Fmc Nna of Providence

“Local, State, Tribal Collaboration Process CFR(s): §403.748(a)(4), §416.54(a)(4), §418.113(a)(4), §441.184(a)(4), §460.84(a)(4), §482.15(a)(4), §483.73(a)(4), §483.475(a)(4), §484.102(a)(4), §485.68(a)(4), §485.542(a)(4), §485.625(a)(4), §485.727(a)(5), §485.920(a)(4), §486.360(a)(4), §491.12(a)(4), §494.62(a)(4) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years [annually for LTC facilities]. The plan must do the following:] (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. * * [For ESRD facilities only at §494.62(a)(4)]: (4) Include a process for cooperation and collaboration with local, tribal, regional, State, and Federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency situation. The dialysis facility must contact the local emergency preparedness agency at least annually to confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency. This Standard is not met as evidenced by: 46715 Based on record review and staff interview it has been determined that the facility failed to develop a comprehensive emergency preparedness program that includes a process for cooperation and collaboration with local, tribal, regional, state, and federal emergency preparedness officials’ efforts to maintain an integrated response during a disaster or emergency. Findings are as follows: Review of a facility policy titled, “FKC [facility] Annual Facility Local Disaster Management Agency Contact Information Plan” dated 8/2/2017 states in part, “...The purpose of this policy is to provide guidance for Annual Notification to the Local Emergency Operations Center (EOC) or other agencies for disasters that interrupt services...Annually, the facility Director of Operations or Area Manager must contact the local EOC or similar agency to explain: The facility’s capabilities and capacities...To confirm that the agency is aware of the dialysis facility’s needs in the event of an emergency...To discuss ways to work together during a disaster situation...” Review of the facility’s Emergency Preparedness Binder revealed that the facility last collaborated with local, tribal, regional, state, and federal emergency preparedness officials in August of 2023. Additional review of the binder failed to reveal evidence that the facility collaborated with the above-mentioned emergency preparedness officials within the 2024 calendar year. During a surveyor interview on 4/25/2025 at 12:22 PM, with the Clinical Nurse Manager, he was unable to provide evidence that the facility had developed a comprehensive emergency preparedness program that included an annual collaboration with emergency preparedness officials, as required, and acknowledged that it should have been done. 47279”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 46715 Based on record review and staff interview, it has been determined that the facility failed to conduct all required exercises to test the facility’s emergency plan. This deficient practice has the potential to impact all in-clinic patients, as well as an indeterminable number of staff and visitors. Findings are as follows: Review of a facility policy titled, “Guidelines for Emergency Preparedness” dated 7/3/2023 states in part, “...Annually, each facility MUST participate in a community-based disaster drill...In addition to the community drills, facilities must select an event of high likelihood and conduct a table-top drill. It is recommended a different drill be completed annually...” Record review failed to reveal evidence that the facility conducted a facility based, full-scale emergency preparedness exercise, participated in a community-based exercise, or conducted a tabletop exercise that includes a group discussion designed to challenge the facility’s emergency plan during the 2024 calendar year. During a surveyor interview on 4/25/2025 at 12:22 PM with the Clinical Nurse Manager, he was unable to provide evidence that the facility participated in, or conducted, a full-scale emergency preparedness exercise or tabletop exercise to challenge their emergency plan and acknowledged they have should conducted a full-scale emergency preparedness exercise or tabletop exercise to challenge their emergency plan. 47279”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 46715 Based on surveyor observation and staff interview, it has been determined that the facility failed to ensure the staff thoroughly disinfect all surfaces of the dialysis stations and treatment areas for 1 of 2 staff members observed during the cleaning and disinfection of a patient treatment area, Certified Clinical Hemodialysis Technician, Staff A. Findings are as follows: Review of a facility policy titled, “Cleaning and Disinfecting the Dialysis Station” dated 9/5/2023 states in part, “...Use a cloth wetted with 1:100 bleach solution...to clean and disinfect the dialysis station...wall behind chair...Clean all surfaces...” During a surveyor observation on 4/22/2025 at 12:52 PM of the patient treatment area, after the dialysis treatment for a patient was completed and s/he had vacated the patient treatment area, Staff A, was observed cleaning and disinfecting Station #1. However, Staff A failed to clean and disinfect the countertop behind the chair. During a surveyor interview immediately following the above observation with Staff A, he acknowledged that he did not clean and disinfect the countertop behind the chair after the patient’s dialysis treatment. He revealed that he typically does not clean and disinfect the countertop behind the chair unless the patient places their belongings on it. During a surveyor interview on 4/24/2025 at approximately 3:15 PM, with the Clinical Nurse Manager, he revealed that he would expect staff to clean and disinfect the countertop behind the chair as part of the cleaning and disinfecting procedure. 