Fkc Liberty Dialysis Camp Hill

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 39671 Based on review of facility policy and procedure and interview with facility employees (EMP), the facility failed to maintain a sanitary environment by bringing an animal onto the clinic treatment floor while patients were receiving treatment. Review of the ’ Service Animals in the Dialysis Facility ’ policy on 4/24/2024 at approximately 9:45 am, section, ’ Policy ’ states, “ No animals are permitted in the dialysis facility, except Service Animals. ... “ Review of the ’ General Cleanliness and Infection Control Guidelines ’ policy on 4/24/2024 at approximately 9:46 a.m. section, ’ Policy ’ states, “ ... The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintaining a clean, safe, aesthetically pleasant environment for patients, staffs and visitors ...Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff. Such cleaning should be done regularly using a schedule developed by the facility. ... “ Findings include: Interviews with staff and facility patients were conducted on 4/24/2024 between 9:30 a.m. to 3:30 p.m. revealed the following: Interview # 1: Interview was conducted with Clinic Manager [Employee # 1] on 4/24/24 at approximately 12:17 pm. Surveyor asked if there was ever a dog or puppy brought into the facility and or clinic treatment floor. Employee # 1 stated, “ I had gotten a mini goldendoodle puppy in September 2023. I brought him in when he was a few weeks old, shortly after I got him. The first week I brought him in I kept him in my office because he was sick. Employee $ 4 and Employee # 5 were helping to take care of him in my office while I was on the treatment floor. I did bring him in the clinic treatment floor during patient ’ s treatments. A few patients asked to hold him, so I placed him on their lap while they were getting their treatments. He did have several peeing accidents in the clinic floor. He also had several peeing and pooping accidents while in my office. He was not potty trained at that time. “ Interview # 2: Interview was conducted with Clinic Social Worker [Employee # 4] on 4/24/24 at approximately 12:56 pm. Surveyor asked if there was ever a dog or puppy brought into the facility and or clinic treatment floor. Employee # 4 stated, “ I had seen Bentley when he was a puppy and he had been in my office a few times. He is [employee # 1]’s puppy. I have not seen him since. “ Interview # 3: Interview was conducted with Patient # 3, at station # 14 on 4/24/2024 at approximately 10:15 a.m. The surveyor asked Patient # 3 if he has ever witnessed any of the staff members bring a dog or a puppy into the clinic facility/clinic treatment center. Patient # 3 replied, “ A long time ago, a puppy. Just once or twice. It was [Employee # 1] ’ s puppy. “ Interview # 4: Interview was conducted with Patient # 4, at station # 8 on 4/24/2024 at approximately 10:31 a.m. The surveyor asked Patient # 4 if she has ever witnessed any of the staff members bring a dog or a puppy into the clinic facility/clinic treatment center. Patient # 4 replied, “ One time. A little puppy and all of the patients loved it. I don ’ t know who it belonged to. I usually just watch TV or sleep. “ Interview # 5: Interview was conducted with Patient # 5, at station # 5 on 4/24/2024 at approximately 10:37 a.m. The surveyor asked Patient # 5 if she has ever witnessed any of the staff members bring a dog or a puppy into the clinic facility/clinic treatment center. Patient # 4 replied, “ Probably just for a visit. It was well behaved while it was here. It was a dog. I ’ d rather not say whose it was. “ Interview # 6: Interview was conducted with Home Therapy RN (Registered Nurse), [Employee # 5] on 4/24/2024 at approximately 2:41 pm. Surveyor asked [Employee # 5] if she has ever witnessed any of the staff members bring in a dog or puppy into the facility/clinic treatment area. Employee # 5 replied, “ [Employee # 1] brought in her puppy a while ago. It was in her office, and I believe she also brought it onto the clinic treatment area. “ On 4/24/2024 at approximately 3:45 p.m. interview was conducted with Employee # 1 that confirms findings.