Davita Cottman Kidney Center

“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: 45377 Based on a review of medical records (MR), facility policies, and an interview with the facility administrator, the facility did not follow its policy regarding the performance of quarterly fire safety/emergency/disaster preparedness drills for eight (8) of eleven (11) records reviewed: MR#3, MR#4, MR#5, MR#6, MR#7, MR#8, MR#10, and MR#11. Findings include: A review of the following policies was conducted on August 6, 2024 starting at 8:00 AM: Policy 4-07-01 The Facility Emergency Management Plan (ICHD, Home) states in part: “Emergency Management Plan Section b. Patients, ii. Quarterly, 1. Fire Safety Preparedness, 2. Emergency Take-off procedures.” Policy 5-01-21 Home Dialysis Monitoring and Ongoing Patient Education reads in part, The following need to be reviewed at least quarterly: Emergency/Disaster Preparedness.” A review of MRs was conducted on August 6, 2024 starting at 11:45 AM and again on August 7, 2024 starting at 8:15 AM. The admission date (AD) is indicated below. MR#3 AD 07/28/2016 did not contain evidence that quarterly fire safety preparedness drills were conducted in the 4th quarter of 2023. MR#4 AD 03/25/2024 did not contain evidence that quarterly fire safety preparedness drills were conducted in the 2nd quarter of 2024. MR#5 AD 05/01/2014 did not contain evidence that quarterly fire safety preparedness drills were conducted in the 4th quarter of 2023, and the 1st quarter of 2024. MR#6 AD 10/18/2022 did not contain evidence that quarterly fire safety preparedness drills were conducted in the 4th quarter of 2023. MR#7 AD 12/16/2019 did not contain evidence that quarterly fire safety preparedness drills were conducted in the 4th quarter of 2023, and the 1st and 2nd quarters of 2024. MR#8 AD 08/05/2009 did not contain evidence that quarterly fire safety preparedness drills were conducted in the 4th quarter of 2023. MR#10 AD 01/15/2019 did not contain evidence that quarterly fire safety preparedness drills were conducted in the 1st and 2nd quarters of 2024. MR#11 AD 09/20/2023 did not contain evidence that quarterly fire safety preparedness drills were conducted at the time of admission, nor in the 1st and 2nd quarters of 2024. An interview conducted with the facility administrator, regional operations director, manager of clinical services, home program manager, biomedical operations manager, and director clinical services on August 8, 2024 starting at 12:00 PM 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: 45377 Based on observations, a review of facility policies, and an interview with the administrator, the facility failed to follow its policies related to discontinuation of dialysis for an arteriovenous (AV) fistula for two (2) of two (2) observations at Station (STN)#4 (MR#18) and STN#5 (MR#19). Findings include: A review of the following policies occurred on August 6, 2024 starting at 8:00 AM. Policy 1-05-01 Infection Control for Dialysis Facilities reads in part, “All teammates, physicians, and non-physicians (NPP) will perform hand hygiene....prior to gloving and immediately after removal of gloves.” Policy 1-04-01 B Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles states in part, “Perform hand hygiene. Put on gloves.” Observations were conducted on August 5, 2024 starting at approximately 9:15 AM. OBS#1 at STN#4 occurred on 8/5/2024 at approximatley 9:50 AM. Prior to removing the 1st needle, PF#3 was observed to remove gloves and don clean gloves without performing hand hygiene in between doffing and donning gloves. PF#3 put the patient’s footrest down and without changing gloves, proceeded to remove the 1st needle. Aseptic technique was not maintained prior to removal of the 1st needle. OBS#2 at STN#5 occurred on 8/5/2024 at approximately 10:05 AM. Prior to removing the 1st needle, PF#2 was observed to remove gloves and don clean gloves without performing hand hygiene in between doffing and donning gloves. PF#2 pushed up the patient’s blanket and put the footrest down and without changing gloves, proceeded to remove the 1st needle. Aseptic technique was not maintained prior to removal of the 1st needle. An interview conducted with the facility administrator, regional operations director, manager of clinical services, home program manager, biomedical operations manager, and director clinical services on August 8, 2024 starting at 12:00 PM confirmed the above findings.”

