Usrc Pottstown

“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: 37972 Based on a review of the facility emergency preparedness plan, facility policy, staff training records, and an interview with facility staff, the facility did not document quarterly staff emergency preparedness training in accordance with facility policy. Findings included: A review of the facility emergency preparedness program was conducted on May 13, 2024, at approximately 3:00 P.M. A review of facility policy #C-EM-0062 titled “Emergency Preparedness Training” was conducted on May 13, 2024, at approximately 3:30 P.M. stated: “PROCEDURE: ... 2. Training Program must include the following: a. Staff training: ... ii. Facility-specific emergency preparedness will be reviewed quarterly by the Facility administrator and/or designee with ALL staff including per-diem/PRN (as needed) staff and physicians/physician extenders...” A review of facility documentation revealed that the last quarterly staff emergency preparedness training was conducted on November 4, 2019. An interview with the Facility Administrator, the Clinical Specialist, the Director of Clinical Services, the Area Manager for Home Therapies, and the Director of Home Therapies on May 13, 2024, at approximately 3:45 P.M. confirmed the above findings.”

“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: 37972 Based on review of facility policies, in-center hemodialysis treatment area observations (OBS), and an interview with the facility staff, the facility failed to ensure the staff followed infection control protocols during two (2) of three (3) Central venous catheter (CVC) exit site care observations (OBS), (OBS #15 and 16); during the initiation of dialysis with a CVC for two (2) of three (3) OBS (OBS #10 and 16); during the discontinuation of dialysis with a CVC for one (1) of two (2) OBS (OBS #3); during initiation of dialysis with an AV fistula or graft for one (1) of two (2) OBS (OBS #1) and during discontinuation of dialysis with an AV fistula or graft for two (2) of two (2) OBS (OBS #6 and 11). Findings included: Review of Policy # C-IC-0060 titled “Hand Hygiene” on May 13, 2024, at approximately 3:15 P.M. stated, “Hand Hygiene will be performed: 1. Before and after touching a patient... 3. Prior to contact with vascular access site... 6. Before clean/aseptic procedure (e.g., vascular access cannulation/decannulation, catheter care or administration of parenteral medications)... 11. After contact with inanimate objects, including medical equipment or environmental surfaces at the patient station... 13. When moving from a contaminated body site to a clean body site of the same patient...” Review of Policy # C-TI-0070 titled “Dialysis Catheter Dressing Change Procedure” on May 13, 2024, at approximately 3:20 P.M. stated, “PROCEDURE: 3. Secure clothing away from dressing/exit site... 5. Remove and discard old exit site dressing. Remove gloves, perform hand hygiene and don clean gloves... 8. Using aseptic technique, cleanse the skin surrounding the exit site with the appropriate skin antiseptic... 9. Using aseptic technique, apply appropriate dressing to exit site... 10. Remove gloves, perform hand hygiene...” Review of Policy # C-TI-0090 titled “Accessing and De-Accessing the Dialysis Catheter” on May 13, 2024, at approximately 3:25 P.M. stated, “PROCEDURE: ... 2. Follow policy C-TI-0070 for Dialysis Catheter Dressing Change Procedure... 4. Remove gloves, perform hand hygiene and don clean gloves. 5. Place the underpad beneath the catheter lumens. 6. Hub disinfection: NOTE: Any time the catheter is disconnected from the bloodlines or caps are removed/applied... Clean the sides (threads) and end of hub thoroughly with friction, making sure to remove any residue (e.g. blood); do not drop the hub or allow hub to touch non-sterile surfaces to prevent contamination... a. Using aseptic technique, grasp the catheter and remove cap from the port... never leave an uncapped catheter unattended. b. Disinfect the hub with an alcohol prep pad with the other hand. Scrub the end of the hub and sides (threads) thoroughly with friction, making sure to remove any residue... d. Attach a 3mL (milliliter) or 10 mL syringe to the port. e. Repeat for 2nd hub. **Leave hubs “open” (e.g., uncapped and disconnected ) for the shortest time possible. Once disinfected, do not allow catheter hubs to touch non-sterile surfaces.” Observations in the in-center hemodialysis treatment area on May 7, 2024, from approximately 9:30 A.M. to 12:30 P.M. and May 9, 2024, from approximately 10:00 A.M. to 12:00 P.M. revealed the following: OBS #1, Station #16, on May 7, 2024, at 9:40 A.M., PCT (patient care technician) #1 was observed completing initiation of dialysis on patient (PT) #1 with an AV fistula. After initiation of dialysis, PCT #1 did not change gloves, perform hand hygiene