Davita Cornell Road Dialysis

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 37237 Based on interview, review of personnel files and review of documentation, it was determined the facility failed to ensure: 1. Fire drills were completed for all patients on all shifts. 2. All staff received EP training. Findings: 1. Review of fire drill documentation between January and December 2024 revealed fire drills failed to be completed for all days and all patients. * During Q1 2024, a fire drill was completed on Monday, 01/22/2024 for 1st shift patients only. The facility lacked documentation that a fire drill was completed for 2nd shift patients and the patients receiving treatments on Tuesdays, Thursdays and Saturdays. * During Q2 2024, a fire drill was completed on Monday, 05/20/2024 for shifts 1 and 2. The facility lacked documentation that a fire drill was completed for the patients receiving treatments on Tuesdays, Thursdays and Saturdays. * During Q3 2024, a fire drill was completed on Tuesday, 09/17/2024 for patients on 1st shift and during turnover. The facility lacked documentation that a fire drill was completed for the patients receiving treatments on Mondays, Wednesdays and Fridays. * On Thursday, 10/17/2024, an emergency earthquake drill exercise was completed. The facility lacked documentation the patients receiving treatments on Mondays, Wednesdays and Fridays participated in the emergency exercise. * During Q4 2024, a fire drill was completed on Tuesday, 12/17/2024 for shifts 1 and 2. The facility lacked documentation that a fire drill was completed for the patients receiving treatments on Mondays, Wednesdays and Fridays. * Review of 5 of 6 patient records (Patient #s 1, 3, 4, 5 and 6) revealed incomplete emergency preparedness training, that included emergency drills and fire drills. - Review of Patient 5’s medical chart (admit date 02/18/2016) revealed an “Emergency Preparedness Training” form dated 06/10/2024, a “Dialysis Emergency Procedure” form dated 03/27/2024 and an undated “Dialysis Emergency Procedure” form. There was no documentation from the days the facility documented fire drills had been completed. There was no fire drill documentation from Q3 and Q4 2024. - Similar findings identified for Patient #s 1, 3, 4 and 6. 2. Review of the “Personnel Audit Tool - ESRD” completed by the FA, revealed 1 of 21 employees (Employee # 16) had no date listed for emergency preparedness training. The FA failed to provide documentation that the Medical Director and other medical practitioners that visit the clinic on a regular basis to provide care to their patients had received any EP trainings. Review of the facility policy titled, “Facility Emergency Management Plan,” dated as last revised April 2022, stipulated in the section titled “Emergency Drills ... 3. Fire safety drills ... b. Required on a QUARTERLY basis ... c. One drill to be conducted for each shift of patients ... Document training for both teammates and patients.” Review of the “Facility Emergency Management Plan (ICD, Home),” dated as last revised “April 2023” stipulated in the section titled, “Training and Education,” that “The FA, or designee, is responsible to provide training of EMP ... Teammates ... Annually ... Policy Facility Emergency Management Plan ... Clinical emergency policies ... Facility specific emergency response procedures.” On 02/04/2025 at approximately 1500, the FA and MCS 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: 37237 Based on observation, interview and review of documentation, it was determined that the facility failed to ensure a sanitary environment to minimize the transmission of infectious agents within the facility and other public areas. Findings: Observation of the facility on 02/03/2025 beginning at 1010 and 02/04/2025 at 1340 revealed: - A visitor sitting with a patient at treatment chair station 13 failed to don a protective gown. - A PCT left the treatment floor to go to the supply room. The PCT failed to remove their protective gown as they exited and reentered the treatment area. - A bleach tub with the lid propped open. The tub was not labeled. Review of facility policy 1-05-01, “Infection Control for Dialysis Facilities,” dated as last revised “April 2023” stipulated: * “5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care area. PPE is to be: a. Removed prior to leaving the treatment area ... c. PPE is not to be worn in non-treatment areas, for example teammate lounge, teammate offices.” * “6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physician Providers (NPP) and visitors when in the treatment area.” Review of facility policies titled “Preparation of One to Ten (1:10) Bleach Solution” and “Preparation of One to One Hundred (1:100) Bleach Solution,” dated as last revised April 2021, stipulated “With indelible marking pen and label, label container with expiration date, time and initials. The solution is good for 24 hours only ... The solution must be changed when the maximum allowable time is exceeded (24 hours).” During an interview with the MCS and FA on 02/04/2025 at 1500, they confirmed the above findings.”

