Davita Cape Arago Dialysis

“CFC-PATIENT ASSESSMENT CFR(s): 494.80 This Condition is not met as evidenced by: 37237 Based on interviews, review of medical records and review of documentation, it was determined that the facility failed to ensure that patients received hemodialysis treatments as prescribed, VS monitoring was completed according to facility policy, that an initial comprehensive assessment was conducted within 30 days, that comprehensive assessments were completed annually and that a comprehensive assessment was conducted at least monthly for unstable patients. This condition-level deficiency substantially limits the capacity of the facility to furnish services of an adequate level of quality. Findings: Refer to Tags V503, V516, V519, V520.”

“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: 37237 Based on interview and review of documentation, it was determined the facility failed to conduct exercises to test the emergency plan annually, and to analyze the facility’s response to all drills and to conduct fire drills as required by this regulation and facility policy. Findings: 1. Review of facility emergency preparedness documentation revealed the facility participated in a community-based exercise on 11/01/2023. Documentation of participation in a drill, tabletop exercise or actual emergency event in 2022 was absent. Review of facility policy 4-07-01 titled “Facility Emergency Management Plan,” with a last revision date of October 2023, stipulated “The facility will conduct and/or participate in one (1) exercise to test the facility EMP at least ANNUALLY, conducted on OPPOSITE years (one year full-scale exercise, next year facility-based/exercise of choice.” The policy further stipulated “Documentation is required ... Utilize FACILITY EMERGENCY PLAN ACTIVATION template and document: Event that occurred ... Plan and policies activated ... Evaluation of plan ... Plan revisions required ... Governing Body review.” During interview with the FA on 12/14/2023 at 1430, they confirmed the above findings. 2. Review of the fire drill documentation for 2023 revealed no fire drills were documented for the following: - Any day/shift in Q1. - First or second shift for MWF in Q2. - Second shift for TTS in Q2. - First shift for TTS in Q3. - Second shift for MWF in Q3. Fire drills were yet to be conducted in Q4 of 2023. Review of the undated facility procedure for conducting fire drills revealed, “Fire safety drills are required by CMS to be conducted on a quarterly basis, [sic] with each shift of patients.” During interviews with the FA on 12/13/2022 at approximately 1500, they 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 review of 3 of 6 medical records (Patients #s 1, 3 and 4) and review of documentation, it was determined that the facility failed to ensure that patients received hemodialysis treatments as prescribed and that VS monitoring was completed according to facility policy. Findings: Patient #1 The review of Patient #1’s medical records included 10 treatment flowsheets dated 11/08/2023 through 12/06/2023. The flowsheets revealed the physician’s orders were not followed for 3 of 10 treatments reviewed. Examples included, but were not limited to: - Review of the treatment sheet dated 11/21/2023 revealed treatment was initiated at 0630. * At 0731 VS and patient assessment checks were documented. The next access and face visualization checks were documented 60 minutes later at 0831. * Similar findings were identified for treatment date 11/19/2023. - Review of the treatment sheet dated 11/19/2023 revealed treatment was initiated at 0632 and terminated at 0943. At 0830, the RN charted “blood returned to go to restroom” and at 0858, a PCT charted “treatment continues; time adjusted.” The patient’s prescribed treatment time is 3h 15m. In the “Post-Treatment Vitals” section, the treatment duration was listed as 2h 46m. The treatment was shortened by 29 minutes. There was no AMA for the shortened treatment time. - Review of the treatment sheet dated 11/29/2023 revealed that at 0923 the RN documented “RN treated pt for diarrhea.” Review of the “Medications Administered” section revealed no anti-diarrhea medication was given to the patient. Patient #3 The review of Patient #3’s medical records included 18 treatment flowsheets dated 11/09/2023 through 12/09/2023. The flowsheets revealed the physician’s orders were not followed for 9 of 18 treatments reviewed. Examples included, but were not limited to: - Review of the treatment sheet dated 12/05/2023 revealed treatment was initiated at 0711. * The next access and face visualization checks were documented 83 minutes later at 0834 and not again until 1122 at the termination of treatment, 168 minutes later. *Similar findings were identified for treatment dates 12/2/2023, 11/28/2023, 11/22/2023, 11/20/2023, 11/19/2023, 11/16/2023, 11/14/2023 and 11/11/2023. Similar findings were identified for Patient #4. Review of the facility policy “1-03-08” titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” dated as last revised “April 2023” stipulated “9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: Vital signs and treatment monitoring ... For non-nocturnal treatment is completed at least every thirty (30) minutes ... The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment.””