and don new gloves before touching the dialysis machine. OBS #3, Station #17, on May 7, 2024, at 10:02 A.M., PCT #1 was observed discontinuing dialysis on PT #2 with a central venous catheter (CVC), without placing a clean field under the CVC ports prior to the procedure. OBS #6, Station #12, on May 7, 2024, at 10:30 A.M., RN (registered nurse) #1 was observed discontinuing dialysis on PT #4 with an AV fistula. RN #1 reinfused the blood from the circuit, touched the dialysis machine and removed the blood pressure (BP) cuff. RN #1 did not change gloves, perform hand hygiene and don new gloves before removing the dialysis needles and applying a dressing to the site. OBS #10, Station #16, on May 7, 2024, at 10:54 A.M., PCT #1 was observed performing hand hygiene, donning gloves, touching the dialysis machine. PCT #1 did not remove gloves, perform hand hygiene and don new gloves prior to performing disinfection of the CVC catheter hubs, connection of the dialysis lines, and initiation of dialysis. OBS #11, Station #10, on May 7, 2024, at 11:05 A.M., RN #1 was observed discontinuing dialysis on PT #7 with an AV fistula. RN #1 reinfused the blood from the circuit, touched the dialysis machine and removed the blood pressure (BP) cuff. RN #1 did not change gloves, perform hand hygiene and don new gloves before removing the dialysis needles and applying a dressing. OBS #15, Station # 5, on May 7, 2024, at 11:38 A.M., PCT # 4 was observed performing CVC exit site care on PT #8. PCT #4 cleansed the exit site with antiseptic, left the area open to air with PT #8’s shirt collar directly above the open catheter exit site. PCT #4 completed the disinfection of the catheter hubs and connection of the dialysis lines prior to applying the dressing to the exit site, leaving the catheter exit site exposed to possible contamination from the PT’s shirt collar. OBS #16, Station #2, on May 9, 2024, at 11:10 A.M., PCT #5 was observed performing CVC exit site care on PT #13. PCT #5 performed CVC exit site care and left the area open to air, did not remove gloves, perform hand hygiene and don new gloves. PCT #5 removed the CVC caps, completed disinfection of the CVC hubs, wrapped the hubs in the alcohol wipe used for disinfection, and placed the hubs on top of PT #13’s oxygen tubing when completed. The alcohol wipes opened, leaving the CVC hubs open to air with the potential for contamination. PCT #5 applied a dressing to the CVC exit site, then connected the dialysis lines. PCT #5 did not remove gloves, perform hand hygiene and don new gloves after disinfection of the CVC hubs and prior to applying the dressing to the exit site, or prior to connecting the dialysis lines. An interview with the Facility Administrator, the Clinical Specialist, the Director of Clinical Services, the Area Manager for Home Therapies, and the Director of Home Therapies on May 13, 2024, at approximately 3:45 P.M. confirmed the above findings.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 37972 Based on review of facility policies, clinical records (CR), and interview with facility staff, the facility failed to assess and manage patient’s blood pressure needs according to facility policy for two (2) of six (6) in-center hemodialysis CR reviewed (CR #4 and #6). Findings Included: Review of facility policy #C-ID-0010 titled “ Intradialytic Monitoring of Patient “ on May 13, 2024, at approximately 3:30 P.M. stated, “ ...PATIENT: ... 2. Vital signs: Obtained and documented at least every 30 minutes and reported to charge nurse if outside of standing orders and/or reportable parameters ... “ CR #4, admission date July 7, 2021. The hemodialysis flow sheet dated April 17, 2024, contained documentation of a blood pressure reading of 62/49 at 12:02 P.M. The patient care technician (PCT) documented “ Possible error BP retake “ . The repeat blood pressure at 12:04 P.M. was 79/52. The PCT documented “ UF (ultra filtration) turned off pt (patient) stable readjusted cuff “ . There was no documentation that the PCT notified the charge nurse of the low blood pressure reading. CR #6, admission date April 6, 2013. The hemodialysis flow sheet dated April 2, 2024, contained documentation of a blood pressure reading of 67/34 at 6:59 A.M. There was no documentation that the PCT notified the charge nurse of the low blood pressure reading. Based on review of facility policies, CR, and interview with facility staff, the facility failed to ensure fluid removal was performed per the plan of care prescribed estimated dry weight (EDW) for four (4) of six (6) in-center hemodialysis CR reviewed (CR #2, #3, #4, and #6). Findings Included: Review of facility policy #C-TP-0060 titled “ Post Dialysis Assessment of Patients “ on May 13, 2024, at approximately 3:30 P.M. stated, “ ASSESSMENT: 1. Post dialysis patient assessment includes but is not limited to: ... f. Weight/volume status. i. Evaluate post weight variance from EDW. If post weight +/- 1 kg (kilogram) from EDW, evaluate patient ’ s condition, document, and contact physician if assessment deems this necessary ... PATIENT TEACHING: 1. Inform patient of post treatment vital signs and fluid status. 