Fresenius Kidney Care Tualatin

“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: 37237 Based on observation and interview, it was determined the facility failed to ensure the building was maintained to ensure the safety of patients, staff and the public. Findings: Observation of the facility on 09/11/2024 beginning at 0910 revealed: - Three D-cell batteries located in the Emergency Light Center box expired in March 2023. - Two “ChemLight Tactical Light” sticks located in the Emergency Light Center box expired in May 2023. - Areas where the floor in the facility could not be cleaned effectively for infection control purposes. * In treatment room #7, there was a gap in the floor where the seams were separating in a section of flooring below the window. *In the hallway there were two areas along the baseboard where the floor had been cut away, leaving unfilled gouges. The CM stated during interview on 09/11/2024 at 1005 that the gouges were due to the removal of a door. *Also in the main hallway, the seams are pulling apart where three flooring types meet. Review of the document titled “Action Plan” that listed the facility’s current QAPI action plans revealed an entry listed under “Update #3 (04/22/2024)” that stated “2 Laminate holes in hallway flooring needing patched. Denied by Corp.” The above findings were confirmed by the CM on 09/11/2024 at 1015.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 37237 Based on review of medical records and review of documentation, it was determined the facility failed to ensure a follow up comprehensive reassessment occurred for 1 of 5 patients (Patient #4) within 90 days of the completion of the initial assessment to provide information to adjust the patient’s plan of care. Findings: Review of Patient #4’s medical record revealed the patient was admitted to the facility on 03/18/2024. The initial 30-day assessment and POC meeting was completed on 04/15/2024. The next POC meeting, 90 days from the initial assessment, should have been on or before 07/14/2024. The POC meeting was held on 09/04/2024, 52 days beyond the 90-day requirement. Review of the facility policy, Comprehensive Interdisciplinary Assessment and Plan of Care,” dated as 07/03/2023 stipulated in the section titled, “CIA and POC for Patients New to Dialysis” that “A follow up CIA must occur within 90 days. The POC should be adjusted as appropriate and implemented with 15 days of reassessment.””

“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: 37237 Based on interview, review patient medical records and review of documentation, it was determined that the facility failed to ensure that 3 of 5 patients’ POCs (Patient #s 1, 3 and 4) were signed by the patient and/or patient’s designee. Findings: Patient #1 Review of Patient #1’s medical record revealed a Plan of Care dated 08/21/2024. The POC was approved by the MD, RN, MSW and RD on 08/21/2024. The facility failed to provide documentation of the patient or patient designee’s signature that signified the patient either attended the meeting, that an IDT member reviewed the POC with the patient or that the patient declined to sign the POC. Review of “RN Home Therapy Progress Note” dated 09/06/2024 revealed the patient had a scheduled clinic visit on 09/06/2024. The facility failed to provide documentation that the POC was reviewed with the patient or patient designee during that visit. - Similar findings were identified for Patent #4. Patient #3 Review of Patient #3’s medical record revealed POCs for the following dates: 02/21/2024, 03/15/2024, 04/15/2024, 05/16/2024, 06/27/2024, 07/16/2024 and 08/20/2024. The patient’s status was listed as unstable during all months listed above except for 02/21/2024 where the patient was listed as stable. The facility failed to provide documentation that the POCs were reviewed by the patient, or patient’s designee, for meetings held on 02/21/2024, 03/15/2024, 04/15/2024, 06/27/2024, 07/16/2024 and 08/20/2024. Review of the facility policy, “Comprehensive Interdisciplinary Assessment and Plan of Care,” dated as 07/03/2023 stipulated in the section titled, “Comprehensive Assessment Participation and Plan of Care Review,” that “The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record.” On 09/11/2024 at 1630, the CM confirmed the lack of the patient’s signature for the plans of care.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 37237 Based on review of patient medical records and review of documentation, it was determined the facility failed to complete or implement an initial plan of care that identified the immediate individual patient care needs for 1 of 5 patients (Patient #1). Findings: Patient #1 was admitted to the facility on 07/08/2024 as an HCCPD patient. Review of Patient #1’s care plan revealed the Initial CIA, Comprehensive Interdisciplinary Assessment, and Plan of Care meeting was completed on 08/21/2024, 44 days after the date of admission. Review of the facility policy, “Comprehensive Interdisciplinary Assessment and Plan of Care,” dated as 07/03/2023 stipulated in the section titled, “CIA and POC for Patients New to Dialysis,” that an initial comprehensive interdisciplinary assessment (CIA) and plan of care (POC) must be conducted on all patients new to dialysis within the later of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session.””