28 minutes left for dialysis treatment and the venous chamber transducer was filled with blood. The surveyor conducted an interview with Patient #5 and the venous chamber transducer continued to be filled with blood. At 2:00 PM, the transducer continued to be wet filled with blood. When the charge nurse II (Personnel #1) was asked who was assigned to Patient #5, she stated Personnel #6 and stated that she can change the wet transducer. At 2:02 PM, the surveyor observed the charge nurse II (Personnel #1) removed the wet transducer, discarded the wet transducer in the sharps container, flushed the line with Normal Saline (NS), and placed a new transducer at the venous chamber. On 04/15/2025 at 2:05 PM, the charge nurse II (Personnel #1) confirmed the above findings. When the charge nurse II (Personnel #1) was asked what the facility’s process and policy on changing a wet transducer, she stated change the transducer and flush the line. On 04/15/2025 at 4:00 PM, when the biomed (Personnel #8) was asked what the process was in wet transducer, he stated the back of the wet transducer needed to be checked for contamination and take the dialysis machine out of service if contaminated, and notify the Biomed. When asked if the facility staff notified Biomed of wet transducers for dialysis machines #888 and #899, he stated not at this time.”

“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: 34689 Based on observation, record review, and interview, the facility failed to ensure that infection control practices for proper infection control techniques for care, maintenance, and disposal of contaminated bio hazard wastes were followed, citing two of two facility staff (Personnel #5 and #9) in that used syringes with blood were placed on top of the chairside table mixed with clean supplies. This practice placed all patients and staff at risk for cross contamination and/or infection. Findings included: A review of the facility’s General Cleanliness and Infection Control Guidelines Policy dated 11/04/2024, included, “Purpose...this policy is to provide guidance for...staff on preventing the spread of infectious disease and maintaining a clean, safe...environment for patients, staff, and visitors...specimens of blood or other potentially infectious materials shall be placed in a container which prevents leakage during collection, handling...” 1. On 04/15/2025 at 1:38 PM, the surveyor observed the registered nurse (RN) (Personnel #5) discontinued Patient #1’s dialysis treatment via left chest central venous catheter (CVC). Personnel #5 disconnected the arterial and venous bloodlines from the CVC ports, then laid the bloodlines with blood, uncapped beside Patient #1’s right side of the dialysis recliner. Personnel #5 flushed Patient #1’s arterial and venous CVC ports with 10 milliliters (ml) Normal Saline (NS) flushed each port and placed the 2 used 10 ml syringes with blood on the hub of each syringe, on the chairside table mixed with clean supplies such as 2 3 ml Heparin syringes, and alcohol prep pads. Cleansed each port with an alcohol prep pads and flushed each port with the 3 ml Heparin syringes from the chairside table. On 04/15/2025 at 1:40 PM, the RN (Personnel #5) confirmed the above findings. 2. On 04/16/2025 at 10:08 AM, the surveyor observed the licensed practical nurse (LPN) (Personnel #9) used a swabstick and cleansed Patient #20’s right chest CVC site and placed the used swabstick on top of the chairside table mixed with clean supplies, such as alcohol prep pads, gauze, and 10 ml NS flush syringes. Personnel #9 flushed Patient #20’s arterial and venous CVC ports with 10 milliliters (ml) Normal Saline (NS) flushed each port and aspirated 10 ml of blood from each port. Personnel #9 removed one syringe with 10 ml of blood, held the 10 ml syringe with blood with her left hand, while she flushed the other port. Personnel #9 placed the 2 used 10 ml syringes with blood with uncapped hub and placed the 2 syringes on the top of the chairside table mixed with clean supplies such as alcohol prep pads, syringes, and gauze. On 04/16/2025 at 10:20 AM, the LPN (Personnel #9) confirmed the above findings.