Davita Lehigh Avenue Dialysis

“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 the facility Medical Records (MR), facility policy, and an interview with the manager of clinical services, the facility did not conduct fire safety drills according to facility policy for eight (8) of nine (9) MR’s reviewed: MR#2, MR#3, MR#4, MR#5, MR#6, MR#7, MR#8, and MR#9. Findings include: A review of Policy 4-07-01 “The Facility Emergency Management Plan (ICHD Home)” on June 5, 2024 at 1:15 PM states in part: “Emergency Management Plan Section b. Patients, ii. Quarterly, 1. Fire Safety Preparedness, 2. Emergency Take-off procedures.” A review of Medical Records was conducted on June 4, 2024 from 8:00 AM to 3:00 PM, and again on June 5, 2024 from 10:00 AM to 11:00 AM. The admission date (AD) is indicated below. MR#2 AD 10/06/20 only had one fire safety drill in 2024 conducted on 2/12/2024, and none in 2023. MR#3 AD 10/07/20 only had one fire safety drill in 2023 conducted on 12/04/2023, and none in 2024. MR#4 AD 10/06/20 did not contain documentation of fire drill for 2023 and 2024. MR#5 AD 10/11/22 only had one fire safety drill in 2023 conducted on 12/12/2023, and none in 2024. MR#6 AD 03/07/22 only had one fire safety drill in 2023 conducted on 12/04/2023, and none in 2024. MR#7 AD 12/19/2020 only had one fire safety drill in 2023 conducted on 12/07/2023, and none in 2024. MR#8 AD 01/21/2023 only had one fire safety drill in 2023 conducted on 12/07/2023 and none in 2024. MR#9 AD 12/05/2022 only had one fire safety drill in 2023 conducted on 12/04/2023 and one in 2024. An interview conducted with the manager of clinical services, facility administrator, group facility administrator, and regional operations director on June 5, 2024 starting at 2:00 PM confirmed the above findings.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 48280 Based on review of facility policy and medical records (MR), and an interview with the manager of clinical services, facility administrator, group facility administrator, and regional operations director, the facility failed to maintain Hepatitis B virus (HBV) vaccination records for one (1) of nine (9) medical records. MR# 1. Findings Include: A review of facility policy titled “ Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance “ was conducted on June 5, 2024, at approximately 12:00 PM. The policy reads in part, “... ADMISSION SCREENING utilizing facility baseline/admit results: antigen: negative, total core: negative, antibody: <10, repeat core: N/A, status: susceptible, next step: offer vaccination series, patient seating: general population using an immune patient as a geographic buffer between any antigen positive patient .... 9. Documentation of the current laboratory values will be accepted if adherent to routine surveillance testing. ROUTINE SURVEILLANCE TESTING: Antigen: negative, core: negative, antibody: <10, status: susceptible, surveillance testing: monthly antigen .... 10. An order will be obtained for hepatitis B vaccination. The patient is provided the Vaccination Information Sheet (VIS) and a consent form (included in patient registration packet found in Reggie). The patient will consent to the vaccination or will decline. The completed form will be kept in the patient’s health record. 11. Patient who start hemodialysis may have a history of vaccination against the hepatitis B. These persons should have responded to the vaccine when their immune status was normal, but if their hepatitis B surface antibody (HBsAb or anti-HBs) levels are less than (<) 10 mIU/mL when they begin dialysis, they should be re vaccinated with a complete primary series. “ A review of Medical Records was conducted on June 4, 2024 from 8:00 AM to 3:00 PM, and again on June 5, 2024 from 10:00 AM to 11:00 AM. The admission date (AD) is indicated below. MR#1 AD 03/12/2024 found that MR#1 is determined to be susceptible to Hepatitis B with HBsAb of 3 tested on 3/12/24, negative of HBsAg tested on 3/12/24 and 5/21/24 and negative of HBcAb tested on 3/12/24. A form titled, “ Consent - Hepatitis B Vaccine “ is in health record, however, the form was not complete - not indicating patient acceptance or declination of vaccination and date and name were left blank. Hepatitis B vaccine Engerix-B status on 5/18/24 reads, “ not given - unknown. “ An interview conducted with the manager of clinical services, facility administrator, group facility administrator, and regional operations director on June 5, 2024, starting at 2:00 