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 31224 Based on interview and review of clinical records, it was determined that the facility had failed to ensure that an initial comprehensive assessment was conducted on all new patients within 13 hemodialysis treatments or 30 days of admission for 1 of 6 patients (Patient # 6). Findings: Review of Patient 6’s clinical records lacked documentation that a comprehensive assessment had been completed by the IDT within 30 calendar days of admission to the peritoneal dialysis program. The Comprehensive Assessment Report documented the MSW portion was not completed until 36 days after admission and the comprehensive assessment was not finalized until 37 days after admission. Review of Policy 12-16-01 titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated 07/2023, stipulated, “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 ... A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first out patient dialysis treatment or per state guidelines.” During interview with a PD RN at 1210 on 12/13/2023, they confirmed the above findings.”

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) 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- (1) At least annually for stable patients; This Standard is not met as evidenced by: 37237 Based on interviews and review of clinical records, it was determined the facility failed to ensure a comprehensive assessment was conducted at least annually for 3 of 6 patients (Patient #s 1, 2 and 5). Findings: Patient #1 Patient #1 transferred into the facility on 03/08/2023 as an ICHD patient. Review of Patient #1’s clinical records revealed the following finalization dates for each discipline for the comprehensive assessment completed 10/16/2023: - MSW finalized on 07/18/2023. - RD finalized on 06/23/2023. - RN finalized on 10/16/2023. The corresponding POC was finalized 32 days later on 11/17/2023. The facility failed to present documentation that a POC had been completed within 3 months of transfer. Patient #2 Patient #2 was admitted to the facility on 07/20/2020 as an ICHD patient. Review of the clinical records revealed an “IDT Patient POC Meeting Report” dated “IDT POC Meeting Date: 2/16/2022.” The IDT members and the patient signed and dated the document on 02/16/2022. All the assessment documentation included in the POC was dated 04/08/2022. From the documentation presented, the actual finalized POC date could not be determined between the 02/16/2022 date that was signed as the IDT meeting date and assessment documentation dated almost two months later on 04/08/2022. Further review of Patient #2’s clinical records revealed the next POC was finalized 1 year and 10 months later on 11/07/2023. The finalized dates for each discipline for the POC were: - MSW finalized on 06/01/2023. - RD finalized on 04/07/2023. - RN finalized on 11/07/2023. Patient #5 Patient #5, a current HPD patient, was admitted to the facility in 01/2021. Review of Patient #5’s clinical records revealed a comprehensive assessment was completed on 05/12/2023 but was also due for an assessment on 11/25/2023. Review of Patient #5’s Plan of Care dated 11/06/2023 revealed the following finalization dates by each discipline: - MSW finalized on 12/29/2022. - RD finalized on 04/07/2023. - RN finalized on 07/13/2023. - IDT finalized on 11/06/2023. The corresponding comprehensive assessments could not be located. Refer to findings identified in Tag V541 for Patient #5. Review of Policy 12-16-01 titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated as last revised “July 2023,”stipulated, “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 ... A comprehensive re-assessment of each patient and a revision of the plan of care will be conducted ... at least annually for stable patients ...” The policy also stipulated in the section titled “Assessment and Plans of Care for Patient Transferring In” that “If the documents are adequate and the patient is stable, the IDT may conduct a re-assessment within 3 months of admission. The IDT will meet within 15 days of the completion of the re-assessment, finalize the Plan of Care and initiate the Plan.” During interview on 12/13/2023 at 1210, a PD RN confirmed the above findings and was not able to explain the discrepancies with dates of assessments and plan of care.”