“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 Incenter Dialysis Treatment Area, a review of facility policies, a review of infection control documents, and an interview with the facility administrator, the facility failed to remove expired supplies and medications for two (2) of four (4) observations: OBS#1 and OBS#2. Findings include: A review of the following facility policies took place on August 6, 2024 starting at approximately 8:00 AM. Policy 1-05-01 Infection Control For Dialysis Facilities reads in part, “Supplies will be stored in a manner that maintains their integrity.” Policy 1-06-01 Medication Policy reads in part, “All medications in the facility are checked monthly; and Medications containing a preservative must be discarded 28 days after opening or accessed.....each vial is labeled with the initials of the person opening the vial and the expiration date.” A review of infection Control Audits was conducted on August 6, 2024 at approximately 8:15 AM. The facility provided a folder labeled 2024 Infection Control Audits (electronic audits). Three audits were contained in the file. One audit was dated April 2024, the other two audits did not contain audit dates. All three audits noted that all medications, medical treatment supplies and lab supplies were not expired. Observation #1 took place on the Incenter Treatment Area from 9:15 AM to 12:30 PM on 08/05/2024. The observation revealed the following: A white three drawer cart near the lab area contained four (4) adult oxygen masks, expired 07/22/2024, lot#1503690. The medication preparation area across from stations 23-24 contained two (2) opened multi-dose vials of Heparin Na (sodium) injection with Benzyl Alcohol (a preservative), 30000 units per 30 ml, located in a drawer. Both vials were opened. Vial #1 contained approximately 10 to 15 milliliters (ml) of remaining solution. Vial #2 contained approximately 20 ml of remaining solution. Neither of the vials contained the initials of the person who opened the vials, nor the expiration dates. The lab area contained: On the counter, fifteen (15) green top lab tubes containing gel and lithium heparin, expired 07/31/2024, lot#3194891. In the cabinet, two-hundred (200) green top lab tubes containing gel and lithium heparin, expired 07/31/2024, lot#3194799. In the cabinet, 4 packages Hemosure IFOB (immunological fecal occult blood test): Lot#E1110767, quantity of five, expired 05/31/2024 Lot#E1200871, quantity of five, expired 05/31/2024 Lot#E1110767, quantity of five, expired 05/31/2024 Lot#G1211275, quantity of five, expired 07/31/2024 Observation #2 on the Incenter Treatment Area on 08/05/2024 from 2:05 PM to 2:30 PM found the following: The crash cart contained five (5) adult oxygen masks with a use by date of 05/06/2024, lot#0004094523, a yankauer suction set, expired 07/31/2024, lot#1504323, and two (2) Med Source Suction Catheters, expired 07/19/2024, lot#1504326. An interview conducted with the facility administrator, regional operations director, manager of clinical services, home program manager, biomedical operations manager, and director clinical services on August 8, 2024 starting at 12:00 PM confirmed the above findings.”

“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: 45377 Based on a review of medical records (MR), facility policy, and an interview with the administrator and clinical coordinator, the facility failed to assure that an interdisciplinary plan of care (POC) was conducted in accordance with timeframes for patients who are declared unstable. One (1) of one (1) medical record noting instability did not meet the requirement: MR#5. Findings include: A review of the following facility policy took place on August 6, 2024 starting at approximately 8:00 AM. Policy 1-14-01 Interdisciplinary Team (IDT) Patient Assessment and Plan of Care states in part that care plans will be conducted, “Monthly (unstable patients) - Monthly until patient is determined by interdisciplinary team to be stable.” A review of MRs was conducted on August 6, 2024 starting at 11:45 AM and again on August 7, 2024 starting at 8:15 AM. The admission date (AD) is indicated below. MR#5 AD 05/01/2024 found that the patient was declared unstable on 01/05/2023. Subsequent care plans were completed on 02/29/2023 (unstable), and 03/20/2023 (unstable). There were no care plans completed after 03/20/2023 until 07/31/2023 at which time the patient was declared to be stable. The facility failed to provide evidence of a monthly care plan after 03/20/2023 when the patient was still found to be unstable. An interview conducted with the facility administrator, regional operations director, manager of clinical services, home program manager, biomedical operations manager, and director clinical services on August 8, 2024 starting at 12:00 PM 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: 45377 Based on review of facility policies, medical records (MR), hemodialysis (HD) treatment records, peritoneal dialysis (PD) treatment records, and an interview with the facility administrator and clinical coordinator, the facility did not address abnormal findings per the facility’s policy and/or did not conduct post treatment nursing assessments for hemodialysis (HD) patients for two (2) of nine (9) HD MR reviewed: MR#1 and MR#4, and did not provide evidence that pertinent clinical data was captured for peritoneal dialysis (PD) patients for one (1) of two (2) PD MR reviewed: MR#10. Findings include: The following facility policies were reviewed on August 6, 2024 starting at 8:00 AM. Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment reads in part, All medications including time administered, dose, route, and initials of person administering the medication and indication and response to PRN medication. Pre-Dialysis: Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initialed. Abnormal Findings: Blood pressure: systolic greater than 180 mmHg or less than 90 mm HG; diastolic greater than or equal to 100 mm HG or less than 50 mm HG. Intradialytic: Abnormal findings will be reported to the licensed nurse immediately (refer to Abnormal Findings section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The licensed nurse notified the physician or NPP as needed of changes in patient status. All findings, interventions and patient response will be documented in the patient’s medical record. Abnormal findings: Blood pressure (BP): systolic greater than 180 mm/Hg or less than 90 mm/Hg; diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg; Post Treatment: If an abnormal finding or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. Licensed nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician or NPP is necessary prior to discharge of the patient from the facility: Abnormal findings: systolic BP greater than 140 mm/Hg or less than 90 mm/HG; diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg.” Facility Policy 5-01-29 Daily Home Treatment Record (Flowsheet) states in part, “As clinically applicable, all treatment data outlined on the Daily Home Treatment Record must be collected. Completed Daily Home Treatment Records must be reviewed to assist in evaluating the patient’s progress and self-care decision-making process. This post-treatment data review will be verified by the Peritoneal Dialysis registered nurse documenting review in the medical record per guidance below: a) the licensed nurse will review the patient’s data via submitted Daily Home Treatment Records....d) the licensed nurse is responsible for end of month review for all Daily Home Treatment Records.” The policy also contains a section on Abnormal Findings which reads in part, “...the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record....Fluid Status: if patient is above or below 2 kg from the target weight; if patient is using 4.25% (red) dialysate....All Daily Home Treatment Records will be reviewed, attested to, and maintained as part of the patient’s medical record.” Policy 1-06-01 Medication Policy reads in part, “Medications are administered as prescribed and then documented in the patient’s medical record; Document the name of the medication, dose, route, time patient response and signature of the teammate administering the medication.” A review of MRs was conducted on August 6, 2024 starting at 11:45 AM and again on August 7, 2024 starting at 8:15 AM. The admission date (AD) is indicated below. MR#1 AD 05/08/2024. HD Treatment Records reviewed from 07/22/2024 to 08/02/2024 found the following: 07/26/2024: HD Treatment was initiated by the licensed practical nurse at 6:27 AM. Blood pressure (BP) was 203/115 at the start of treatment. RN was notified of the elevated blood pressure. The RN, at 6:34 AM, noted that the patient was hypertensive, and that PRN (as needed) Clonidine would be administered. BP at 7:04 AM was 224/183, and 200/104 at 7:05 AM as noted by the RN. BP improved to 156/90 at 7:34 AM per the RN. However, there was no documentation on the treatment details report or in the electronic medical record that PRN Clonidine was administered. MR#4 AD 02/07/2024. HD Treatment Records reviewed from 7/11/2024 to 08/01/2024 found the following: 07/11/2024: BP readings were as follows: 7:30 AM (start of treatment) 175/110, 7:32 AM 184/109, 8:02 AM 171/105, 8:32 AM 159/107, 9:02 AM 172/100, 9:32 AM 159/98, 10:02 AM 151/105, 10:11 AM 164/110 (end of treatment). There was no indication that the licensed nurse was notified of the elevated diastolic blood pressures throughout the treatment. There was no evidence of completion of a post nursing assessment addressing the abnormal findings. 