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 39671 Based on review of facility policy and procedure, observation of the clinic treatment area and interview with facility employee (Employee # 6), the facility failed to ensure no drinks were located in the clinic treatment area for one (1) of two (2) clinic treatment observations. (Clinic Treatment Area Observation # 2) Review of the ’ General Cleanliness and Infection Control Guidelines ’ policy on 4/24/2024 at approximately 10:00 a.m. section, ’ Policy ’ states, “ ... The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintaining a clean, safe, aesthetically pleasant environment for patients, staffs and visitors ...Food and drink shall not be kept in refrigerators, freezers, shelves, cabinets or on countertops or benchtops where blood or other potentially infectious material are present ...Eating, drinking, applying cosmetics, or lip balm, and handing contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure ... “ Findings include: Clinic treatment area observations were conducted on 4/24/2024 between approximately 9:30 a.m. and 11:00 a.m. revealed the following: Clinic Treatment Area Observation # 2: Surveyor also observed a coffee mug with liquid inside sitting on the nurse ’ s station countertop. When the surveyor asked who the coffee mug belonged to, [Employee # 6] said it was hers and that she was drinking it before the patient ’ s came in that morning, while things were being set up. On 4/24/2024 at approximately 3:45 p.m. interview was conducted with Employee # 1 that confirms findings.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 39671 Based on review of facility policy and procedure, observation of the clinic treatment area and interview with facility Clinical Manager (Employee # 1), the facility failed to ensure medication syringes were properly labeled for one (1) of two (2) clinic treatment observations. (Clinic Treatment Area Observation # 2) Review of the ’ Medication Preparation and Administration ’ policy on 4/24/2024 at approximately 9:10 a.m. section, ’ Labeling Reconstituted Medication Solutions and Syringes ’ states “ All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication ....Filled syringes do not have to be labeled if drawn up and administered immediately. These unlabeled, filled syringes must not be placed down at any time ... “ Findings include: Clinic treatment area observations were conducted on 4/24/2024 between approximately 9:30 a.m. and 11:00 a.m. revealed the following: Clinic Treatment Area Observation # 1: At the medication counter surveyor observed, one (1) 10 mL (milliliters) syringe filled with a clear liquid to the 5.2 mL line. There was no label on this syringe. Surveyor asked clinical manager what this was, and she replied, “ It is Heparin, it was drawn up this morning. We don ’ t have labels for that. “ Surveyor also observed, one (1) 3 mL syringe filled to 2.9 mL line with a label marked “ [Patient # 7], Etelcalcetide (Parsabiv) (medication for: secondary hyperparathyroidism), 15 mg (milligrams) IVP (intravenous push) 3x week )three times a week) “ - The ’ Time ’ and ’ Initial ’ sections were blank on the label. Surveyor also observed, two (2) 3 mL syringes filled to the 1.8 mL line with a label marked “ [Patient # 8], Heparin Sodium (Porcine) 1,000 units/mL catheter Lock Venous Cath fill vol (mL) 1.8, 1,800 units venous Blue Port, Every Treatment “ - The ’ Time ’ and ’ Initial ’ sections were blank on the label. On 4/24/2024 at approximately 3:45 p.m. interview was conducted with Employee # 1 that confirms 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: 39671 Based on review of facility policy and procedure and interview with facility employees (EMP), the facility failed to maintain a safe and comfortable treatment environment by bringing a non service animal onto the treatment floor while patients were receiving treatment. Review of the ’ Service Animals in the Dialysis Facility ’ policy on 4/24/2024 at approximately 9:45 am, section, ’ Policy ’ states, “ No animals are permitted in the dialysis facility, except Service Animals. ... “ Review of the ’ General Cleanliness and Infection Control Guidelines ’ policy on 4/24/2024 at approximately 9:46 a.m. section, ’ Policy ’ states, “ ... The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintaining a clean, safe, aesthetically pleasant environment for patients, staffs and visitors ...Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff. Such cleaning should be done regularly using a schedule developed by the facility. ... “ Findings include: Interviews with staff and facility patients were conducted on 4/24/2024 between 9:30 a.m. to 3:30 p.m. revealed the following: Interview # 1: Interview was conducted with Clinic Manager [Employee # 1] on 4/24/24 at approximately 12:17 pm. Surveyor asked if there was ever a dog or puppy brought into the facility and or clinic treatment floor. Employee # 1 stated, “ I had gotten a mini goldendoodle puppy in September 2023. I brought him in when he was a few weeks old, shortly after I got him. The first week I brought him in I kept him in my office because he was sick. Employee $ 4 and Employee # 5 were helping to take care of him in my office while I was on the treatment floor. I did bring him in the clinic treatment floor during patient ’ s treatments. A few patients asked to hold him, so I placed him on their lap while they were getting their treatments. He did have several peeing accidents in the clinic floor. He also had several peeing and pooping accidents while in my office. He was not potty trained at that time. “ Employee # 1 failed to ensure that patients and/or staff would be free from the possibility of the puppy biting the patients/employees, chewing on equipment or slipping on the puppy’s urine. Employee # 1 also failed to ensure to provide a safe and comfortable environment to those patients/employees who did not like or were afraid of animals. On 4/24/2024 at approximately 3:45 p.m. interview was conducted with Employee # 1 that confirms findings.”

“PR-RESPECT & DIGNITY CFR(s): 494.70(a)(1) The patient has the right to- (1) Respect, dignity, and recognition of his or her individuality and personal needs, and sensitivity to his or her psychological needs and ability to cope with ESRD This Standard is not met as evidenced by: 39671 Based on review of facility policies and procedures, ‘FMCNA Patient Rights ’ and interviews with facility employees (EMP), the facility failed to ensure patients were treated with respect, dignity, recognition of his or her individuality and personal needs and sensitivity to his or her psychological needs and ability to cope with ESRD for two (2) of five (5) complaint allegations investigated. (Allegation # 1 and allegation # 3) Review of the ’ Behavior in the Workplace ’ policy on 4/24/2024 at approximately 1:00 p.m. section, ’ Guidelines ’ states, “ ...The Behavior in the Workplace Policy provides a guidance for expectations of behaviors in the workplace and consequences when such expectations are not met ...Violations of policies, rules and regulations, unsatisfactory work performance, or any behavior that adversely affects the employment relationship may result in a violation of this policy ....While not all inclusive; the following are examples of behaviors that are not in accordance with expected workplace behaviors: Failure to comply with the Company ’ s core values; Refusal or failure to perform or follow reasonable directions or prescribed policies and procedures ...any action jeopardizing the safety or posing a risk to others including, but not limited to coworkers, patients, customers and venders; Failure to maintain or adhere to quality standards ... “ Review of the ’ Prohibiting Discrimination, Harassment, Sexual Harassment and Retaliation in the Workplace ’ policy on 4/24/2024 at approximately 1:10 p.m. section, ’ Applies to ’ states, “ This policy applies to all employees in all aspects of the employment relationship ... Because the Company has an obligation and is committed to providing a workplace free of discrimination, harassment, sexual harassment, and retaliation, this policy extends to: Conduct by employees towards other employees, whether a supervisor, subordinate or peer, and non-employees including but not limited to, physicians, patients, visitors, vendors, contractors, applicants and other third parties ...Harassment Definition and Examples: For the purposes of this policy, “ harassment “ is defined as verbal or physical behavior toward an individual that, whether intended or not: is or can be interpreted as, unwelcome or personally offensive; has the intent or effect of creating an intimidating, hostile or offensive work environment ....Harassment may take many forms. The legal definition of harassment is broad and it is not possible to list all circumstance of prohibited conduct, therefore, by the way of example only, and without limitation, harassment may include: suggestive, offensive, demeaning or hostile jokes, whether written, verbal or electronic, threats, intimidation, and other menacing behavior; other verbal, graphic, or physical abuse or conduct; or other conduct based upon one or more of the protected categories identified in this policy ... “ Review of ’ FMCNA Patient Rights ’ form conducted on 4/24/2024. ’ FMCNA Patient Rights ’ states, “ YOU HAVE THE RIGHT TO: ...Care