Fkc Northeast Philadelphia

“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: 45377 Based on observations (OBS) of the in-center treatment (ICTX) area and interviews with the director of operations and clinical manager, the facility failed to remove expired medications and supplies from the ICTX area for one (1) of three (3) observations (OBS): OBS#2. Findings include: Facility Policy Storage of Supplies and Supply Expiration Dates for Inpatient Services, Reference Number: 47588, Version 4 reviewed on August 5, 2025 at approximately 8:00 AM reads in part, “Supplies will be rotated First-in-First-out (FIFO) to ensure products maintain quality and to monitor expiration dates. Any item that is expired, damaged ....will be removed from stock and disposed of appropriately.” OBS #2 of the in-center treatment area conducted August 4, 2025 from 2:15 PM to 3:00 PM revealed the following: OBS #2 Medication Cart located at the nurses’ station contained one (1) bottle Cinacalcet HCl (Hydrochloride) 30 mg (milligram) tablets, lot #PB30221, expired 02/2025; eleven (11) tablets were in the container; and one (1) bottle Cinacalcet HCL 30 mg tablets, lot #PB30586, expired 07/2025. Twenty-five (25) tablets were in the container. Left cabinet above clean sink (cabinets to the right of the crash cart) contained four (4) unopened bottles Cinacalcet HCl 30 mg tablets (30 tablets in each container). Three containers had the same lot #PB30221 and expiration date: 02/2025, and one container had lot #PB30586, expiration date: 07/2025. Medication Refrigerator contained one (1) single dose 0.5 ml (milliliter) Influenza Vaccine Flucelvax 2024-2025 Formula, lot #391315, expired: 06/30/2025. Emergency Evacuation Boxes (top box) contained forty-five (45) 2x2 sterile sponges, lot #91607-1, use by date: 03/2025. All expired medications and supplies were given to the charge nurse on duty. An interview conducted with the director of operations and clinical manager on August 6, 2025 starting at 3:30 PM confirmed the above findings.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 45377 Based on review of facility policies and procedures, medical records (MR), dialysis treatment documentation, and an interview with the director of operations and clinical manager, the facility did not follow its policy for monitoring during hemodialysis treatment (HDTX) for six (6) of six (6) in-center medical records reviewed: MR#1, MR#2, MR#3, MR#4, MR#5 and MR#6. Findings include: Facility Policy 5008X Patient Assessment and Monitoring, Reference Number 64462, Version 3 reviewed on August 5, 2025 at approximately 9:30 AM reads in part, “Monitoring During Treatment: Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations .....Check machine settings and measurements. Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow. Record KECN value with 30 minute safety checks.” A review of medical records and hemodialysis treatment (HDTX) records was conducted on August 6, 2025 starting at approximately 7:45 AM, and again on August 7, 2025 starting at approximately 8:00 AM. The admission date (AD) is below. MR#1 AD 04/30/2025: HD Treatment (HDTX) Record Review: 07/21/2025: HDTX was initiated at 6:13 AM. Documentation of KECN values (a measure used to determine the adequacy of the dialysis treatment) occurred at 6:58 AM, 7:33 AM, 8:02 AM, and 9:32 AM. The interval between 8:02 AM and 9:32 AM was 90 minutes which exceeded the monitoring threshold per facility policy. 07/23/2025: HDTX was initiated at 6:14 AM. Documentation of KECN values occurred at 6:36 AM, 7:01 AM, 8:00 AM, 8:29 AM, and 9:00 AM. The interval between 7:01 AM and 8:00 AM was 59 minutes which exceeded the monitoring threshold per facility policy. 07/25/2025: The HD prescription contained an order for a blood flow rate (BFR) of 400 mL (milliliters)/m (minute). Treatment was initiated at 6:20 AM. BFR was 200 mL/min and remained at 200mL/min until the end of the treatment at 9:32 AM. The RN evaluation note at 6:38 AM states that machine settings were verified. There was no documentation as to the reason for the change in BFR. 07/28/2025: HDTX was initiated at 6:03 AM. Documentation of KECN value occurred at 7:05 AM only which was not in accordance with facility policy. 