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 34689 Based on observation, record review, and interview, the facility failed to evaluate the appropriateness of the dialysis prescription, citing two of two dialysis patients (Patients #8 and #19) who did not have physician’s orders for the provision of care. Findings included: A review of the facility’s Bed Bug Control Policy dated 11/07/2023, included, “...Documentation...clinic staff should document all interventions taken and response to interventions in the medical records...” A review of the facility’s Physician Order Documentation Policy dated 07/03/2023, included, “...Background...all medications, laboratory tests, and treatments a patient receives require electronic order signed by the physician...It is the nurses’ responsibility to ensure that all treatments...or any care provided to the patient have an accurately documented physician order...general policy...nurse practice acts require nurses to carry out treatment care, medication...procedures and other treatments, based on physician orders...Telephone orders...signed by the physician, at the time of the physician’s next facility visit. The orders must be signed, within 30 days, or earlier...” 1. Patient #8: A review of clinical records included the following: Referral and Physician Orders for Patients Receiving Peritoneal Access Care Services dated 12/30/2024, included, “...type of access...peritoneal dialysis (PD) catheter (cath)...Physician orders...exit site dressing change...flush Peritoneal Dialysis (PD) catheter incrementally X 2 - 3 weeks...received verbal telephone order (RVTO) from physician (Personnel #16)...noted registered nurse (RN) (Personnel #14)...date 12/30/2024...” Home Dialysis Nursing Support Record dated 12/30/2024, included, “...comments...first (1st) dressing (drsg) changed/flush increments 250 milliliter (ml)...nurse’s signature_(Blank)_________.” The physician order written on 12/30/2024 showed no documented evidence of the amount and type of solution to flush the PD catheter of Patient #8 on 12/30/2024. On 12/30/2024, the home dialysis nursing record showed Patient #8’s PD catheter was flushed with 250 ml of solution. The was no documented evidence physician (Personnel #16) signed the RVTO from the written order dated 12/30/2024. On 04/15/2025 at 4:57 PM, the registered nurse (RN) (Personnel #3) was asked when Patient #8’s PD catheter placed, he stated placement date was on 12/23/2024. On 04/15/2025 at 4:57 PM, the registered nurse (RN) (Personnel #14) confirmed the above findings. 2. Patient #19: On 04/17/2025 at 10:00 AM, the surveyor conducted an interview with the registered nurse (RN) (Personnel #2) and the patient care technician (PCT) (Personnel #7). When asked if there were patients with bed bugs and how they cared for the patients, Personnel #2 and #7 stated there were patients that had bed bugs and that there was an infestation before. Personnel #7 stated that they ask patients to change their clothes and put their clothes in th blue hot boxes and after their dialysis treatments, they change back to their own clothes. Personnel #7 showed the surveyor the blue hot boxes stored in the lobby area of the facility. There were approximately 6 -9 blue hot boxes. A review of the Psychosocial Progress Note by social worker (SW) (Personnel #18) dated 08/15/2024, included, “SW was advised staff had seen bed bug on patient. SW talked to patient explained the policy...expressed understanding and will be bringing extra pair of clothes for the hot box...provided some do it yourself (DIY) resources...will follow up with patient as needed...” A review of the Psychosocial Progress Note by social worker (SW) (Personnel #18) dated 08/22/2024, included, “SW met with patient chairside...working at home on getting rid of bed bugs...has not seen anymore...will continue to monitor...” A review of Patient #19’s Treatment Sheets dated 08/15/2024 and 08/17/2024, included, “Nursing Evaluation...physical assessment...no unusual findings...Registered Nurse (RN) (Personnel #20), and 08/22/2024, included, “Nursing Evaluation...physical assessment...no unusual findings...RN (Personnel #21)...” A review of the Orders Summary Report dated 08/10/2024 - 04/10/2025 showed no documented evidence of orders for bed bug protocol from Patient #19’s physician (Personnel #16). There were no documented evidence facility staff notified Patient #9’s physician of the condition status in regards to presence or absence of bed bugs. A review of Patient #19’s clinical records showed no documented evidence facility staff found bed bugs, assessed or reassessed for presence or absence of bed bugs. There was no documented evidence facility staff maintained bed bug protocol. On 04/17/2025 at 11:05 AM, the director of operations (Personnel #4) confirmed the above findings.”