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 In-Center Hemodialysis (ICHD) Treatment Area, the laboratory room, the storage supply room, an interview with the manager of clinical services, and a review of facility policy, the facility failed to properly remove expired supplies for one (1) of three (3) observations (OBS): OBS#1. Findings include: A review of Facility Policy: 1-05-01 Infection Control For Dialysis Facilities, conducted on June 3, 2024 at approximately 5:00 PM reads in part, “Supplies will be stored in a manner that maintains their integrity.” Observation #1 took place in the In-Center Hemodialysis Treatment Area and Laboratory Room on June 3, 2024 from approximately 9:30 AM to 11:30 AM. The observation revealed the following: The Emergency Evacuation Box located in the ICHD Treatment Area contained the following expired items: Four (4) Nipro Safety Fistula Needles 16 gauge, lot #18K16C, expired 10/31/2023. The Laboratory Room contained the following expired items: Two (2) Einstein Exempt Human Monthly Blood Shipper Kits, lot #3293061022, item #3298, expired 01/31/2023. An interview conducted with the manager of clinical services, facility administrator, group facility administrator, and regional operations director on June 5, 2024 starting at 2:00 PM confirmed the above findings.”

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 48280 Based on review of facility policy and medical records (MR) and an interview with the manager of clinical services, the facility failed to test Tuberculosis Infection per agency ’ s policy for one (1) of nine (9) MR’s reviewed: MR#1. Findings include: A review of clinic policy titled, “ Tuberculosis Infection Control Policy” was conducted on June 5, 2024 approximately at 12 PM. The policy reads in part, “ ...1. Patients with chronic kidney disease (CKD) are considered the high risk for progression from latent to TV infection (LTBI) to active TB disease and will screen the four TB prior to first treatment, as well as the participate in ongoing surveillance following admission, per the requirement of this policy, regardless of BCG history. ...2. Admission requirements and the surveillance following admission: ... documentation available: 5. TST or IGRA not available, Prior to 1st treatment: CXR (chest x-ray), upon admission: complete TB-RAG (TB-Risk Appraisal Questionnaire), administer one step TST followed by a second TST (2nd step of two step TST (tuberculin skin test)) one (1) to three (3) weeks after the admission TST or draw QFTG (QuantiFERON-TB Gold test), annual surveillance: TB-RAQ and single step TST or QFTG.” A review of Medical Records was conducted on June 4, 2024 from 8:00 AM to 3:00 PM, and again on June 5, 2024 from 10:00 AM to 11:00 AM. The admission date (AD) is indicated below. MR#1 AD 3/12/2024 contained a form titled, “ TB testing “ showed that initial dose of TST was administered on 4/25/24 which is 44 days after the admission date and result was read on 4/27/24. However, there is no record of 2nd TST. Another form titled, “ Vaccinations and Surveillance Report “ showed that initial dose of TST was administered on 4/25/24 and result was read on 4/27/24. However, there is no record of 2nd TST. On 3/28/24, Tubersol was drawn, but status reads, “ not given - unknown. “ An interview conducted with the manager of clinical services, facility administrator, group facility administrator, and regional operations director on June 5, 2024 starting at 2:00 PM confirmed the above findings.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 45377 Based on a review of medical records (MR), facility policy, and an interview with the clinical services manager, the agency failed to ensure that an initial comprehensive assessment was conducted on all new patients within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session for four (4) of nine (9) MR’s reviewed: MR#1, MR#5, MR#8, and MR#9. A review of Policy 1-14-01 Interdisciplinary Team Patient Assessment and Plan of Care conducted on June 3, 2024 at 5:30 PM reads in part, “A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines.” A review of Medical Records was conducted on June 4, 2024 from 8:00 AM to 3:00 PM, and again on June 5, 2024 from 10:00 AM to 11:00 AM. The admission date (AD) is indicated below. MR#1 AD 03/12/2024 did not have the initial comprehensive assessment completed until 06/03/2024, eighty-three (83) days after the beginning of the first dialysis session. MR#5 AD 10/11/2022 did not have the initial comprehensive assessment completed until 12/15/2022, sixty-five (65) days after the beginning of the first dialysis session. MR#8 AD 01/21/2023 did not have the initial comprehensive assessment completed until 05/02/2023, one-hundred one (101) days after the beginning of the first dialysis session. MR#9 AD 12/05/2022 did not have the initial comprehensive assessment completed until 02/20/2023, seventy-seven (77) days after the beginning of the first dialysis session. An interview conducted with the manager of clinical services, facility administrator, group facility administrator, and regional operations director on June 5, 2024 starting at 2:00 PM confirmed the above findings.