that is Respectful ...Be treated with dignity, consideration, respect and full recognition of your individuality and personal needs. The includes sensitivity to your psychological needs and ability to cope with ESRD ...Privacy and confidentiality in all aspects of treatment. This includes: the right to privately discuss your condition; the right to privacy during activities that may require the exposure of body parts while in the dialysis facility. Privacy screens, curtains, or blankets that do not cover your face or access, may be used to provide privacy ...resolve any issues before a final decision to transfer from the facility is made ...Make a complaint and receive a response ... “ Review of the ’ Interruption of Treatment ’ policy sections, ’ Purpose and Policy ’ states, “ Although all patients should be educated about the importance of completing their full treatment without interruption, it occasionally may be necessary for treatment to be interrupted in order to accommodate a patient ’ s request to use the restroom ... A patient ’ s treatment may be interrupted to allow the patient to use the restroom for bladder or bowel needs. “ Findings include: Interviews with staff and facility patients were conducted on 4/24/2024 between 9:30 a.m. to 3:30 p.m. revealed the following: Allegation # 1- Allegation of clinic manager verbally abusing/harassing Patient # 1 about his choice of dialysis Modality: Interview was conducted with Clinic Manager [Employee # 1] on 4/24/24 at approximately 12:17 pm. Surveyor asked she or any of the other employees have recently had any issues with patients and their chosen modality. Employee # 1 stated, “ More recently on April 1, 2024, that ’ s when [patient # 1] asked to use the urinal while he was on the machine. I asked him, “Why don ’ t you go to the bathroom before you come back for treatment? He replied, “I do.” and I replied, “Well then you need to go a second time.” I was talking to him in a joking manner. Then he said, “Isn’t it good that I still pee?” And I said, “It would be if you were on PD, then it would actually count.” and he said, “Oh don ’ t start that again, I ’ m not doing home.” So then on 4/3/24, that ’ s when I was in the office doing paperwork when [patient # 1] came in, I jokingly said, “Hey, [patient # 1] make sure you go to the bathroom” and he said, “I did” and I said, “Well try again” and he said, “I don ’ t have to go again. “ I don ’ t exactly know how it got the home therapy topic but he then stated, “I suppose you are going to tell me that I should do PD again and I shouldn’t be taking up a chair for someone who needs it?” and I replied, “Yes, that is true, you should be doing it at home.” then I said, “ Hey [Employee # 5], I got one for you. “ [Employee # 5] replied, “Who?” I replied, “[Patient # 1]” and she said, “Then I would have to take a picture of you for PD” and he replied, “I ’ m not getting my picture taken.” Then he said, “I want to transfer” and I said “Let me know where you want to go, and I ’ ll put it in.” Then [Employee # 4] went out to talk to him because she had some papers to give to him. He never once mentioned to her anything about our conversation or being upset. And he also didn ’ t mention it to me that he was upset about our conversation. “ Interview was conducted with Social Worker [Employee # 4] on 4/24/24 at approximately 12:17 pm. Surveyor asked she or any of the other employees have recently had any issues with patients and their chosen modality. Employee # 4 stated, “ More recently on April 1, 2024, [Employee # 1] was out front and I couldn ’ t hear the whole conversation, but I believe they were discussing home modalities again because [Employee # 5] was here. [Patient # 1] was supposed to bring me chronic renal proof of income on Monday, 4/1/24 but he had forgot it so I went out front to the waiting room to see if he had the info. He is standing in front of the window in the waiting room talking to [Employee # 1]. There was one other patient in the waiting room that I saw, [Patient # 6]. He told me, “Yes I have your paperwork.” He asked me to make copies. I went to make copies in the secretary office. While making copies, these two [Employee # 1 and Patient # 1] are bantering back and forth about the PD modality. What I heard [Patient # 1] say to [Employee # 1] is, “I don ’ t want to do PD, it ’ s my choice and I have heard negative things about PD from other people.” I went out to the waiting room, and I said to [Patient # 1], “Maybe we need better and more positive