“QAPI-INDICATOR-MEDICAL INJURIES/ERRORS CFR(s): 494.110(a)(2)(vi) The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification. This Standard is not met as evidenced by: 34689 Based on record review and interview, the facility failed to ensure that adverse events were reported and continuously monitored in the facility’s Quality Assessment and Performance Improvement (QAPI), citing one of one patient (Patient #17) in that patient’s caregiver reported blood loss and adverse events were not reported to the physician, trended, tracked, and/or analyzed to prevent and/or decrease adverse events from reoccurring to protect the health and safety of the patients, the staff, and the public. Findings included: A review of the facility’s Patient Safety Event Reporting and Documentation Policy dated 02/06/2023, included, “...Definitions...Safety Event results in mild to moderate patient clinical harm, not due to an underlying disease or condition. Requires additional monitoring, intervention, and/or medical care...Policy...when a near miss, safety event or serious safety event occurs, staff are required to report, document and review the event...clinical staff are required to report all Safety Events...to the patient’s physician...any bleeding involving a patient’s dialysis access, regardless of where the event occurred, should be considered a safety or serious safety event...quality assessment and performance improvement (QAPI) review of patient event...patient safety events should be reviewed during QAPI...” Patient #17: A review of Patient #17’s clinical records showed Patient #17’s caregiver called facility staff on 04/07/2025 and 04/09/2025 and notified facility staff of, “filled up the saline bag with blood on 04/07/2025,” and “...caregiver called to notify that patient lost another line of blood on 04/09/2025.” Clinical Notes Report dated 04/07/2025, included, “...7:10 PM...caregiver called to report that he got confused on what line goes back to the bag and connected the wrong line to start rinseback...filled up the saline bag with blood. Stated that patient did not feel good...advised patient to review...advised that if patient feels too bad to present to the emergency room...registered nurse (RN) (Personnel #3)...” Clinical Notes Report dated 04/09/2025, included, “...12:29 PM...patient’s caregiver called to notify that patient lost another line of blood, approximately 140 milliliters (ml) due to an error in rinsing back. This is the 3rd time this has happened. Advised to present to emergency room (ER), for hemoglobin and hematocrit (H&H) evaluation...RN (Personnel #3)...” Patient #17’s clinical records showed no documented evidence facility staff called and notified Patient #17’s physician (Personnel #16) of patient’s caregiver reported issues with blood loss and confusion with home hemodialysis (HHD) treatment procedures. A review of the facility’s Patient Safety Event reports showed no documented evidence Patient #17’s reported blood loss issues were reported to the quality assessment and performance improvement (QAPI) program of the facility. On 04/17/2025 at 12:45 PM, when the director of operations (Personnle #4) was asked if there was an adverse event report for home therapy or for Patient #17’s reported issues on 04/07/2025 and 04/09/2025, she stated there were none. Personnel #4 confirmed the above findings. On 04/17/2025 at 2:40 PM, the director of operations (Personnel #4) confirmed the above findings.”

“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: 34696 Based on observation and interview, the facility failed to ensure the building in which dialysis services were furnished was maintained in three of five areas (Water Treatment area, Storage area, and Hemodialysis Treatment area ). Findings included: A review of the “General Cleanliness and Infection Control Guidelines” policy dated 02/07/22 indicated, “All areas should be kept clean and organized including, but not limited to the treatment area, water/supply room, and offices...Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff. Such cleaning should be done regularly using a schedule developed by the facility.” On 12/13/2023, the following was observed: 1. ~ At 12:45 PM, it was observed that the floors in the water treatment area had not been maintained. The ceramic tiled floor had a dried white powder film through out the area. In an interview at the time of the findings, the Faciilty Administrator (FA, Personnel #3) said the bicarbonate mixer had overflowed. He said the staff was responsible for maintaining the area since the janitorial service was not authorized to enter the area. ~ At 12:50 PM, it was further observed that a pail of fluid sat in front of the bicarbonate mixer. The pail was filled to the brim and almost overflowed. At the time of the finding, the Facility Administrator said the staff should empty the pail when it is full. 2. ~ At 12:55 PM, it was further observed that the floor in the storage area adjacent to the water treatment area had not been maintained. The cement floor in front of the acid tank was dirty and stained. The floor in front of the storage shelving was dirty and gritty. At the time of the findings the Area Technical Operations Manager (ATOM, Personnel #5) said there had been some construction done in the area. He said the staff was responsible for maintaining the storage area. 3. ~ At 1:15 PM, Patient #5 was observed dialyzing in the isolation room in the hemodialysis treatment area. It was further observed that the pull cord to call direct patient care staff in the event of an emergency was behind Patient #5’s dialysis chair. Patient #3 was asked if he could reach the pull cord. Patient #5 said, “No.” At the time of the findings, the Director of Operations (Personnel #2) said the cord should always be readily available when patients are dialyzing in the room.”