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 45377 Based on a review of medical records (MR), facility policy, and an interview with the clinical services manager, the agency failed to ensure that a follow-up comprehensive reassessment occurred within 3 months after the completion of the initial assessment in order to provide information to adjust the patient’s plan of care for two (2) of nine (9) MR’s reviewed: MR#5 and MR#9. A review of Policy 1-14-01 Interdisciplinary Team Patient Assessment and Plan of Care conducted on June 3, 2024 at 5:30 PM reads in part, “A follow-up 90 day reassessment will be completed to evaluate patient’s status and provide information to adjust the patient’s plan of care.” A review of Medical Records was conducted on June 4, 2024 from 8:00 AM to 3:00 PM, and again on June 5, 2024 from 10:00 AM to 11:00 AM. The admission date (AD) is indicated below. MR#5 AD 10/11/2022 had an initial comprehensive assessment completed on 12/15/2022. There was no 90 day reassessment in the medical record. The next assessment contained in the medical record was completed on 05/02/2023. MR#9 AD 12/05/2022 had an initial comprehensive assessment completed on 02/20/2023. There was no 90 day reassessment in the medical record. The next assessment contained in the medical record was completed on 05/13/2024. An interview conducted with the manager of clinical services, facility administrator, group facility administrator, and regional operations director on June 5, 2024 starting at 2:00 PM confirmed the above findings.”

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- (1) At least annually for stable patients; This Standard is not met as evidenced by: 48280 Based on a review of medical records (MR), facility policy, and an interview with the clinical services manager, the agency failed to ensure that a follow-up comprehensive reassessment occurred annually for stable patients in order to provide information to adjust the patient’s plan of care for one (1) of nine (9) MR’s reviewed: MR#2. A review of Policy 1-14-01 Interdisciplinary Team Patient Assessment and Plan of Care conducted on June 3, 2024 at 5:30 PM reads in part, “ ...7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: at least annually for stable patients or semiannually when required by State Regulation .... “ A review of Medical Records was conducted on June 4, 2024 from 8:00 AM to 3:00 PM, and again on June 5, 2024 from 10:00 AM to 11:00 AM. The admission date (AD) is indicated below. MR#2 AD 10/06/2020 had a 90-day comprehensive assessment completed on 01/21/2021. The annual assessment contained in the medical record was completed on 5/23/22 which is 4 months and 2 days late. The next annual assessment contained in the medical record was completed on 8/28/23 which is 3 months, 2 days late. An interview conducted with the manager of clinical services, facility administrator, group facility administrator, and regional operations director on June 5, 2024 starting at 2:00 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, and an interview with the manager of clinical services, the facility did not address abnormal findings per the facility’s policy and/or ensure that the HD prescription was followed for eight (8) of nine (9) MR’s reviewed: MR#2, MR#3, MR#4, MR#5, MR#6, MR#7, MR#8, and MR#9. Findings include: A review of Facility Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment conducted on June 3, 2024 at approximately 6:00 PM 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). If the dialysis prescription is not being met the reason will be documented and the licensed nurse informed...