08/01/2025: HDTX was initiated at 6:15 AM. Documentation of KECN value occurred at 7:00 AM only which was not in accordance with facility policy. MR#2 AD 01/08/2024: HD Treatment Record Review 07/24/2025: : The HD prescription contained an order for a blood flow rate (BFR) of 400 mL (milliliters)/m (minute). Treatment was initiated at 12:28 PM. BFR 12:31 PM = 350 mL/m, then decreased to 300 mL/m at 1:06 PM and remained at 300mL/min until the end of the treatment (3:03 PM). The RN evaluation note at 12:45 PM states that HD orders and machine setup checked and verified. There was no documentation as to the reason for the change in BFR. 07/26/2025: HDTX was initiated at 12:37 PM. Documentation of KECN values occurred at 12:58 PM and 1:35 PM. There was no further documentation of KECN values which was not in accordance with facility policy. 07/28/2025: The HD prescription contained an order for a BFR 400 mL/m. Treatment was initiated at 5:00 PM. BFR 350 mL/m at 5:00 PM, then decreased to 300 mL/m at 6:06 PM and remained at 300mL/min until the end of the treatment (7:45 PM). There was no documentation as to the reason for the change in BFR. Documentation of KECN value occurred at 6:06 PM only which was not in accordance with facility policy. 07/29/2025: The HD prescription contained an order for a BFR 400 mL/m. Treatment was initiated at 12:11 PM. BFR 280 mL/m at 12:12 PM. BFR remained at 280 mL/m until the end of treatment at 3:22 PM. There was no documentation as to the reason for the change in BFR. No KECN values were recorded. 08/02/2025: The HD prescription contained an order for a BFR 400 mL/m. Treatment was initiated at 12:42 PM. BFR 350 mL/m at 12:43 PM and remained at that rate until 2:32 PM at which time the BFR was decreased to 300 mL/m. Treatment ended at 3:02 PM. There was no documentation as to the reason for the change in BFR. MR#3 AD 05/10/2024: HD Treatment Record Review 07/21/2025: HDTX was initiated at 7:15 AM. Documentation of KECN values occurred at 8:01 AM, 9:02 AM, and 10:04 AM which was not in accordance with facility policy. 07/25/2025: HDTX was initiated at 7:00 AM. Documentation of KECN values occurred at 8:31 AM and then not again until 9:38 AM which was not in accordance with facility policy. 07/30/2025: HDTX was initiated at 7:10 AM. Documentation of KECN values occurred at 8:04 AM, 8:32 AM and then not again until 9:02 AM and 10:03 AM which was not in accordance with facility policy. 08/04/2025: HDTX was initiated at 7:20 AM. Documentation of KECN values occurred at 8:01 AM, and then not again until 9:02 AM which was not in accordance with facility policy. MR#4 AD 06/16/2020: HD Treatment Record Review 07/21/2025: HDTX was initiated at 11:30 AM. Documentation of KECN values occurred at 12:04 PM, 12:32 PM, and then not again until 2:05 PM and 3:00 PM which was not in accordance with facility policy. 07/23/2025: The HD prescription contained an order for a blood flow rate (BFR) of 400 mL (milliliters)/m (minute). Treatment was initiated at 11:52 AM. BFR was 430 mL/min and remained at 430 mL/min until the end of the treatment at 4:22 PM. he RN evaluation note at 12:00 PM states that machine settings were verified. There was no documentation as to the reason for the change in BFR. 07/25/2025: HDTX was initiated at 11:31 AM. Documentation of KECN value occurred at 12:03 PM only which was not in accordance with facility policy. 07/30/2025: HDTX was initiated at 12:30 PM. Documentation of KECN values occurred at 1:01 PM, 1:33 PM, and then not again until 3:32 PM which was not in accordance with facility policy. MR#5 AD 12/15/2023: HD Treatment Record Review 07/23/2025: HDTX was initiated at 14:11 PM. No KECN values were recorded during the entire treatment. 07/25/2025: HDTX was initiated at 14:11 PM. Documentation of KECN value occurred at 4:37 PM only which was not in accordance with facility policy. 07/28/2025: HDTX was initiated at 2:13 PM. Documentation of KECN values occurred at 3:08 PM, 3:32 PM, 4:07 PM, and then not again until 5:37 PM which was not in accordance with facility policy. 08/01/2025: HDTX was initiated at 2:16 PM. Documentation of KECN values occurred at 2:45 PM, 3:09 PM and then not again until 4:10 PM which was not in accordance with facility policy. MR#6 AD 04/12/2024: HD Treatment Record Review 07/23/2025: HDTX was initiated at 4:11 PM. Documentation of KECN values occurred at 5:05 PM then not again until 6:04 PM which was not in accordance with facility policy. 07/25/2025: HDTX was initiated at 4:03 PM. Documentation of the first KECN value occurred at 6:05 PM which was not in accordance with facility policy. Treatment ended at 8:02 PM. 08/01/2025: HDTX was initiated at 4:01 PM. Documentation of the first KECN value occurred at 6:02 PM, and then not again until 7:03 PM which was not in accordance with facility policy. An interview conducted with the director of operations and clinical manager on August 6, 2025 starting at 3:30 PM confirmed the above findings.”