07/13/2024: BP readings were as follows: 7:59 AM (start of treatment) 201/131, 8:02 AM 201/130. There was no note that RN was notified of the elevated blood pressures at the start of treatment. An RN note at 8:12 acknowledged the elevated BP and stated that the patient would take his/her BP medications at chairside. Continued BP readings by the patient care technician (PCT) throughout the treatment were: 8:32 AM 187/123, 9:02 AM 181/113 (note that patient took BP medications), 9:32 AM 187/115, 10:02 AM 191/110, 10:32 AM BP 179/114, 11:02 AM 192/122, 11:21 AM 178/123 (end of treatment). There was no indication that the RN was notified of the continued elevated diastolic BP’s, nor was there a subsequent RN note or post nursing assessment addressing the abnormal findings. MR#10 AD 01/15/2019. PD Treatment Records reviewed from 05/06/2024 to 07/29/2024 found that the patient failed to document the dextrose concentration (either 1.5%, 2.5% or 4.25%) over the time frame noted above. Therefore, it was unable to be determined if the patient had used a 4.25% dextrose solution which is considered an abnormal finding per facility policy. An interview conducted with the facility administrator, regional operations director, manager of clinical services, home program manager, biomedical operations manager, and director clinical services on August 8, 2024 starting at 12:00 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 a review of medical records (MR), hemodialysis (HD) treatment records, facility policies, and an interview with the administrator, the agency failed to follow hemodialysis (HD) treatment physician orders for five (5) of nine (9) HD MR’s reviewed: MR#1, MR#3, MR#4, MR#5, and MR#6. Findings include: The following policies were reviewed on August 6, 2024 starting at approximately 8:00 AM. Facility Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment reads in part, “Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment...The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation. Prescription components include but are not necessarily limited to:.....Blood flow rate (BFR), Dialysate flow rate... The nursing assessment includes the following components: verification or prescription including machine parameters; If the dialysis prescription is not being met the reason will be documented and the licensed nurse informed...” A review of MRs was conducted on August 6, 2024 starting at 11:45 AM and again on August 7, 2024 starting at 8:15 AM. The admission date (AD) is indicated below. MR#1 AD 05/08/2024. A review of hemodialysis treatment records from 07/22/2024 to 08/02/2024 revealed the following: 07/26/2024: Dialysate Flow Rate (DFR) was ordered to run at 600 ml (milliliters) per min. The HD treatment started at 6:27 AM and ended at 9:18 AM. Throughout the treatment, the DFR ran at 500 ml/min. instead of the ordered 600 ml/min. There was no reason for or note addressing the altered DFR. MR#3 AD 07/28/2016. A review of hemodialysis treatment records from 07/23/2024 to 08/03/2024 found the following: 08/03/2024: DFR was ordered at run at 700 ml/min. The HD treatment began at 6:13 AM and ended at 9:29 AM. Throughout the treatment, the DFR ran at 500 ml/min, instead of the ordered 700 ml/min. 07/30/2024: DFR was ordered at 700 ml/min. The HD treatment began at 6:13 AM and ended at 9:43 AM. Throughout the treatment, the DFR ran at 500 ml/min, instead of the ordered 700 ml/min. 07/25/2024: DFR was ordered at 700 ml/min. The HD treatment began at 6:06 AM. The DFR ran at 500 ml/min until 7:03 AM at which time it was increased to 700 ml/min. There was no reason for or note addressing the altered DFR during the first hour of treatment. MR#4 AD 03/25/2024. A review of hemodialysis treatment records from 7/11/2024 to 08/01/2024 found the following: 08/01/2024: Blood Flow Rate (BFR) was ordered to run at 400 ml/min. The HD treatment began at 7:27 AM and ended at 10:52 AM. The BFR ran at 350 ml/min from 7:27 AM to 10:32 AM instead of 400 ml/min. There was no indication or note addressing the reason for the altered BFR. MR#5 AD 05/01/2014. A review of hemodialysis treatment records from 07/12/2024 to 07/31/2024 found the following: 07/31/2024: BFR was ordered to run at 400 ml/min. The HD treatment began at 7:54 AM and ended at 9:31 AM. BFR varied throughout the treatment from 200 ml/min to 350 ml/min. 07/26/2024 BFR was ordered to run at 400 ml/min. The HD treatment began at 7:02 AM and ended at 10:19 AM. The BFR ran at 350 ml/min throughout the treatment. There was no reason for or note addressing the altered BFR. 07/22/2024: DFR was ordered to run at 700 ml/min. The HD treatment began at 7:24 AM and ended at 9:29 AM. The DFR ran at 500 ml/min throughout the treatment. MR#6 AD 10/18/2022. A review of the hemodialysis treatment records from 07/23/2024 to 08/03/2024 revealed the following; 08/01/2024: DFR was ordered to run at 800 ml/min. The HD treatment began at 9:52 AM and ended at 2:09 PM. The DFR ran at 500 ml/min throughout the treatment. There was no reason for or note addressing the altered DFR. An interview conducted with the facility administrator, regional operations director, manager of clinical services, home program manager, biomedical operations