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...Abnormal findings Fluid Status: Pre-treatment: Any weight loss from last post weight; Post treatment - if patient is above or below 1 kg from the target weight.....Blood pressure (BP) intradialytic: systolic greater than 180 mm/Hg or less then 90 mm/Hg; diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg; Post treatment: 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.” A review of Medical Records was conducted on June 4, 2024 from 8:00 AM to 3:00 PM, and again on June 5, 2024 from 10:00 AM to 11:00 AM. The admission date (AD) is indicated below. MR#2 AD 10/06/2020 found that HD treatment was initiated on 5/28/2024. blood pressure (BP) recorded by the PCT was 185/99 at 7:00 AM. There was no indication that the patient care technician (PCT) notified the licensed nurse of the elevated BP per facility policy. There was no documentation on the nursing assessment pertaining to or addressing the elevated blood pressure. Another HD treatment was initiated on 5/25/2024. BPs recorded by the PCT were 189/98 at 6:31 AM, 198/92 at 8:01 AM, 193/101 at 8:31 AM and 187/71 at 9:31 AM. There was no indication that the PCT notified the licensed nurse of the elevated BP per facility policy. There was no documentation on the nursing assessment pertaining to or addressing the elevated blood pressure. HD prescription contained an ordered target weight of 82.5kg. and an ordered UFR (ultrafiltration rate) of 13.0 ml/kg/hr. HD Treatment Records reviewed from 5/21/2024 to 05/30/2024 found the following: 05/21/2024: Post treatment weight was 85.2 kg, a difference of 2.7 kg from the target weight of 82.5kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. 5/23/2024 The actual UFR during treatment was 14.5 ml/kg/hr. MR#3 AD 10/07/2020 found that HD treatment was initiated on 5/10/2024. BP recorded by the PCT were 189/68 at 11:31 AM. There was no indication that the PCT notified the licensed nurse of the elevated BP per facility policy. There was no documentation on the nursing assessment pertaining to or addressing the elevated blood pressure. Another HD treatment initiated at 11:04 AM on 5/15/2024. The BP recorded by PCT on the intradialytic flowsheet at the start of treatment was 210/80. Subsequent BP recorded by the PCT at 12:02 PM was 205/77. There was no indication that the PCT notified the licensed nurse of the elevated BP per facility policy. There was no documentation on the nursing assessment pertaining to or addressing the elevated blood pressure. HD prescription contained an ordered target weight of 48.7 kg. and an ordered UFR (ultrafiltration rate) of 13.0 ml/kg/hr. HD Treatment Records reviewed from 5/6/2024 to 05/31/2024 found the following: 5/6/2024 The actual UFR during treatment was 13.5 ml/kg/hr. There were no orders to change the UFR. 05/15/2024: Post treatment weight was 51.5 kg, a difference of 2.8 kg from the target weight of 48.7 kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. MR#4 AD 10/06/2020. HD prescription contained an ordered target weight of 70 kg. HD Treatment Records reviewed from 5/21/2024 to 6/1/2024 found the following: 05/21/2024: Post treatment weight was 73.2 kg, a difference of 3.2 kg from the target weight of 70 kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. 05/23/2024: Post treatment weight was 72.8 kg, a difference of 2.8 kg from the target weight of 70 kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. MR#5 AD 10/11/2022 HD prescription contained an ordered target weight of 100 kg. HD Treatment Records reviewed from 5/21/2024 to 6/1/2024 found the following: 05/21/2024: Post treatment weight was 105.6 kg, a difference of 5.6 kg from the target weight of 100 kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. 05/23/2024: Post treatment weight was 105.7 kg, a difference of 5.7 kg from the target weight of 100 kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. 05/25/2024: Post treatment weight was 104.8 kg, a difference of 4.8 kg from the target weight of 100 kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. 05/28/2024: Post treatment weight was 106.5 kg, a difference of 6.5 kg from the target weight of 100 kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. 05/30/2024: Post treatment weight was 103.9 kg, a difference of 3.9 kg from the target weight of 100 kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. 