“IC-CDC MMWR 2001 CFR(s): 494.30(a) The facility must demonstrate that it follows standard infection control precautions by implementing- (1)(i) The recommendations (with the exception of screening for hepatitis C), found in “Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients,” developed by the Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, volume 50, number RR05, April 27, 2001, pages 18 to 28. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html. The recommendation found under section header “HBV-Infected Patients”, found on pages 27 and 28 of RR05 (“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients”), concerning isolation rooms, must be complied with by February 9, 2009. This Standard is not met as evidenced by: 37237 Based on interview and review of documentation, it was determined that the facility failed to follow the tuberculosis screening requirements for ESRD staff and patients outlined in OAR 333-019-0041. Findings. 1. Review of patient vaccine documentation for 62 patients revealed 17 (Patient #s 7 - 23) lacked current documentation of TB screening or the TB screening was done incorrectly. - Patient #8 was administered a tuberculin skin test with Tubersol, a PPD Tuberculin solution, on 04/23/2024. The date the TST was resulted was also 04/23/2024. Instructions for Tubersol stipulate the test should be read 48 to 72 hours after the PPD solution is placed. *Similar findings were identified for Patient #s 10, 14, 15, 16, 17, 19 and 23. - Patient #12’s vaccine documentation lacked evidence that a TST was performed. The only documentation listed was for the “TB RAQ.” *Similar findings were identified for Patient #s 7, 11, 18, 20, 21 and 22. - Patient #9’s vaccine documentation lacked evidence that a TST or TB RAQ was performed. * Similar findings were identified for Patient #13. - Review of facility policy 1-05-03 “Tuberculosis Infection Control Policy,” dated as last revised “April 2024” stipulated “Patients with chronic kidney disease (CKD) are considered high risk for progression from latent TB infection (LTBI) to active TB disease and will be screened for TB prior to first treatment, as well as participate in ongoing surveillance following admission, per the requirements of this policy, regardless of BCG history.” 2. Review of personnel records revealed 5 of 21 staff (Staff #s 8, 10, 12, 15 and 14) failed to receive a TB TST upon hire. - The TST for Staff # 5 with a DOH of 10/10/2022 was documented as complete on 12/27/2022, over two months from hire date. - The TST for Staff #10 with a DOH of 08/28/2023 was documented as complete on 09/21/2023, over one month from hire date. * Similar findings were identified for Staff #s 12, 15 and 17. Review of facility policy 4-06-05 “Tuberculosis Monitoring and Follow-Up” dated as last revised “October 2024” stipulated “Baseline new hire requirements for all new teammates including volunteers, per diem teammates, non-DaVita agency personnel and teammates will complete the following ... Testing options (any of the following).” Three options were outlined in the policy. All options included the statement “Documentation must be provided within 10 days of employment.” During interview with the MCS on 02/04/2025 at 1015, they confirmed that TB testing docmentation was lacking.”

“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: 47148 Based on observation and review of documentation, it was determined the facility failed to ensure that gloves were changed and hands were washed between each patient contact and/or between patient stations. Findings: Observation of the treatment floor on 02/03/2025 beginning at 1010 revealed: - A PCT was observed failing to perform hand hygiene while providing CVC care. At one point, the PCT removed their gloves, walked out of the patient station to grab a roll of tape from a drawer in the clean area then returned to continue providing CVC care, all without performing hand hygiene. Observation of the treatment floor on 02/04/2025 beginning at 1408 revealed: - A PCT was observed moving between five different patient stations to document on the chairside computer without performing hand hygiene between stations. - A PCT failed to perform hand hygiene after removing gloves and prior to re-gloving. Review of facility policy 1-05-01, “Infection Control for Dialysis Facilities,” dated as last revised “April 2023” stipulated: * “1. All teammates, Physician and Non-Physician [Practitioner] (NPP) will perform hand hygiene ... upon entering and exiting the patient treatment area ... prior to gloving and immediately after removal of gloves ... after contamination with blood or other infectious material ... between patients even if the contact is casual ... before touching clean areas such as supplies, supply cart and chairside keyboard/mouse ...” * “7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station ... ii. When going from a ‘dirty’ area or task to a ‘clean area or task...””