2. Advised patient regarding dietary/fluid precautions if target fluid removal is not met. 3. Discuss with patient steps to achieve target fluid removal next treatment ... “ Review of CR on May 9, 2024, from approximately 12:30 P.M. to 4:00 P.M. and May 13, 2024, from approximately 12:15 P.M. to 2:30 P.M. revealed the following: CR #2, admission date December 1, 2021. Prescribed EDW was 58 kg. Review of in-center hemodialysis treatment records from April 8, 2024, through April 20, 2024, revealed that the patient failed to achieve a post hemodialysis treatment EDW within +/- 1 kg on April 8, 2024 (63.9 kg), April 10, 2024 (59.8 kg), April 11, 2024 (59.2 kg), April 12, 2024 (59.2 kg), April 15 2024 (60 kg), April 17, 2024 (60.5 kg), April 19, 2024 (61 kg), and April 20, 2024 (61.1 kg). There was no documentation of patient education regarding EDW. CR #3, admission date July 1, 2021. Prescribed EDW was 89.5 kg. Review of in-center hemodialysis treatment records from April 22, 2024, through May 10, 2024, revealed that the patient failed to achieve a post hemodialysis treatment EDW within +/- 1 kg on April 22, 2024 (94.9 kg), April 24, 2024 (95.9 kg), April 26, 2024 (95.5 kg), April 29, 2024 (94 kg), May 1, 2024 (96 kg), May 3, 2024 (96 kg), May 6, 2024 (97.8 kg), May 8, 2024 (99.9 kg), and May 10, 2024 (98.1 kg). The patient was seen weekly by the nurse practitioner and monthly by the attending nephrologist. The nephrologist documented the weight gain in the physician notes on February 12, 2024, and March 11, 2024. The patient was placed on a 1500 ml (milliliter) per day fluid restriction. No patient education regarding EDW was documented by the nurse on May 1, 2024, and May 10, 2024. CR #4, admission date July 7, 2021. Prescribed EDW was 108 kg. Review of in-center hemodialysis treatment records from April 17, 2024, through May 10, 2024, revealed that the patient failed to achieve a post hemodialysis treatment EDW within +/- 1 kg on April 19, 2024 (109.9 kg), May 1, 2024 (110.4 kg), May 6, 2024 (109.3 kg), and May 10, 2024 (109.7 kg). There was no documentation of patient education regarding EDW. CR #6, admission date April 6, 2013. Prescribed EDW was 68 kg. Review of in-center hemodialysis treatment records from April 2, 2024, through May 7, 2024, revealed that the patient failed to achieve a post hemodialysis treatment EDW within +/- 1 kg on April 2, 2024 (65.8 kg), April 9, 2024 (66.7 kg), April 16, 2024 (64.9 kg), April 23, 2024 (65 kg), and April 30, 2024 (66.9 kg). There was no documentation of patient education regarding EDW. An interview with the Facility Administrator, the Clinical Specialist, the Director of Clinical Services, the Area Manager for Home Therapies, and the Director of Home Therapies on May 13, 2024, at approximately 3:45 P.M. 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: 37972 Based on review of facility policies, clinical records (CR), and staff interviews, the facility failed to ensure the staff members confirmed the hemodialysis prescription and communicated with physicians when blood flow rates (BFR) required adjustment beyond the current physicians’ orders for two (2) of six (6) in-center hemodialysis CR reviewed (CR #1 and #3). Findings included: Review of the facility policy # C-TI-0010 titled “ Initiation of Dialysis Treatment “ on May 13, 2024, at approximately 3:15 P.M. stated, “ PROCEDURE: ...14. Prior to walking away from patient’s dialysis machine, verify all prescribed orders are followed. If unable to follow any part of the patient’s prescription after trouble shooting, notify the charge nurse and document notification. Charge nurse will notify the physician if indicated and document any follow up or new orders. Prescription orders and safety measures include, but are not limited to the following: a. Blood flow is at prescribed rate ... “ Review of CR on May 9, 2024, from approximately 12:30 P.M. to 4:00 P.M. and May 13, 2024, from approximately 12:15 P.M. to 2:30 P.M. revealed the following: CR #1, start of care March 21, 2024, contained orders for hemodialysis treatments to be completed three (3) times per week for four (4) hours per treatment, with a blood flow rate (BFR) of 400 ml/min (milliliters/minute). Review of the patient’s hemodialysis flowsheet dated April 18, 2024, revealed that the BFR was delivered lower than prescribed, at 350 ml/min from 10:27 A.M. to 2:26 P.M. Three (3) different staff members documented conducting checks during the treatment. There was no documented reason for the BFR to run lower than ordered or that the physician was