6/1/2024: Post treatment weight was 103.7 kg, a difference of 3.7 kg from the target weight of 100 kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. MR#6 AD 03/07/2022 found that HD treatment was initiated at 7:06 AM on 05/24/2024. The blood pressure (BP) recorded by the patient care technician (PCT) on the intradialytic flowsheet at the start of treatment was 208/108. Subsequent BP’s recorded by the PCT at 7:07 AM and 7:31 AM were 200/100 and 197/96, respectively. There was a notation by PCT that the “pat (patient) BP high; Pat didn’t take his meds before tx (treatment).” There was no indication that the PCT notified the licensed nurse of the elevated BP per facility policy. There was no documentation on the nursing assessment pertaining to or addressing the elevated blood pressure. MR#7 AD 12/19/2020 found that the HD treatment prescription contained an ordered target weight of 73 kg (kilograms). HD Treatment Records reviewed from 05/21/2024 to 06/01/2024 found the following: The target weight was last updated 05/04/2024. 05/21/2024: Post treatment weight was 71.8 kg, a difference of -1.2 kg from the target weight of 73 kg. 05/23/2024: Pre treatment weight was 65.5 kg, a weight loss of -6.3 kg from the last post weight on 05/21/2024. There was no indication that the licensed nurse or the physician was notified of the weight loss since the last treatment prior to, during or after the treatment. Post treatment weight was 64.6 kg, a difference of -8.4 kg from the target weight of 73 kg. There was no notation that the licensed nurse or the physician was notified of the post weight below 1.0 kg from the target weight per facility policy. 05/25/2024: Post treatment weight was 67.0 kg, a difference of -6.0 kg from the target weight of 73 kg. 05/28/2024: Post treatment weight was 68.2, a difference of -4.8 kg from the target weight of 73 kg. 05/30/2024: Post treatment weight was 69.2 kg, a difference of -3.8 kg from the target weight of 73 kg. 06/01/2024: Post treatment weight was 69.3 kg, a difference of -3.7 kg from the target weight of 73 kg. For all of the above treatments, there were no notes on the flowsheet or in the electronic medical record concerning the significant discrepancy from the target weight. A limited encounter note was written by the physician on 06/04/2024. Acceptable IDWG (interdialytic weight gain) and achieving target weight were not addressed in the physician’s note. However, an interdisciplinary plan of care signed on 06/04/2024 declared the patient unstable due to concurrent conditions (patient has a history of cancer). MR#8 AD 01/21/2023 found that the HD treatment prescription contained an ordered target weight of 118 kg (kilograms). HD Treatment Records reviewed from 05/21/2024 to 05/30/2024 found the following: 05/30/2024: Post treatment weight was 119.8, a difference of 1.8 kg from the target weight of 118.0 kg. There was no indication that the licensed nurse was notified of the post weight above 1.0 kg from the target weight per facility policy, nor was there any documentation from the nurse addressing same. MR#9 AD 12/05/2022 found that the HD prescription contained an ordered target weight of 60.5 kg. and an ordered UFR (ultrafiltration rate) of 13.0 ml/kg/hr. HD Treatment Records reviewed from 05/20/2024 to 05/31/2024 found the following: 05/20/2024: Post treatment weight was 63.2 kg, a difference of 2.7 kg from the target weight of 60.5 kg. The actual UFR during treatment was 14.8 ml/kg/hr. 05/24/2024: Post treatment weight was 63.4 kg, a difference of 2.9 kg from the target weight of 60.5 kg. The actual UFR during treatment was 17.7 ml/kg/hr. 05/27/2024: Post treatment weight was 62.8 kg, a difference of 2.3 kg from the target weight of 60.5 kg. The actual UFR during treatment was 14.7 ml/kg/hr. 05/31/2024: The actual UFR during treatment was 15.7 ml/kg/hr. For the above treatments, there were no indications that the licensed nurse was notified of the post weight above 1.0 kg from the target weight as per facility policy, nor was there any documentation from the nurse addressing the target weight. There were no orders to change the ultrafiltration rate. An interview conducted with the manager of clinical services, facility administrator, group facility administrator, and regional operations director on June 5, 2024 starting at 2:00 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 facility policies/procedure, medical records (MR), hemodialysis (HD) treatment documentation, and an interview with the manager of clinical services, the facility failed to ensure that the blood flow rate (BFR) or dialysate flow rate was administered per physician order and/or the facility failed to provide documentation that a patient requested early treatment termination for four (4) of nine (9) MR’s reviewed: MR#3, MR#7, MR#8, and MR#9. Findings include: A review of