“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: 45377 Based on a review of facility policies, medical records (MR), and interviews with the home therapy nurse, director of operations, and clinical manager, the facility failed to assure that an initial plan of care occurred within 30 calendar days after admission to the dialysis facility for one (1) of nine (9) MR’s reviewed: MR#9. Findings include: Facility Policy Home Dialysis Patient Education and Training Guidelines, Reference Number 15598, Version 6 reviewed on August 5, 2025 at 3:10 PM states in part, “Completion of the initial Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC) must be completed within 30 days or 13 treatments of the patient’s admission according to the Comprehensive Interdisciplinary Assessment and Plan of Care policy, regardless of when the patient begins contiguous modality training.” Facility Policy Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC), Reference Number 45283, Version 6 reviewed on August 5, 2025 reviewed on August 5, 2025 at 3:30 PM reads in part, “CIA and POC for Transfers or Transients: If the comprehensive patient assessment and plan of care for an experienced dialysis patient transferring from one dialysis facility to another is received with the patient in transfer, the receiving facility’s IDT must conduct a reassessment within three months of the patient’s admission to the new facility. If a patient is transferring dialysis facility and the transferring facility has NOT provided a current CIA and POC, the receiving facility must complete a CIA and POC within 30 days of admission....patients changing modality are classified as new patients and must have comprehensive interdisciplinary assessment and plans of care completed with the same frequency as patients new to dialysis. The timeline for both the completion of the initial comprehensive assessment and the beginning of implementation of the initial plan of care is the latter of 30 days from the date of admission or 13 treatments at the facility. A follow-up CIA must occur within 90 days. The POC should be adjusted as appropriate and implemented within 15 days of reassessment.” A review of medical records and dialysis treatment (TX) records was conducted on August 6, 2025 starting at approximately 7:45 AM, and again on August 7, 2025 starting at approximately 8:00 AM. The admission date (AD) is below. MR#9 AD 06/03/2025 was transferred and admitted to BMA of Northeastern Philadelphia (receiving facility) from an out of State Fresenius dialysis center on 06/03/2025. The MR contained a POC dated 07/30/2025. The POC noted that the last POC meeting was held at the previous facility on 03/24/2025 due to the patient’s change in modality to peritoneal dialysis (PD) on/around 03/05/2025. There was no 90 day reassessment after the 03/24/2025 POC due to the patient’s transfer from the out of State dialysis center. The POC meeting dated 07/30/2025, which occurred at the receiving facility, was classified as an Initial CIA. The interval for the next meeting was 90 days, scheduled for 10/28/2025. The CIA and POC were not completed within 30 days of admission to the receiving facility. An interview conducted with the director of operations and clinical manager on July 6, 2025 starting at 3:30 PM confirmed the above findings.”