“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: 37237 Based on interview and medical record review, it was determined that the facility failed to conduct a comprehensive reassessment at least monthly for unstable patients for 1 of 6 patient records reviewed (Patient #3). Findings: Refer to findings identified in Tag V557.”

“POC-GOALS=COMMUNITY-BASED STANDARDS CFR(s): 494.90 The interdisciplinary team as defined at §494.80 must develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and must include measurable and expected outcomes and estimated timetables to achieve these outcomes. The outcomes specified in the patient plan of care must be consistent with current evidence-based professionally-accepted clinical practice standards. This Standard is not met as evidenced by: 37237 Based on interviews, review of facility policy, and review of patient clinical records, it was determined the facility failed to ensure a plan of care developed by the IDT was specific to meet the identified individual care needs of the patient for 1 of 6 patients (Patient #5) Findings: Patient 5’s clinical records revealed the following: - A Plan of Care corresponding to the 05/12/2023 comprehensive assessment could not be located. - They had challenges with complying with medication administration and diabetes control. - They had been hospitalized several times due to infection at the PD catheter site. - They had been hospitalized on 07/30/2023 through 08/01/2023 for infection at the PD catheter site with a rehospitalization occurring on 11/02/2023 through 11/06/2023 for the same concern. Review of Patient 5’s Plan of Care dated 11/06/2023 did not identify or address patient challenges with diabetes control, adherence to medication regimen, or infection control concerns related to infections of the PD catheter site. Additionally, it revealed the following finalization dates by each discipline: - MSW finalized on 12/29/2022. - RD finalized on 04/07/2023. - RN finalized on 07/13/2023. - IDT finalized on 11/06/2023. Review of Policy 12-16-01 titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated as last revised “July 2023,” stipulated: * “The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient’s needs, as identified by the comprehensive assessment and changes in the patient’s condition, and will include measurable and expected outcomes and estimated timetables to achieve these outcomes.” * “If applicable, the peritoneal dialysis catheter will be monitored to include assessment of the exit site and tunnel for condition and absence of infection and for patency and function.” During interview on 12/13/2023 at 1210, a PD RN was asked about challenges Patient 5 faced. The PD RN reported that compliance/adherence to the medication regimen was a challenge and that they faced greater complications from diabetes compared to others of the same age due to lack of adequate diabetes management. The PD RN reported these areas had shown improvement but remain concerns. The PD RN also noted challenges with keeping the PD catheter site clean due to pets and other factors in the home. When asked how these challenges were reflected in the patient’s plan of care, the PD RN confirmed they were not addressed. Refer to findings identified in Tag V519.”

“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 6 patients (Patient #3). Findings: Patient #3 was admitted to the facility on 01/25/2023 as an ICHD patient. Review of the clinical records revealed a Plan of Care finalized on 11/07/2023. The finalized dates for each discipline for the POC were: - MSW finalized on 02/17/2023. - RD finalized on 03/24/2023. - RN finalized on 11/07/2023. The facility failed to present documentation that an initial assessment and POC were completed within 30 days of admission or 13 hemodialysis treatments. There was also no 90-day reassessment documentation presented. Further review of the “Patient Plan of Care” dated 11/07/2023 listed the patient’s status as “Unstable.” The facility failed to present documentation that identified why the patient was listed as unstable. The facility also failed to present a plan of care or comprehensive assessment done within 30 days after the patient was identified as unstable on 11/07/2023. Review of Policy 12-16-01 titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” dated as last revised “July 2023,” stipulated “4. A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines ... 5. A follow up 90 day re-assessment will be completed to evaluate patient’s status and provide information to adjust the patient’s plan of care ... 7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted ... At least monthly for unstable patients ...””