Facility Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment conducted on June 3, 2024 at approximately 6:00 PM 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 (DFR). If the dialysis prescription is not being met the reason will be documented and the licensed nurse informed...” A review of Facility Policy 1-01-09 Prescribed Treatment Time Not Met conducted on June 3, 2024 at approximately 6:30 PM states in part, “The registered nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice Form any time the patient requests to terminate their treatment earlier than the prescribed run time. The RN will obtain the patient’s signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient’s signature prior to rinse-back, the RN will obtain the patient’s signature on the form prior to the patient’s departure from the facility. A RN must countersign all Early Termination of Treatment Against Medical Advice Forms. A witness signature is required only if the patient refuses to sign the form. If shortened/early termination of treatment exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs. Shortened/Early Termination of the dialysis treatment includes all reasons the prescribed dialysis time is not met by 30 or more minutes. This includes but is not limited to: the late initiation of treatment with termination at scheduled time, early termination at the end of treatment and interruptions of dialysis during treatment, i.e., machine or access problems or use of the bathroom by the patient. Reasons why a patient’s treatment may be terminated early include, but are not limited to:.....patient choice. If a patient’s treatment is shortened/early terminated, the RN will document the event in the patient’s electronic health record.... A completed copy of the Early Termination of Treatment Against Medical Advice form will be kept in the patient’s health record.” A review of Medical Records was conducted on June 4, 2024 from 8:00 AM to 3:00 PM, and again on June 5, 2024 from 10:00 AM to 11:00 AM. The admission date (AD) is indicated below. MR#3 AD 10/07/2020 found that the HD treatment prescription contained an ordered Dialysate Flow Rate (DFR) of 500 ml/min (milliters/minute). HD Treatment Records reviewed from 05/6/2024 to 5/31/2024 found the following: 05/8/2024: HD Treatment was initiated at 11:21 AM. The dialysate flow rate at 10:24 AM, 10:31 AM, 11:04 AM, 11:33 AM, 12:01 PM, 12:31 PM, 1:01 PM, 1:31 PM was 800 ml/min instead of 500 ml/min as ordered. At 10:29 AM, the prescription order was verified by the registered nurse on the HD Treatment Record. There were no physician orders or notes found indicating that the DFR should run at 800 ml/min. MR#7 AD 12/19/2020 found that the HD treatment prescription contained an ordered treatment duration of 4 hours(h), 0 minutes(m). HD Treatment Records reviewed from 05/21/2024 to 06/01/2024 found the following: 5/23/2024: Total treatment duration was 3h, 27m. There was no Early Termination of Treatment Against Medical Advice Form found in the medical record. 05/25/2024: Total treatment duration was 3h, 1m. There was no Early Termination of Treatment Against Medical Advice Form found in the medical record. MR#8 AD 01/21/2023 found that the HD treatment prescription contained an ordered treatment duration of 4h, 0m, and a Blood Flow Rate (BFR) of 350 ml/min (milliters/minute). HD Treatment Records reviewed from 05/21/2024 to 06/01/2024 found the following: 05/21/2024: Total treatment duration was 3h, 22m. There was no Early Termination of Treatment Against Medical Advice Form found in the medical record. 05/28/2024: HD Treatment was initiated at 11:21 AM. The blood flow rate at 11:21 AM, 12:02 PM, 12:32 PM, 1:02 PM, 1:32 PM, 2:02 PM, 2:32 PM, 3:02 PM was 400 ml/min instead of 350 ml/min as ordered. At 11:31 AM, the prescription order was verified by the registered nurse on the HD Treatment Record. There were no physician orders or notes found indicating that the BFR should run at 400 ml/min. MR#9 AD 12/05/2022 found that the HD treatment prescription contained an ordered treatment duration of 3h, 30m. HD Treatment Records reviewed from 05/20/2024 to 05/31/2024 found the following: 05/29/2024: Total treatment duration was 2h, 41m. There was no Early Termination of Treatment Against Medical Advice Form found in the medical record. An interview conducted with the manager of clinical services, facility administrator, group facility administrator, and regional operations director on June 5, 2024 starting at 2:00 PM confirmed the above findings.”