“H-IDT OVERSEES HOME TRAINING CFR(s): 494.100(a) The interdisciplinary team must oversee training of the home dialysis patient, the designated caregiver, or self-dialysis patient before the initiation of home dialysis or self-dialysis (as defined in §494.10) and when the home dialysis caregiver or home dialysis modality changes. This Standard is not met as evidenced by: 45377 Based on a review of facility policy, medical records (MR), and interviews with the home training nurse, director of operations and clinical manager, the facility failed to provide evidence of competency for home dialysis for one (1) of three (3) home dialysis MR’s reviewed: MR#9. Findings include: Facility Policy Home Dialysis Patient Education and Training Guidelines, Reference Number 15598, Version 6 reviewed on August 5, 2025 at 3:00 PM states in part, “Transfer of Trained Home Therapies Patients: The receiving facility must verify the competency of the patient, and if applicable care partner, to safely perform home dialysis .....Training treatments will be documented in the medical record. Patient and care partner (if applicable) training and competency of required material and performing home dialysis procedures must be documented in the patient medical record.” An interview with PF#4 occurred on August 5, 2025 at approximately 3:20 PM. PF#4 noted that a home Continuous Ambulatory Peritoneal Dialysis (CAPD) patient (MR#9) had been transferred into the facility from an out of state Fresenius dialysis location. PF#4 stated that s/he contacted the transferring facility and spoke with the nurse to confirm that the patient had received training and was competent to perform home dialysis. An interview with PF#4 on August 6, 2025 at approximately 1:00 PM reiterated the same information as noted above. In addition, PF#4 stated that MR#9 does not have a care partner. A review of medical records and dialysis treatment (TX) records was conducted on August 6, 2025 starting at approximately 7:45 AM, and again on August 7, 2025 starting at approximately 8:00 AM. The admission date (AD) is below. MR#9 AD 06/03/2025. The patient transferred into BMA of Northeastern Philadelphia (receiving facility) from an out of state Fresenius facility. There was no evidence of, or documentation provided, that the receiving facility verified the competency of the patient to safely perform home dialysis upon transfer into the facility per facility policy. An interview with the director of operations and clinical manager on August 6, 2025 starting at 3:30 PM confirmed the above findings.”

“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: 45377 Based on a review of facility policies, medical records (MR), and interviews with the home therapy nurse, director of operations, and clinical manager, the facility failed to assure that self-monitoring data and other information from self-care patients or their designated caregivers was retrieved and reviewed by the facility for one (1) of three (3) MR’s reviewed: MR#9. Findings include: Facility Policy PD Home Patient Responsibility Consent, Reference Number 23544, Version 6 reviewed August 6, 2025 at 3:50 PM reads in part, “Maintain accurate home treatment records (electronic and/or paper) and equipment logs and bring them with me for review during my monthly clinic visit.” Facility Policy Home Therapies Patient Treatment Record Keeping, Reference Number 47992, Version 2 reviewed on August 5, 2025 at 3:50 PM states in part, “Home treatment records will be reviewed by the home therapy registered nurse during patient monthly clinic visits to identify trends, errors or omissions, and other issues or concerns to be addressed with the patient and/or care partner.” Facility Policy Review and Documentation of Home therapies Patient Health Data, Reference Number 23557, Version 4 reviewed on August 5, 2025 at 3;55 PM reads in part, “In instances in which the patient is not transmitting any data electronically or via portable device, whether intermittently due to patient choice or as the result of connectivity issues, they may be required to document treatment data via paper flowsheets and regularly provide the flowsheets for review by the home therapies nurse....At a minimum, the home therapies nurse will perform a comprehensive monthly review of all treatment data, regardless of the method of data submission. Data review will be discussed with the patient and/or care partner during the patient’s regular clinic visit and concerns will be addressed and documented accordingly.” Facility Policy Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC), Reference Number 45283, Version 6 reviewed on August 5, 2025 reviewed on August 5, 2025 at 3:30 PM reads in part, “Patient stability must be reviewed monthly. The interdisciplinary team will offer input to the attending physician who will determine whether the patient is stable or unstable on the criteria included in this policy...Failure to Achieve Plan of Care Outcome: if the patient specific expected outcome as determined by the attending physician, IDT and patient for the POC is not achieved within