information about PD. On 4/5/24, I was on the floor in the Millersburg location, I get a call. I don ’ t know who it was at that time because it was loud, and I couldn ’ t hear the other person on the line. What I did hear a person say is, “I ’ m sure you saw my email, and I’m filing a complaint.” and I said, “Okay if you emailed me today or yesterday, I didn’t see it. I was in a meeting all day on 4/4/24 with the social worker. “ I stated, “Let me get your number and I will call you back from a different location in the building so I can hear you.” He gave me his phone number. I went in the back and called the number. While the phone was ringing, I went to check my emails. I realized that the email and the individual that called was [Patient #1]. I read the email that he sent, while he was on the phone. He said, “He was very upset about Wednesday and the interaction between him and [Employee # 1]. He didn ’ t like how he was being approached about Home after he has already stated that he didn ’ t want to do it and he didn ’ t like that it was discussed in the waiting room. He said, “You heard the conversation. I am tired of it and am filing a complaint.” I said, “ I didn ’ t hear the whole conversation, I heard part of it.” He felt that I should have spoken up for him and advocated for him between him and [Employee # 1]. I stated, “You did not seem upset that day, in fact you were stating up in front of the window in the waiting room and were engaging in that conversation. [Employee #1] seemed like she was joking and bantering. It did not seem hostile. If you needed me to step in, I didn’t feel that or get that, If I misread that I apologize. “ He said, “It shouldn’t have been something to joke around with.” I said, “You seem more upset today then you did Wednesday” and he did not like that comment. I said, “We have discussed things before, and I have explained the process on how to file a grievance. If you had communicated to me that you were upset, we could have taken the steps” and he said, “I will.” and I said, “Okay, you have all rights to do so.” He stated that he was going to talk to [Employee # 2] that next day and I said “Okay.” Then the phone call ended. It felt like he didn ’ t believe me when I explained to him that I was in a meeting the previous day and did not get a chance to review my emails. I updated Employee #1], the social worker manager, [Employee # 7], and the Director of Operations. When I talked to [Employee # 3] that day and explained the events of that day, [Employee # 3] said thank you for letting me know and that he was going to reach out to the patient ASAP. [Employee # 3] said he was going to meet with [Patient # 1] in person to discuss the situation. [Patient # 1] talked and met with [Employee # 2] as well in person while he was getting treatment and [Employee # 2] came back to speak with me as well. She asked me to provide him again with the grievance numbers to just make sure he had them. I said, “Okay” and provided him the phone number again. [Patient # 1] mentioned wanting to speak to someone outside of Fresenius to me. He said, “You all work for the same company so there is a similar interest.” I said, “You can call the Renal Network 4” and I gave him the phone number and my contact there. One of the recommendations that [Employee # 3] provided to our staff after the discussion with [Patient # 1] was ’ Trust & Inclusion ’ training that was administered by my manager, [Employee # 7] on 4/17/24. All the staff at this clinic participated. There is a sign in sheet for that. My manager had suggested a meeting between myself, [Patient # 1] (if he is agreeable), [Employee # 1 and Employee # 3]. [Employee # 3] is off next week April 29, 24-May 3rd, 2024)-- I told [Employee # 7] that I would speak to [Patient # 1] to see if he would be agreeable to have a meeting after [Employee # 3] returns. “ Provider note completed by Nurse Practitioner [Employee # 8] dated 4/5/2024, section, ’ H&P Assessment ’ states, “ ...Per [Employee # 1] pt has been upset by the “ unprofessional “ interactions he has experienced with staff. He has been in touch with [Employee # 4 , SW [social worker] about this. He did not mention it during course of our conversation but did mention that he would like to discuss with [Employee 3 2] when she rounds ... “ Provider note completed by the Medical Director, Employee # 2 dated 4/10/2024, section, ’ H&P Assessment ’ states, “ ...Spoke with pt (patient)- he has been upset by interactions with [Employee # 1], RN and more