“IC-SINKS AVAILABLE CFR(s): 494.30(a)(1)(i) A sufficient number of sinks with warm water and soap should be available to facilitate hand washing. This Standard is not met as evidenced by: 37237 Based on observation and interview, it was determined that the facility failed to ensure that warm water was available at all of the sinks. Findings: Observation of the facility on 02/03/2025 beginning at 1010 and 02/04/2025 beginning at 1345 revealed all the handwashing sinks in the facility failed have warm water. Every sink that was tested, the water remained cool even after running up to 30 seconds. On 02/04/2025 at 1500, the FA confirmed the water in all the sinks was cold and did not warm up.”

“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: 47148 Based on observation and review of documentation, it was determined the facility failed to ensure that all staff followed written policies and procedures to prevent catheter-related infections. Findings: Observation of the treatment floor on 02/03/2025 at 1010 revealed a patient with a CVC who received care in treatment chair #4. As the hemodialysis machine was running while the tubing remained connected to the CVC catheter limbs, the PCT proceeded to provide CVC care and failed to ensure a new clean barrier was placed under the catheter to prevent contamination. The PCT removed the old dressing from the CVC exit site and wiped the CVC exit site with an alcohol prep pad. While using the alcohol prep pad, the patient’s button-up shirt was touched twice by the alcohol pad and the patient was looking downward directly towards the CVC exit site about two to three inches away from the site. The PCT failed to use an antiseptic technique to clean the limbs of the CVC prior to placement of the clean dressing. Hand hygiene was not performed after the old dressing was removed prior to the application of a clean dressing. Further observation revealed that the PCT failed to perform any hand hygiene while providing CVC care. At one point, they removed their gloves, walked out of the patient station to grab a roll of tape from a drawer in the clean area then returned to continue providing CVC care, all without performing hand hygiene. Review of the facility’s policy titled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure” dated “October 2024” revealed “Procedure ... 3. Verify patient’s clothing is secured away from the exit site/work area ... Instruct patient to turn head to opposite side of CVC exit site ... 4. Remove old dressing and discard ... 7. Remove gloves ... Perform hand hygiene ... re-glove ... 9. Clean each CVC limp/cap with a new large alcohol prep pad ... Upon Completion of Dialysis ... 28. Discard used barrier that was used during treatment and place a new clean, moisture proof barrier under catheter to prevent contamination ... 30. Aseptically disconnect arterial blood line from CVC limb ... 33. Disinfect the CVC hubs with a new alcohol prep pad for each CVC hub ... 36. Remove gloves ... perform hand hygiene ...””

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 37237 Based on interview, review of personnel records and review of documentation, it was determined that the facility failed to ensure that 3 of 19 clinical staff (Staff #s 4, 5 and 14) responsible for operating, testing and monitoring the water and dialysate systems completed the required training and annual skills checks required by the facility policy and this regulation. Findings: Review of the personnel file worksheet presented on 02/04/2025 revealed: - Staff #4 with a DOH of 04/03/2023 last completed the annual water monitoring and skills checklist training on 07/11/2023. No training was completed during 2024. - Staff #5 with a DOH of 11/28/2022 last completed the annual water monitoring and skills checklist training on 07/11/2023. No training was completed during 2024. - Staff #14 with a DOH of 06/06/2016 last completed the annual water monitoring and skills checklist training on 07/07/2023. No training was completed during 2024. Review of facility policy 8-02-08 titled, “Auditing of Clinical Practice Requirements for Water and Dialysate Concentrate,” dated as last revised “April 2021” stipulated “The ESRD Conditions for Coverage require the operators of the water/dialysate system equipment to be trained by the manufacturer of the equipment or the training must be done form materials provided by the manufactures. Initial training will be completed after new hire an annually thereafter.” During an interview with the FA and MCS on 02/04/2025 at approximately 1030 the above findings were confirmed.”