“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: 34696 Based on record review and interview, the IDT (Interdisciplinary Team) failed to ensure the home therapies RN (Registered Nurse, Personnel #6) communicated with one of three HHD (home hemodialysis) patients (Patient #6) when there was a change in the dialysis prescription. Findings included: ~ Patient #6: A review of a nurse’s note dated 10/27/2023 included, “Dry weight changed to 103.5 kg. (kilograms) per doctor...” Further review of the HHD treatment records dated from 11/17/2023 to 12/13/2023 indicated the prescribed EDW (estimated dry weight) printed on Patient #6’s treatment records was 108 kgs. Patient #6 was below the EDW printed on the treatment record. The records indicated Patient #6’s low pre-treatment weight gains ranged from 1.5 kgs. to 4.6 kgs. below the the EDW. There was no documented evidence Personnel #6 communicated to Patient #6 the change of the prescribed EDW. On 12/15/2023 at 8:20 AM, in an interview, the home therapies RN (Personnel #6) said the EDW was supposed to be changed in October 2023 to 103.5 kgs. She said she did not send the weight change to Patient #6’s iPad.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 34696 Based on record review and interview, the IDT (Interdisciplinary Team) failed to review all home therapies patients’ treatment records for complete self-monitoring data and address concerns noted on the records, citing one of six home therapy patients (Patients #7) who did not have documented evidence that the RN (Registered Nurse) reviewed and addressed patients’ home therapy treatment records for complete self-monitoring data and address concerns that warrant an evaluation by the RN or physician. Findings included: ~Patient 7: The home hemodialysis treatment records for Patient #7 dated from 11/01/2023 to 12/14/2023 were incomplete. There was no documented evidence that the RN reviewed and addressed the records for complete self-monitoring data. The treatment records on various treatment days did not include documented evidence of the following: The pre-treatment section did not include “Today’s weight, dry weight, oral fluid, UF (ultrafiltration) volume goal kilogram (kg)” The intradialytic treatment section did not include the, “Time, Blood Pressure, Pulse, Rates...Dialysate.UF, Blood Flow, Volumes...Dialysate, UF, Pressures...Venous, Affluent, Access...Alarms...FF Changes...Comments...Initials.” The post treatment section did not include, “End Time, Total treatment Time, Total Dialysis, Total UF, BLP, Total Fluids. Blood Pressure sitting, Blood Pressure standing, Pulse, Temp, and Weight...Any access/bleeding problems...Needle site held for...minutes...any other medical complaints.” On 12/15/2023 at 9:15 AM, the Hoe Therapy Clinic Manager (Personnel #7) said the home therapies RN should review patients’ treatment records for accuracy and completeness.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 34696 Based on record review and interview, the facility failed to ensure that the PD RN (Peritoneal Dialysis Registered Nurse, Personnel #6) demonstrated the competencies necessary to serve collectively the comprehensive needs of the home therapy patients. Findings included: ~The training records for Personnel #6 did not include documented evidence that they demonstrated the specified competency and skills required to perform PD and HHD (home hemodialysis). Personnel #6 did not have documented evidence of a current emergency preparedness training. On 12/14/2023 at 1:15 PM, the Director of Operations (Personnel #2) and the Facility Administrator (Personnel #3) said the skills checklist provided was not specific for HHD annual evaluation with the Nxstage machine. The PD annual training was not specific to the liberty cycler.”