recently [Employee # 4], SW. He spoke about this with Area mgr. (manager) [Employee # 3] but was not satisfied with this discussion. I asked him to continue to pursue the process of filing a grievance and going up the chain of command within FKC. I also told him he could discuss this with the ESRD Network if he is still having issues despite speaking with higher FKC managers. As a final option if he is still not satisfied and continues to feel uncomfortable doing HD in this clinic, he can also consider changing to an alternate clinic. He understood these options and will continue to follow this process. “ Social Worker, ’ Psychosocial Progress Notes ’ for Patient # 1 were reviewed for the date range of 10/17/2023 through 4/11/20024. ’ Psychosocial Progress Notes ’ completed by social worker, Employee # 4 dated 4/5/2024, section, ’ Problems/Goals discussed/other ’ states, “ Pt (patient) called and said that he was upset about a conversation he had with the CM (clinical manager-Employee # 1) on wed (Wednesday). Pt said that she was talking about how he would be doing home and how he is taking up a chair for someone that really needs it. Pt said that she was also getting on him about urinating. Pt said that this has been ongoing and he feels that it ’ s inappropriate and unprofessional. I offered SW support and active listening. Pt has been having ongoing issues with staff and reports he is finally going to take action. I reviewed again the grievance procedure with pt and informed him where to find numbers to call to file a complaint. I updated CM and DO. I also reached out to SW manager to discuss. “ ’ Psychosocial Progress Notes ’ completed by social worker, Employee # 4 dated 4/11/2024, section, ’ Problems/Goals discussed/other ’ states, “ DO met with pt on 4/8. DO suggests empathy/professionalism training for the staff. MD said that she spoke with pt, and he informed her about the issue and informed her that he spoke with the DO. MD reported that pt said that he may want to speak to someone else regards to the issue and asked that I provided contact number for filing a grievance. I met with pt and offered SW support and active listening. I provided and reviewed grievance policy and contact numbers. Pt talked about his conversations with both the DO and MD. Pt said that he thought it might be good for him to speak with someone outside of FKC. I provided Network 4 info. I informed him that I would continue to follow up and to reach out if there are further issues or concerns. I updated CM, DO and SW manager. “ Allegation # 3- Allegation of clinic manager harassing Patient # 1 about having to use the urinal/bathroom during treatment: Interview was conducted with Clinic Manager [Employee # 1] on 4/24/24 at approximately 12:17 pm. Surveyor asked she or any of the other employees have recently had any issues with patients using the bathroom and/or urinals. Employee # 1 stated, “ More recently on April 1, 2024, that ’ s when [patient # 1] asked to use the urinal while he was on the machine. I asked him, “Why don ’ t you go to the bathroom before you come back for treatment? He replied, “I do.” and I replied, “Well then you need to go a second time.” I was talking to him in a joking manner. Then he said, “Isn’t it good that I still pee?” And I said, “It would be if you were on PD, then it would actually count.” and he said, “Oh don ’ t start that again, I ’ m not doing home.” So then on 4/3/24, that ’ s when I was in the office doing paperwork when [patient # 1] came in, I jokingly said, “Hey, [patient # 1] make sure you go to the bathroom” and he said, “I did” and I said, “Well try again” and he said, “I don ’ t have to go again. “ On 4/24/2024 at approximately 3:45 p.m. interview was conducted with Employee # 1 that confirms findings.”

“MD RESP-STAFF ED, TRAINING & PERFORM CFR(s): 494.150(b) Medical director responsibilities include, but are not limited to, the following: (b) Staff education, training, and performance. This Standard is not met as evidenced by: 39671 Based on review of facility policies and procedures, employee handbooks, job descriptions and interviews with facility employees (EMP), the facility failed to ensure employees followed employee handbook, policies and procedures and job descriptions for three (3) of eight (8) employees. (Employee # 1, Employee # 4 and Employee # 5) ’ Employee Handbook ’ section, ’ Expected Behavior ’ states, “ Successful performance promotes efficiency, productivity, collaboration and teamwork. You are expected to follow