“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: 37237 Based on observation and interview, it was determined the facility failed to maintain the building in which dialysis services were provided was constructed and maintained to ensure the safety of the patients, the staff and the public. Findings: Observation of the facility on 02/03/2025 beginning at 1010 revealed: - The door leading from the treatment floor to a hallway leading to multiple offices was propped open during the survey. - The door leading from the treatment area to the hallway with the biomed office and storage areas was propped open during the survey. - The wall box of treatment station 8 had a gouge in the laminate that could not be cleaned effectively for infection control purposes. - The faucets at one of the dirty sinks had an accumulation of white precipitate built up around the faucet and counter laminate. During interview with the FA and MCS on 02/03/2025 at 1535, they stated that both doors were broken and the screws were stripped. They also stated that there was a work order to have the doors fixed. Review of the work order received via email on 02/05/2025 at 1:59 PM revealed “Utilities room needs a new lock/door handle. FA requests installing a coded door handle ...” Two part numbers for Deadlocking Latches were listed. The “Target Start” date was “4/4/2024 11:02:59 AM” and the “Target Completion” date was “4/24/2024 11:02:59 AM.” No actual completion date was listed.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 47148 Based on interview and the review of documentation, it was determined that the facility failed to ensure that all equipment was maintained and operated in accordance with the manufactures’ recommendations. Findings: 1. Review of the facility’s “Oxygen Concentrator Weekly Cleaning and Safety Check log” dated, December 2024 listed three duties to clean and check for each numbered (1-12) oxygen concentrators. Those duties were “Clean Air Filter ... “Clean Exterior ... Check Alarm.” There were handwritten weekly dates and a checkmark if the duty was completed by the staff member. Examples of duties missed include, but not limited to: * Machine 1, 12/14/2024 * Machine 2, 12/07/2024, 12/14/2024, 12/28/2024 * Machine 7, 12/07/2024, 12/14/2024, 12/28/2024 * Machine 10, 12/07/2024, 12/14/2024, 12/28/2024 * Machine 11, 12/07/2024 * Machine 12, 12/07/2024 * Machines 1-12, all lacked checks on 12/21/2024 Review of the facility’s “Oxygen Concentrator Weekly Cleaning and Safety Checklist Cornell Road (08654)” dated January 2025 lists three duties to clean and check for each numbered (1-10) oxygen concentrator. Those duties are “Clean Air Filter ... “Clean Exterior ... Check Alarm.” There is handwritten weekly dates and a checkmark if the duty is completed by the staff member. Examples of duties missed include, but are not limited to: * Machine 1, 01/25/2025 * Machine 7, 01/04/2025, 01/11/2025, 01/18/2025, 01/25/2025 * Machine 9, 01/04/2025, 01/11/2025, 01/18/2025 Review of facility policy titled, “Use of Oxygen Concentrators,” dated as last revised “October 2023,” stipulated, “Follow Manufacturer Instructions for Use regarding any additional cleaning/maintenance of the device and document on the Oxygen Concentrator Filter Cleaning Log, as applicable.” During interview on 02/03/2025 at 1500, the FA and MCS confirmed the above findings. 2. Review of the daily “Medication Refrigerator Management Log” for the medication refrigerator revealed numerous days when the fridge temperature was not documented. Examples included, but not limited to: * October 2024 missed days included 10/04/2024, 10/08/2024 and 10/25/2024. * October 2024 lacked initials of the staff that recorded the temperature on 10/01/2024, 10/11/2025, 10/15/2025, 10/23/2024 and 10/25/2024. * November 2024 missed days included 11/04/2024, 11/05/2024, 11/15/2024, 11/18/2024, 11/19/2024, 11/25/2024, 11/26/2024 and 11/29/2024. * November 2024 lacked initials of the staff that recorded the temperature on 11/14/2024, 11/29/2024 and 11/30/2024. * December 2024 missed days included 12/03/2024. * December 2024 lacked initials of the staff that recorded the temperature on 12/03/2024, 12/09/2024, 12/10/2024, 12/11/2024 and 12/19/2024. * January 2025 missed days included 01/03/2025. * January 2025 lacked initials of the staff that recorded the temperature on 01/03/2025, 01/09/2025, 01/10/2025 and 01/28/2025. Review of the facility policy, “Medications Requiring Refrigeration,” dated as last revised “December 2022” stipulated “The refrigerator is checked during facility normal operating hours, by a licensed nurse teammate or designee. Checks will be documented on the ‘Medication Refrigerator Management Log’ ... Twice daily temperature checks located on the Digital Data Logger (DDL) display, at the beginning and end of the day ... Verify that the temperatures remains between 2°C and 8°C (36°F and 46°F) ...” During interview on 02/03/2025 at 1500, the FA and MCS confirmed the above findings.”