manager, and director clinical services on August 8, 2024 starting at 12:00 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 medical record (MR) reviews, observations on the incenter treatment area, facility policies, and an interview with the administrator, the facility failed to provide evidence of following its policies related to hemodialysis (HD) access visibility for three (3) of ten (10) observations at the following stations (STN): STN#4, STN#5, and STN#6, cleansing of the HD access site for one (1) of two (2) observations: STN#5, and temperature monitoring related to peritoneal dialysis (PD) patients for two (2) of two (2) MR’s reviewed: MR#10 and MR#11. Findings include: The following policies were reviewed on August 6, 2024 starting at approximately 8:00 AM Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment reads in part, “The vascular access site, blood line connections and the patient’s face should be visible throughout the dialysis treatment; the nursing assessment includes the following components...verification that the patient access is visible...” Policy 1-04-01 Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Access Care states in part, “Patient are encouraged to wash access extremity with soap and water upon arrival for dialysis, if able. If patient unable to wash site, patient care teammate will clean access extremity with skin cleansing agency and pat dry.” Policy 1-04-01E AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose reads in part, “Procedure: Have patient wash access site with appropriate antibacterial soap, if able. If patient unable to wash access site, patient care teammate will clean access extremity with skin cleansing agent and pat dry. Rationale: Verifies that access extremity has been cleaned.” Policy 5-01-29 Daily Home Treatment Record (Flowsheets) states in part, “Abnormal Findings: Temperature Pre/Post/PRN (as needed): Greater than 100 degrees Fahrenheit or a 2 degree rise over baseline.” Observations on the dialysis treatment area took place on Monday, August 5, 2024 starting at 9:15 AM. The facility provided a seating chart/schedule for Monday-Wednesday-Friday (3 shifts), and Tuesday-Thursday-Saturday (2 shifts). The following situations were observed: STN#4 (MR#18) was observed on 08/05/2024 at 9:20 AM to have a blanket covering the access site such that the access site was not able to be visualized. STN#5 (MR#19) was observed on 08/05/24 at 9:25 AM to have a blanket covering the access site such that the access site was not able to be visualized. STN#6 (MR#22) was observed on 08/05/2024 at 9:30 AM to have a blanket covering the access site such that the access site was not able to be visualized. STN#5 (MR#16) was observed on 08/05/2024 at 11:20 AM as PF#2 prepared to access the arteriovenous (AV) fistula. PF#2 did not wash the patient’s arm with soap or an antibacterial scrub prior to palpating and cannulating the access site, and PF#2 did not ask the patient if s/he cleansed the arm upon entering the incenter dialysis unit. After initiating treatment, PF#2 was interviewed and asked by the surveyor if s/he cleansed the patient’s arm, to which PF#2 responded yes. PF#2 was asked to show the surveyor what process what used to cleanse the arm. PF#2 produced an alcohol swab. PF#2 was asked if s/he cleansed the arm with the alcohol swab to which PF#2 stated that s/he only cleansed the access sites with the alcohol swab, and did not cleanse the arm. The surveyor then proceeded to ask the patient is s/he cleansed his/her arm upon entering the unit. The patient responded that s/he did not cleanse the arm because s/he did not put cream on his/her arm. It should be noted that the sink intended to be used by patients for cleansing the arm upon entry to the unit is not visible from the treatment floor. It is located at the patient entrance and sits behind a wall which prohibits viewing the sink/activity unless one is standing in the immediate area. The incenter treatment area does contain other sinks throughout the unit which are labeled as clean sinks. A review of MRs was conducted on August 6, 2024 starting at 11:45 AM and again on August 7, 2024 starting at 8:15 AM. The admission date (AD) is indicated below. MR#10 AD 01/15/2019. PD treatment records for the time frame 05/06/2024 and 07/29/2024 did not contain any evidence that the patient was monitoring his/her temperature pre or post PD treatments during the time frame noted above. MR#11 AD 09/20/2024. PD treatment records for the time frame 05/09/2024 to 07/31/2024 did not contain any evidence that the patient was monitoring his/her temperature pre or post PD treatments during the time frame noted above. An interview conducted with the facility administrator, regional operations director, manager of clinical services, home program manager, biomedical operations manager, and director clinical services on August 8, 2024 starting at 12:00 PM confirmed the above findings.”