established standards of conduct by acting in a manner that is safe, professional, ethical, and in accordance with the Company ’ s core values ... “ Section, ’ Safety and Security ’ states, “ FMCNA is committed to providing a safe and secure work environment for all employees and visitors and does not tolerate abusive or violent behavior at any FMCNA locations or events. Employees are required to observe commonsense safety rules in the workplace and immediately report any safety hazard or on-the-job injury to a supervisor. “ Section, ’ Compliance ’ states, “ Each and every employee is responsible for furthering our culture of ethical business behavior. This commitment is reflected in our Global Core Values- in particular, we are Reliable; we do what we say and work to earn the trust of our patients, partners, and colleagues. We operate our business with honesty and integrity, in an ethical and responsible manner, and in compliance with applicable laws and regulations ... “ Section, ’ Reporting Compliance Concerns ’ states, “ FMCNA requires all employees to report actions or practices that they believe may be in violation of FMCNA ’ s Code of Ethics and Business Conduct, policies, or legal or regulatory obligations. Employees who fail to report a violation of law or Company policy or who fail to cooperate in or hinder an investigation may be subject to corrective action, up to and including termination of employment. “ ’ Clinical Manager ’ job description section, ’ DUTIES/ACTIVITIES: CUSTOMER SERVICE ’ states, “ Responsible for driving the FMS culture through values and customer service standards; accountable for outstanding customer service to all external and internal customers; and develops and maintains effective relationships through effective and timely communication ... “ Section, ’ PRINCIPAL RESPONSIBILITIES AND DUTIES: QUALITY ’ states, “ Responsible for supporting and driving FMS quality standards through meeting all ESRD regulatory requirements and the practice of Quality Assessment and Improvement (QAI), including use of FMS QAI tools; accountable for outstanding quality of patient care ...by working with the appropriate Service Director, Regional Quality Manager and Vice President of Quality, Regional Vice President and FMS Clinical Services Department to ensure that FMS policy and procedure is followed; accountable for compliance with all applicable federal, state and local laws and regulations; ... and maintains facility environment integrity, including safety. “ Findings include: Interviews with staff and facility patients were conducted on 4/24/2024 between 9:30 a.m. to 3:30 p.m. revealed the following: Employee # 1: failed to comply with Employee Handbook section ’ Expected Behavior. ’ Employee # 1 failed to follow established standards of conduct by acting in a manner that is safe, professional, ethical, and in accordance with the Company ’ s core value by harassing Patient # 1 regarding his dialysis modality choice and his requests to use the urinal/bathroom during dialysis treatments. Employee # 1 also failed to comply with the ‘Clinical Manager’ job description by not being accountable for outstanding customer service standards, not being accountable for outstanding quality of patient care; not ensuring that FMS policy and procedures are following; not being accountable for compliance with all applicable federal, state and local laws and regulations and not maintaining facility environment integrity, including safety. Employee # 4: failed to immediately report any safety hazard or on-the-job injury to a supervisor when a puppy was brought into the dialysis facility and clinic treatment area multiple times. Employee # 4 also failed to report actions or practices that they believe may be in violation of FMCNA ’ s Code of Ethics and Business Conduct, policies, or legal or regulatory obligations. Employee # 5: failed to immediately report any safety hazard or on-the-job injury to a supervisor when a puppy was brought into the dialysis facility and clinic treatment area multiple times. Employee # 5 also failed to report actions or practices that they believe may be in violation of FMCNA ’ s Code of Ethics and Business Conduct, policies, or legal or regulatory obligations. On 4/24/2024 at approximately 3:45 p.m. interview was conducted with Employee # 1 that confirms 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: 39671 Based on review of facility policies and procedures, and interviews with facility employees (EMP), the facility failed to