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 47148 Based on interview, review of 4 of 6 patients’ Plan of Care (Patient #s 2, 3, 5 and 6) and review of documentation, it was determined the facility failed to ensure the patient’s right to be informed of and participate in all aspects of their care, including the right to refuse any intervention. Findings: Review of patient comprehensive assessments and signed plans of care revealed the plans of care were signed prior to completion of the comprehensive assessment or the finalizing of the plan of care. For example: *Patient #3: An IDT meeting was held on 08/26/2024. The patient signed that they acknowledged “review and approval of Patient Plan of Care at Interdisciplinary Team meeting” on 09/16/2024. However, the comprehensive assessment was not dated as final until 10/23/2024 and the plan of care was not dated as final until 10/28/2024. *Patient #6: An IDT meeting was held on 04/23/2024. The patient signed that they acknowledged “review and approval of Patient Plan of Care at Interdisciplinary Team meeting” on 04/23/2024. However, the comprehensive assessment was not dated as final until 06/21/2024 and the plan of care was not dated as final until 06/24/2024. Similar findings were noted for Patient #s 2 and 5. Review of facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated as last revised “October 2024,” stipulated, “The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or patient’s personal representative.” During interview on 02/04/2025 at 1215, the MCS 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: 37237 Based on interview, review of patient medical records and review of documentation, it was determined that the facility failed to ensure that patients received appropriate and timely hemodialysis monitoring or that the dialysis prescription was followed for 6 of 6 patients (Patients #s 1 - 6). Findings: Review of patients’ treatment flowsheets, “Treatment Details Reports,” revealed two sections titled “Intradialytic Vitals Stat Line.” The first section included a brief table of times and dialysis machine readings, at mostly routine times. The second section included two more detailed entries. One entry, “System Posted,” included the patient’s VS and other prescription readings taken from the dialysis machine and were automatically recorded every 30 minutes. The second entry was by PCTs/RNs and time stamped when staff did the actual patient evaluation, face and access visualization and heparin documentation. Review of patient treatment flowsheets reflected VS and safety checks were missed, RN assessments and prescription verifications were late, the patient’s dialysis prescription was not followed and/or abnormal findings were not reported to the RN. Examples included, but were not limited to: Patient #1 Review of Patient #1’s dialysis orders and treatment sheets dated 01/04/2025 through 02/01/2025 (13 hemodialysis treatments) revealed the following: - Patient VS, visualization and access checks were late for 11 of 13 treatments. * On 01/30/2025, a PCT documented a VS and access check at 1402. The next VS and access check was documented 61 minutes later at 1503. * Similar findings were identified for treatment dates 01/30/2025, 01/28/2025, 01/25/2025, 01/23/2025, 01/21/2025, 01/18/2024, 01/16/2025, 01/11/2025, 01/09/2025 and 01/07/2025. - The RN verification of the dialysis prescription and initial patient assessment were late on 2 of 13 treatment dates. *On 01/28/2025, treatment was initiated at 1221. The RN verified the patient’s prescription 92 minutes later at 1353 and documented the initial assessment at 1431. * Similar findings were identified for treatment date 01/07/2025. - Similar findings were noted for Patients #3-6. Patient #2 Review of Patient #2’s dialysis orders and treatment sheets dated 01/04/2025 through 02/01/2025 (13 hemodialysis treatments) revealed the following: - Patient VS, visualization and access checks were late for 11 of 13 treatments. * On 02/01/2025, a PCT documented a VS and access check at 0925. The next VS and access check was documented 54 minutes later at 1019 and then 59 minutes later at 1118. A VS and access check was done at 1207 and then 60 minutes later at 1307. * On 01/11/2025, a