the identified timeframe, the IDT must adjust the patient’s POC and document changes made to the POC and implement the POC changes to address the identified needs.” An interview was held with PF#4 on August 6, 2025 at approximately 1:00 PM. PF#4 stated that MR#9 is to complete paper flowsheets with each continuous ambulatory peritoneal dialysis (CAPD) treatment, does not have a care partner (lives alone) and that MR#9 is not compliant with monthly clinic visits. PF#4 stated that MR#9 came to the facility in July for labwork but did not attend the monthly clinic visit. A review of medical records and dialysis treatment (TX) records was conducted on August 6, 2025 starting at approximately 7:45 AM, and again on August 7, 2025 starting at approximately 8:00 AM. The admission date (AD) is below. MR#9 AD 06/03/2025 did not contain any CAPD flowsheets from 06/03/2025 to 08/06/2025 for review. The patient attended clinic with a family member on 06/20/2025. An RN note dated 06/20/2025 stated, “S/he was given flowsheets at initial visit but did not bring in any flowsheets. Unable to assess what s/he does at home. BP (blood pressure) is high; s/he admits to missing doses. Reinforced the importance of documenting vital signs to give him/her insight on how body is functioning.” A physician note dated 06/20/2025 stated, “Patient is not adhering to prescription.” The patient was seen at the dialysis clinic on 7/16/2025 but apparently did not stay for the clinic visit. An RN note dated 06/20/2025 stated, “S/he is not documenting treatments. S/he has been given flowsheets. S/he states it does not look like the one s/he is used to and s/he cannot see well.” The RN review further noted that patient data was not available for review and that treatment data was not complete and satisfactory.” The plan of care dated 07/30/2025 did not address the patient’s non-compliance with providing flowsheets for patient monitoring. An interview conducted with the director of operations and clinical manager on August 6, 2025 starting at 3:30 PM confirmed the above findings.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 45377 Based on review of facility policies and procedures, medical records (MR), dialysis treatment documentation, and an interview with the home therapy nurse, director of operations and clinical manager, the facility did not follow its policy for monitoring during treatment for two (2) of nine (9) treatment records reviewed: MR#4 and MR#5, and did not follow its policy for managing home dialysis (HoD) patients for one (1) of three (3) HoD records reviewed; MR#9. Findings include: Facility Policy 5008X Patient Assessment and Monitoring, Reference Number 64462, Version 3 reviewed on August 5, 2025 at approximately 9:30 AM reads in part, “ Monitoring During Treatment: Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes or per state regulation. Document machine parameters and safety checks every 30 or more often as needed but not to exceed 45 minutes or per state regulations.” Facility Policy Documenting Progress Notes, Transfers, Transplants, Discharges and Order Review, Reference Number 46934, Version 6 states in part, “Progress/clinical note documentation should provide a picture of the patient’s care, including response to treatment, change in condition and changes in treatment. Progress notes shall be written as necessary or according to state requirements to document the condition and care of the patient.” Facility Policy Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC), Reference Number 45283, Version 6 reviewed on August 5, 2025 reviewed on August 5, 2025 at 3:30 PM reads in part, “Patient stability must be reviewed monthly. The interdisciplinary team will offer input to the attending physician who will determine whether the patient is stable or unstable on the criteria included in this policy...Failure to Achieve Plan of Care Outcome: if the patient specific expected outcome as determined by the attending physician, IDT and patient for the POC is not achieved within the identified timeframe, the IDT must adjust the patient’s POC and document changes made to the POC and implement the POC changes to address the identified needs.” Facility Policy Home Dialysis Patient Education and Training Guidelines, Reference Number 15598, Version 6 reviewed on August 5, 2025 at 3:00 PM states in part, “Transfer of Trained Home Therapies Patients: The receiving facility must verify the competency of the patient, and if applicable care partner, to safely perform home dialysis .....Training treatments will be documented in the medical record. Patient and care partner (if applicable) training and competency of required material and performing home dialysis procedures must be documented in the patient medical record.” Facility Policy PD Home Patient Responsibility Consent, Reference Number 23544, Version 6 reviewed August 6, 2025 at 3:50 PM reads in part, “I understand and agree that I must adhere to the following requirements in order to be qualified to receive treatment as an FKC (Fresenius Kidney Care) home peritoneal dialysis patient and that