ensure employees adhered to all patient care, infection control and safety policies and procedures for six (six) of eight (8) policies reviewed. (Policy # 1, Policy # 2, Policy # 3, Policy # 4, Policy # 5 and Policy # 6) Findings include: Policies and procedures reviews were conducted on 4/24/2024 between 9:30 a.m. to 3:30 p.m. revealed the following: Policy # 1: ’ Behavior in the Workplace ’ policy section, ’ Guidelines ’ states, “ ...The Behavior in the Workplace Policy provides a guidance for expectations of behaviors in the workplace and consequences when such expectations are not met ...Violations of policies, rules and regulations, unsatisfactory work performance, or any behavior that adversely affects the employment relationship may result in a violation of this policy ....While not all inclusive; the following are examples of behaviors that are not in accordance with expected workplace behaviors: Failure to comply with the Company ’ s core values; Refusal or failure to perform or follow reasonable directions or prescribed policies and procedures ...any action jeopardizing the safety or posing a risk to others including, but not limited to coworkers, patients, customers and venders; Failure to maintain or adhere to quality standards ... “ Policy # 2: ’ Prohibiting Discrimination, Harassment, Sexual Harassment and Retaliation in the Workplace ’ policy section, ’ Applies to ’ states, “ This policy applies to all employees in all aspects of the employment relationship ... Because the Company has an obligation and is committed to providing a workplace free of discrimination, harassment, sexual harassment, and retaliation, this policy extends to: Conduct by employees towards other employees, whether a supervisor, subordinate or peer, and non-employees including but not limited to, physicians, patients, visitors, vendors, contractors, applicants and other third parties ...Harassment Definition and Examples: For the purposes of this policy, “ harassment “ is defined as verbal or physical behavior toward an individual that, whether intended or not: is or can be interpreted as, unwelcome or personally offensive; has the intent or effect of creating an intimidating, hostile or offensive work environment ....Harassment may take many forms. The legal definition of harassment is broad and it is not possible to list all circumstance of prohibited conduct, therefore, by the way of example only, and without limitation, harassment may include: suggestive, offensive, demeaning or hostile jokes, whether written, verbal or electronic, threats, intimidation, and other menacing behavior; other verbal, graphic, or physical abuse or conduct; or other conduct based upon one or more of the protected categories identified in this policy ... “ Policy # 3: ’ Interruption of Treatment ’ policy sections, ’ Purpose and Policy ’ states, “ Although all patients should be educated about the importance of completing their full treatment without interruption, it occasionally may be necessary for treatment to be interrupted in order to accommodate a patient ’ s request to use the restroom ... A patient ’ s treatment may be interrupted to allow the patient to use the restroom for bladder or bowel needs. “ Policy # 4: ’ Service Animals in the Dialysis Facility ’ policy section, ’ Policy ’ states, “ No animals are permitted in the dialysis facility, except Service Animals. ... “ Policy # 5: ’ General Cleanliness and Infection Control Guidelines ’ policy section, ’ Policy ’ states, “ ... The purpose of this policy is to provide guidance for FKC staff on preventing the spread of infectious disease and maintaining a clean, safe, aesthetically pleasant environment for patients, staffs and visitors ...Facility staff are accountable for cleaning rooms/areas not assigned to contracted cleaning staff. Such cleaning should be done regularly using a schedule developed by the facility. ... “ Policy # 6: ’ Medication Preparation and Administration ’ section, ’ Labeling Reconstituted Medication Solutions and Syringes ’ states “ All medications in syringes not being administered immediately shall be labeled appropriately with the name of the medication, route, dose, name of patient, date, time and initials of the person who prepared the medication ....Filled syringes do not have to be labeled if drawn up and administered immediately. These unlabeled, filled syringes must not be placed down at any time ... “ On 4/24/2024 at approximately 3:45 p.m. interview was conducted with Employee # 1 that confirms findings.”