PCT documented a VS and access check at 0916. The next VS and access check was 2 hours and 52 minutes later at 1208. * Similar findings were identified for treatment dates 01/30/2025, 01/28/2025, 01/25/2025, 01/23/2025, 01/21/2025, 01/18/2024, 01/09/2025, 01/07/2025 and 01/04/2025. - Similar findings were noted for Patients #3-6. - Physician orders included a BFR of 350 mL/min. * The BFR was changed without documentation to indicate why the physician orders were not followed in 2 of 13 treatments. * On 01/28/2024 the BFR was set to and remained at 300 mL/min for the duration of the treatment with no documentation by the PCT or RN as to why the physician orders were not met. * Similar findings were noted for treatment dates 01/09/2025. - Physician orders included a target weight of 100 kg. The patient was over target weight for 13 of 13 treatments. * On 02/01/2025, the patient’s “Post Weight” was documented as 106.5 kg, 6.5 kg above the prescribed 100 kg “Target Weight.” * Similar findings were identified for treatment dates 01/30/2025, 01/28/2025, 01/25/2025, 01/23/2025, 01/21/2025, 01/18/2024, 01/16/2025, 01/14/2025, 01/11/2025, 01/09/2025, 01/07/2025 and 01/04/2025. Review of facility policy 1-03-08, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated as last revised “April 2024” stipulated: * “ Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law.” * “Patient identity, prescription, and machine settings are verified by teammate prior to initiation of treatment ...” * “Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: * “Vital signs and treatment monitoring ... are completed at least every 30 minutes.” * “At a minimum, obtain and document the following ... Blood pressure ... Heart or pulse rate ... Blood and dialysate flows, arterial and venous pressures ... Fluid removal and/or replacement ... Vascular access visible and line connections intact ... Patient subjective statement(s) i.e., patient report on overall health, any complaints.” During interview with the FA and MCS on 02/04/2025 at 1500, they confirmed that prescription verifications and initial patient assessments were done late and/or charted late due to the work load of the RNs.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 37237 Based on interview and review of documentation, it was determined that the facility failed to offer pneumococcal vaccination to patients based on assessment of status as required by facility policy and CDC guidelines for 5 of 62 patients (Patient #s 11, 16, 21, 22 and 24). Findings: 1. Review of the “Vaccinations and Surveillance Report,” printed on 02/03/2025, revealed 3 patients (Patient #s 16, 21 and 22), were eligible to receive the PCV20 vaccine, but it was not administered. Examples included, but not limited to: * Patient #16 had documentation showing they received an unknown pneumococcal vaccine in 01/2024. According to facility policy and CDC guidelines, this patient should have received a pneumococcal vaccine in January 2025. * Patient #21 had documentation showing they received the PPSV23 in 2008. The vaccine was administered to Patient #21 prior to the age of 65 years. According to facility policy and CDC guidelines, this patient is overdue for the PCV20 vaccine. *Patient #22 had documentation showing they received the PPSV23 in 2019. According to facility policy and CDC guidelines, this patient was due for PCV20 in 2020. 2. Review of the Vaccination and Surveillance Report for pneumococcal vaccinations dated 12/20/2024 revealed 2 patients (Patient #s 11 and 24) failed to have documentation of any pneumococcal vaccination in their medical record. Examples included: * Patient #11 with an admit date of 06/24/2024 lacked pneumococcal vaccination documentation. * Patient #24 with an admit date of 04/12/2024 lacked pneumococcal vaccination documentation. Review of the facility policy titled, “Pneumococcal Vaccine for Adult Patients,” dated as last revised “October 2023,” stipulated: * Patients of any age who have only received PPSV23 required “PCV20 at least one year after most recent PPSV23” to complete the vaccination series. * Patients who received PPSV23 before age 65 and also received PCV13 required “PCV20 at least 5 years after most recent pneumococcal dose” to complete the vaccination series. CDC pneumococcal vaccine recommendations for patients with chronic renal failure were found at https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html#adults and included: * Patients who have only received PPSV23 regardless of risk condition required “1 dose of PCV15 or PCV20 at least 1 year after the most recent PPSV23 vaccination.” * Patients who have received PCV13 and 1 dose of PPSV23 required 1 dose of PCV20 “at least 5 years after the last pneumococcal vaccine” to be complete. During an interview with the MCS and FA on 02/04/2025 at 1210, they confirmed the above findings.