notified of the lower BFR. CR #3, start of care July 1, 2021, contained orders for hemodialysis treatments to be completed three (3) times per week for four (4) hours and thirty (30) minutes per treatment, with a BFR of 450 ml/min. Review of the patient’s hemodialysis flowsheets dated April 22, 2024, and May 10, 2024, revealed that the BFR was delivered at a rate lower than prescribed. The BFR was delivered at 400 ml/min on April 22, 2024, from 11:01 A.M. to 3:07 P.M. and on May 10, 2024, from 11:35 A.M. to 3:31 P.M. Four (4) different staff members documented conducting checks during the treatment on April 22, 2024, and five (5) different staff members documented conducting checks during the treatment on May 10, 2024. There was no documented reason for the BFR to run lower than ordered or that the physician was notified of the lower BFR. Based on review of facility policies, CR review, and staff interviews, the facility failed to retain the required AMA (against medical advice) form when patients refused to complete the prescribed hemodialysis treatment for one (1) of six (6) in-center hemodialysis CR reviewed. (CR # 4). Findings included: Review of facility policy #C-AD-0530 titled “ Against Medical Advice “ on May 13, 2024, at approximately 3:30 P.M. stated, “ PROCEDURE: ... 2. a. iii. The charge nurse will review and have the patient sign the AMA form ... DOCUMENTATION: 1. A nurse ’ s note will be completed to document the interaction. Documentation will include at a minimum: a. Reason for acting against medical advice; b. Intervention to encourage adherence to orders and advice; c. Education related to the risks of not following medical advice; d. Physician notification and any further orders provided. 2. Patient and/or legal representative signature is required on the AMA form. a. Refusals will be witnessed by the charge nurse and one other clinical staff member. 3. The AMA form will be maintained in the patient ’ s medical record. “ Review of CR on May 9, 2024, from approximately 12:30 P.M. to 4:00 P.M. and May 13, 2024, from approximately 12:15 P.M. to 2:30 P.M. revealed the following: CR #4, start of care July 7, 2021, contained physician ’ s orders for hemodialysis treatment three (3) times per week for four (4) hours per treatment. The patient requested that the hemodialysis treatment be ended after three (3) hours and forty-five (45) minutes on April 17, 2024; after three (3) hours and seventeen (17) minutes on April 26, 2024; and after three (3) hours and three (3) minutes on May 1, 2024. The registered nurse (RN) documented on each date that the patient “ requested sign-off “ . There was no documentation of patient education, physician notification, or an AMA form completed and signed by the patient. An interview with the Facility Administrator, the Clinical Specialist, the Director of Clinical Services, the Area Manager for Home Therapies, and the Director of Home Therapies on May 13, 2024, at approximately 3:45 P.M. confirmed the above findings.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 37972 Based on review of facility policies, clinical record (CR), and interview with facility staff, the facility failed to ensure staff members documented access site care in the treatment record for five (5) of six (6) in-center hemodialysis CR reviewed. (CR # 2, #3, #4, #5, and #6) Findings Included: Review of facility policy #C-TI-0010 titled “ Initiation of Dialysis Treatment “ on May 13, 2024, at approximately 3:30 P.M. stated, “ PROCEDURE: ...2. Clean and disinfect the patient ’ s access per policy and procedure according to the type of vascular access (e.g., AVF (arteriovenous fistula), AFG (arteriovenous graft) or catheter). 3. Follow policy and procedure for accessing the patient ’ s blood ... 13 a. Remove gloves; perform hand hygiene; don clean gloves to document the initiation of dialysis treatment in EMR (electronic medical record) ... “ Review of CR on May 9, 2024, from approximately 12:30 P.M. to 4:00 P.M. and May 13, 2024, from approximately 12:15 P.M. to 2:30 P.M. revealed the following: CR #2, admission date December 1, 2021. The PCT (patient care technician) failed to document accessing of the patient ’ s blood and initiation of dialysis in the treatment record on April 10, 2024. CR #3, admission date July 1, 2021. The PCT failed to document accessing of the patient ’ s blood and initiation of dialysis in the treatment record on April 24, 2024, and May 1, 2024. CR #4, admission date July 7, 2021. The PCT failed to document accessing of the patient ’ s blood and initiation of dialysis on May 6, 2024. CR #5, admission date February 16, 2023. The PCT failed to document catheter exit site care, accessing of the patient ’ s blood, and initiation of dialysis on April 27, 2024. CR #6, admission date April 6, 2013. The RN (registered nurse) failed to document accessing of the patient ’ s blood and initiation of dialysis on April 30, 2024, and May 7, 2024. An interview with the Facility Administrator, the Clinical Specialist, the Director of Clinical Services, the Area Manager for Home Therapies, and the Director of Home Therapies on May 13, 2024, at approximately 3:45 P.M. confirmed the above findings.