failure to comply with the patient responsibilities may result in the re-evaluation of my ability to perform home dialysis. Failure to comply with these responsibilities could place me at serious risk. Therefore, my provider and the interdisciplinary team (IDT) may decide that another kind of dialysis treatment is better for ensuring my safety and well-being: Maintain accurate home treatment records (electronic and/or paper) and equipment logs and bring them with me for review during my monthly clinic visit.” Facility Policy Home Therapies Patient Treatment Record Keeping, Reference Number 47992, Version 2 reviewed on August 5, 2025 at 3:50 PM states in part, “Home treatment records will be reviewed by the home therapy registered nurse during patient monthly clinic visits to identify trends, errors or omissions, and other issues or concerns to be addressed with the patient and/or care partner.” Facility Policy Review and Documentation of Home therapies Patient Health Data, Reference Number 23557, Version 4 reviewed on August 5, 2025 at 3;55 PM reads in part, “In instances in which the patient is not transmitting any data electronically or via portable device, whether intermittently due to patient choice or as the result of connectivity issues, they may be required to document treatment data via paper flowsheets and regularly provide the flowsheets for review by the home therapies nurse....At a minimum, the home therapies nurse will perform a comprehensive monthly review of all treatment data, regardless of the method of data submission. Data review will be discussed with the patient and/or care partner during the patient’s regular clinic visit and concerns will be addressed and documented accordingly.” A review of the Fresenius Kidney Care template document titled “Find the right dextrose (sugar) solution for you” was reviewed on 08/06/2025 at 3:10 PM. The document is intended to be completed by the facility, in conjunction with the patient, to provide guidance to the patient as to the concentration of dextrose to be used, based on blood pressure (BP), weight, swelling, or the presence or absence of shortness of breath.” Dextrose concentrations of 1.5%, 2.5% or 4.25% are chosen based on the above parameters. A concentration of 1.5% dextrose removes the least amount of fluid, while a concentration of 4.25% removes the most amount of fluid. An interview was conducted with PF#4 on 08/06/2025 at approximately 3:20 PM. PF#4 was asked if s/he knew which concentration of dextrose MR#9 was using since no flowsheets were provided by the MR#9. PF#4 responded that s/he believed that MR#9 was using “mostly 1.5% dextrose.” A review of medical records and dialysis treatment (TX) records was conducted on August 6, 2025 starting at approximately 7:45 AM, and again on August 7, 2025 starting at approximately 8:00 AM revealed the following: MR#2 AD 01/08/2024 was admitted to the hospital on 04/28/2025 due to problems with the permacath (catheter used for dialysis). The patient was found to be fluid overloaded during this hospitalization. Discharge date was unknown. The patient was readmitted to the hospital 05/31/2025 to 06/04/2025 due to shortness of breath. The MR contained a plan of care (POC) meeting date of 11/29/2024 at which time the patient was declared stable. Next POC meeting date was scheduled for 11/29/2025. A comprehensive physician note dated 06/12/2025 stated that the patient was not stable, underdialyzed and fluid overloaded despite orders for HD treatments 4 times per week. The note also stated that the patient was not compliant with the treatment frequency due to either missed treatments or shortened treatments (coming late to treatments). The HD prescription was last updated 06/18/2025. A basic physcian note dated 07/01/2025 stated that the patient was not stable. A comprehensive physician note dated 07/29/2025 stated that the patient was not stable, continued to be underdialyzed, fluid overloaded, and not consistently adherent to the dialysis treatment schedule. There was no evidence that the POC was adjusted and changed due to the patient not achieving the expected outcome and the physicians’ notes indicating continued instability. There were no progress notes after 06/19/2025 from other members of the IDT addressing the patient’s non-compliance to treatment times. MR#4 AD 09/16/2020 Hemodialysis (HD) Treatment Date 07/23/2025 found that treatment was started at 11:52 AM. Vital signs were documented every 30 to 45 minutes except for the time frame between 2:38 PM and 3:33 PM whereby the interval between vital sign monitoring was 55 minutes which exceeded facility policy. MR#5 AD 12/15/2023 HD Treatment Date 08/01/2025 found that treatment was started at 2:16 PM. Vital signs were documented every 30 to 45 minutes except for the time frame between 3:09 PM and 4:10 PM whereby the interval between vital sign monitoring was 61 minutes which exceeded facility policy. MR#9 AD 06/03/2025. The patient began continuous ambulatory peritoneal dialysis (CAPD) around 03/2025 at an out of State dialysis center and was transferred and admitted to BMA