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 47148 Based on interview, review of 3 of 6 patients’ Plan of Care (Patient #s 3, 5 and 6) and review of documentation, it was determined that the facility failed to ensure that plans of care were reviewed with and signed by the patient in a timely manner. Findings: Review of patient comprehensive assessments and signed plans of care revealed the plans of care were signed prior to completion of the comprehensive assessment or the finalization of the plan of care. For example: * Patient #3: An IDT meeting was held on 08/26/2024. The patient signed that they acknowledged “review and approval of Patient Plan of Care at Interdisciplinary Team meeting” on 09/16/2024. However, the comprehensive assessment was not dated as final until 10/23/2024 and the plan of care was not dated as final until 10/28/2024. * Patient #6: An IDT meeting was held on 04/23/2024. The patient signed that they acknowledged “review and approval of Patient Plan of Care at Interdisciplinary Team meeting” on 04/23/2024. However, the comprehensive assessment was not dated as final until 06/21/2024 and the plan of care was not dated as final until 06/24/2024. * Similar findings were noted for Patient # 5. Review of facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated as last revised “October 2024,” stipulated, “The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or patient’s personal representative.” During interview on 02/04/2025 at 1215, the MCS confirmed the above findings.”

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 37237 Based on interview and medical record review, it was determined that the facility failed to ensure that the plan of care was updated within 15 days of the comprehensive patient assessment for 1 of 6 patients (Patient # 2). Review of Patient 2’s medical records revealed the a Patient Plan of Care Interdisciplinary Team meeting dated as “IDT Meeting Date ... 4/18/2023.” The RD, MSW, Provider, Patient and an Additional Participant signed the POC on 04/23/2024. The POC also had an undated RN signature. Review of the corresponding Comprehensive Assessment of the POC revealed it was finalized by: * The RN on 03/27/2024, 22 days prior to the POC meeting date; * The RD on 11/07/2023, 163 days prior to the POC meeting date; and * The MSW on 11/14/2023, 156 days prior to the POC meeting date. Review of the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated as last revised “October 2024” stipulated “The Plan of Care following re-assessments must be completed within 15 days of completing the re-assessment.” During interview on 02/04/2025 at 1215, the MCS confirmed the above findings.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 47148 Based on interview and medical record review, it was determined the facility failed to maintain an accurate medical record for 6 of 6 patient records reviewed (Patients #s 1 - 6). Findings: Review of the medical records for 6 of 6 patients (Patient #s 1 - 6) failed to contain documentation of any progress notes or assessments completed by the RN in the past three months. Review of the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” dated October 2024 stipulated, “The facility’s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse, a physician ... a social worker, and a qualified renal dietitian per CMS ... 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. During an interview with the MCS on 02/04/2025 at 1215, they confirmed the above findings. They stated they were only able to locate one RN assessment/progress note for one of the requested patients listed for medical record review.”