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 37972 Based on a review of facility policy, the monthly “ Facility Quality Management Meeting “ minutes for in-center hemodialysis services, and an interview with the facility staff, the facility did not provide sufficient documentation of continuously monitoring its performance, action plans, take actions resulting in performance improvements and tracking performance to ensure that improvements are sustained over time. Findings include: Review of facility policy #C-QM-0010 titled “ Introduction to Quality Assessment and Performance Improvement (QAPI) “ on May 13, 2024, at approximately 2:45 P.M. stated, “ Program Description: A quality assessment and performance improvement program (QAPI) is a well-defined organized program which monitors standards of patient care. The process includes systematically examining patient care, identifying deficiencies, establishing priorities, searching for a probable cause, generating and choosing a solution, implementing the solution and then re-examining the case ... “ Review of the facility ’ s “ Facility Quality Management Meeting “ minutes for in-center hemodialysis services from October, 2023, through March, 2024, on May 9, 2024 from approximately 10:00 A.M. to 11:30 A.M. revealed the following: 1. Mortality Review contained not documentation for cause of death three (3) of four (4) deaths reported during the timeframe. One (1) death was noted to be due to the patient electing hospice care. The Mortality log book contained not documentation regarding patient deaths since 2019. 2. 7.2% to 11.2% of shortened treatments due to “ various reasons “ . No root causes were identified. “ Plan of Action/Follow-up Needed/Root Cause “ listed “ 1) cont. to educate patient on the importance to follow prescribed treatment time. 2) refer pt. to MSW to explore reason for non compliance. 3) PCT to inform RN of request to sign off early, so RN can address reason and document. 4) reschedule missed treatment if willing “ . 3. 32.1% to 33.9% of patients have a central venous catheter (CVC) with 18.6% to 22% having a CVC greater than 90 days. “ Plan of Action/Follow-up Needed/Root Cause “ lists “ cont. to educate patient of high risk of infection with CVC; educate patients on importance of permanent access placement; assist patient to make appointment with vascular surgeon and provide referral; provide patient with names of different surgeons in the area, make appointments “ . 4. 1.19% to 1.33% of patients were hospitalized. The “ Hospitalization Review “ contained no reason for hospitalizations for February, 2024 and March, 2024. 5. 33.1% to 38.9% of patients were readmitted to the hospital within four (4) to thirty (30) days of discharge. 6. Seven (7) of twenty-three (23) indicators did not contain a “ Person Resp./Assigned “ 7. Twenty-two (22) of twenty-three (23) indicators did not contain a “ Resolution Date/Status “ . An interview with the Facility Administrator, the Clinical Specialist, the Director of Clinical Services, the Area Manager for Home Therapies, and the Director of Home Therapies on May 13, 2024, at approximately 3:45 P.M. confirmed the above findings.”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 37972 Based on review of facility documentation and interview with facility staff, the facility failed to provide documentation of the required information for infection surveillance. Findings included: A written list of documentation required for the survey was provided to the facility Administrative Assistant on May 7, 2024, at approximately 8:30 A.M. Infection logs were requested for the past six (6) months. Review of the infection log on May 7, 2024, at approximately 1:30 P.M. revealed a spreadsheet with the number of infections listed per month. The infection logs did not contain the date of infection onset, site of infection, full identification of infecting organism(s), and antimicrobial susceptibility results. An interview was conducted with the Clinical Specialist on May 13, 2024, at approximately 3:30 P.M. The Clinical Specialist stated that the facility does not retain a log with the date of infection onset, site of infection, full identification of infecting organism(s), and antimicrobial susceptibility results. An interview with the Facility Administrator, the Clinical Specialist, the Director of Clinical Services, the Area Manager for Home Therapies, and the Director of Home Therapies on May 13, 2024, at approximately 3:45 P.M. confirmed the above findings.”