of Northeastern Phila (facility) on 06/03/2025. There was no evidence that the facility conducted or verified competency to perform CAPD upon transfer. The CAPD prescription was last updated 06/02/2025. The CAPD order noted the following: # Exchanges: 2. Days per week: 7. Daytime fill volume: 2500 mL (milliliters). Nighttime fill volume: 2500 mL. Minimum dwell time: 8 hours, 0 minutes. EDW (estimated dry weight): 68 kg (kilograms). Dextrose: 1.5% or 2.5% or 4.5%. There was no completed or customized “Find the right dextrose solution for you” document provided or in the MR to establish which dextrose concentration the patient should be using with each treatment, based on the formerly noted parameters. There were no CAPD flowsheets provided or contained in the MR for review, for the time frame 06/03/2025 (admission date) to 08/06/2025 (survey exit date). A review of the treatment history found that the patient’s weight progressively increased over a 4 month period: April (70 kg), May (74 kg), June (77.3 kg), July (80.2 kg). Kt/V Peritoneal (a measure used to assess dialysis adequacy) was 0.97 (target is 1.7) in June 2025; previous Kt/V in March 2025 (prior to transfer) was 2.07. The patient attended a monthly clinic visit on 06/20/2025 with a family member. The physician note stated, “First visit. Does 2 exchanges daily. No RRF (residual renal function). Not enough. Inc (increase) to 3 (exchanges) with 2.5L (liters). BP high, BP rx (medication regimen) adjusted. Add Valsartan (an antihypertensive) 80 mg daily.” The physician further documented the following: patient is not adhering to prescription; adequacy target was not met - prescription change discussed with staff and patient; changes to plan of care made in orders; prescription reviewed with patient and daughter. Eventual increase to 4x (4 exchanges per day). The physician documented that the patient was stable and high blood pressure was noted. There was no exam documented, i.e., pulmonary, edema, cardiovascular, feet. The patient also interacted with PF#4 on 06/20/2025 during the monthly clinic visit. Recorded BP’s were 253/125 (sitting) and 249/133 (standing). Asymptomatic. PF#4 noted that no patient data was available for review and treatment data was not complete or satisfactory, further commenting, “s/he was given flowsheets at initial visit but did not bring in any flowsheets. Unable to assess what s/he does at home. BP is high. S/he admits to missing doses. Reinforced the importance of documenting vital signs to give insight on how body is functioning.” Exam by PF#4 revealed 1+ (2mm or less) ankle edema (fluid), decreased breath sounds. A note by PF#5 on 06/20/2025 found that MR#9 stated that s/he had caregiver support to assist with daily care, but the caregiver did not live with MR#9. MR#9 came to the dialysis clinic on 7/16/2025 for lab work but did not attend the monthly clinic visit. An RN note dated 7/16/2025 recorded a sitting BP 206/115, and standing BP 159/107. There was no documentation that the physician was notified of the blood pressure readings especially given that the patient had been started on an additional antihypertensive the month prior. The RN note recorded that MR#9 was “having vision issues, was not documenting treatments, had been given flowsheets,” and MR#9 stated that “the flowsheets did not look like the one s/he was used to and s/he cannot see well.” A plan of care meeting was held on 07/30/2025. Documentation by PF#4 in the POC on 07/25/2025 found the following interventions: “Increase dialysis time (MD order) (PD); Increase volume (MD order).” PF#4 noted: “Poor eye sight” and “s/he has not met PD adequacy. S/he is resisting the education to increase PDF (peritoneal dialysis fluid) volume).” There was no mention in the POC meeting dated 07/30/2025 of MR#9 being non-compliant with providing PD flowsheets for review, nor attendance at the most recent clinic visit, especially since continual monitoring of treatment adherence and effectiveness was otherwise absent except for lab values. There was also no discussion in the POC meeting minutes of possible alternative strategies to address the non-compliance such as modifying the PD flowsheet to accommodate the patient’s poor vision, changing the modality given the inability to effectively monitor the safety and well-being of the patient (and given that the patient lived alone), and/or contacting the end stage renal disease (ESRD) network for assistance with non-compliance. There was no evidence that consideration was given to establishing the patient as unstable. While the physician and RN both noted that a prescription change was made to increase the dialysis exchanges from 2 exchanges to 3 exchanges per day, the last prescritpion was dated 06/02/2025 and contained orders for only 2 exchanges. Likewise, an order printed on 08/06/2025 continued to show that only 2 exchanges were ordered. The patient was hospitalized as of 08/03/2025 due to fluid overload. An interview conducted with the director of operations and clinical manager on August 6, 2025 starting at 3:30 PM confirmed the above findings.”