47279”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 46715 Based on surveyor observation and staff interview it has been determined that the facility failed to ensure the room containing the water treatment system was restricted to only those employees who were responsible for monitoring and maintaining the water treatment system for 1 of 1 water treatment room. Findings are as follows: During a surveyor observation on 4/22/2025 at approximately 9:05 AM, during the initial flash tour, in the presence of the Clinical Nurse Manager, he accessed the water treatment room without utilizing a code, indicating persons who were not responsible for monitoring and maintaining the water treatment system could potentially gain access to the water treatment system. Additionally, a door that leads to the dialysis treatment room, from within the water treatment room, was propped open. During a surveyor interview, immediately following the above observation, with the Clinical Nurse Manager he revealed, that there is not a code to access the water treatment room. During surveyor observations from 4/22 through 4/25/2025, a unsecured door that provided access to conference rooms, an education room, offices and the water treatment room was accessed by the surveyors. During a surveyor interview on 4/25/2025 at 9:34 AM with the Clinical Nurse Manager he acknowledged the risk of the entrance door being unlocked which would allow unauthorized persons access to the water treatment room. During a surveyor observation on 4/25/2025 at 11:11 AM, in the presence of a Patient Care Technician, Staff B, the surveyor was able to open the door to the water treatment room without the use of a code. During a surveyor interview on 4/25/2025 at 11:20 AM with the Biomedical Technician, he revealed that there is a code for the door to the water treatment room, however, the striker plate on the door was malfunctioning making it possible to access the room without utilizing a code. The door was repaired after this concern was brought to the facility’s attention by the surveyor.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 46715 Based on surveyor observation and staff interview it has been determined that the facility failed to have a system to assure patient safety is in place, relative to a method for patients to call for help in the event of an emergency for 1 of 3 home dialysis (a treatment for kidney failure that helps remove unwanted toxins, waste products, and excess fluids from your blood when your kidneys are unable to perform this function) training rooms, the peritoneal dialysis (PD, treatment for kidney failure that uses the lining of the abdomen, known as the peritoneum, to filter blood inside the body) training room. Findings are as follows: During a surveyor observation on 4/22/2025 at approximately 9:15 AM, during the initial flash tour of the PD training room, revealed there was no call light or method for patients to call for help from within the room. During a surveyor interview during the above noted observation with a Home Therapy Registered Nurse (RN), Staff C, she revealed that at times patients left alone in the room for short periods. During a surveyor interview on 4/23/2025 at 1:26 PM with Home Therapy RN, Staff D, she acknowledged that there is not a call light in the PD training room or any other means for a patient to call for help. During a surveyor interview on 4/25/2025 at 9:58 AM with the Clinical Nurse Manager, he acknowledged that there is not a call light in the PD training room and there should be a method for patients to call for help, in the event of an emergency.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 41729 Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that each patient’s vascular access site and bloodline connections (the two tubes that are connected to the patient to clean the blood and to return the blood to the patient’s body) were able to be seen by staff throughout the hemodialysis treatment (a treatment that removes waste and excess fluid from the blood when the kidneys are not functioning to perform this task) for 2 of 4 days, during the survey process. Findings are as follows: Review of a facility policy titled, “Patient Assessment and Monitoring” dated 5/1/2023 states in part, “...Observe connections are secure and visible...Ensure access remains uncovered throughout the treatment...” 1a. During a surveyor observation on 4/22/2025 at 12:42 PM, Patient ID #17 was receiving a dialysis treatment, and his/her vascular access site and bloodline connection was covered and not visible. 1b. During a surveyor observation on 4/23/2025 at approximately 10:00 AM, Patient ID #14 was receiving a dialysis treatment and his/her vascular access site and bloodline connections were covered and not visible to the staff. 1c. During a surveyor observation on 4/23/2025 at approximately 10:00 AM, Patient ID #16 was receiving a dialysis treatment and his/her vascular access site and bloodline connections were covered and not visible to the staff. During a surveyor interview and observation of Patient ID #s 14 and 16 on 4/23/2025 at 11:07 AM, with the Clinical Nurse Manager, he acknowledged Patient ID #s 14 and 16 access sites and bloodline connections were covered and not visible to the staff. Additionally, he revealed that he would expect that the patients’ access sites and bloodline connections to be visible throughout the patients’ dialysis treatment.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 46539 Based on staff interview and record review, it has been determined that the facility failed to ensure that staff follow the hemodialysis (HD, a procedure where a dialysis machine and a special filter called an artificial kidney, or a dialyzer, are used to clean the blood) prescription when administering HD treatments for 8 of 8 patients reviewed, Patient ID #s 1, 3, 5, 6, 10, 12, 13, and 14. Findings are as follows: Review of a facility policy titled, “Unable to Achieve Prescribed Blood Flow Rate” dated 11/1/2021, states in part, “...Notify physician/extender if unable to achieve prescribed blood flow rate...Document in patients treatment record what action taken to address the inadequate blood flow and if unable to resolve. The nurse shall document any physician orders...” 1. Record review revealed that Patient ID #1 was admitted to the facility in June of 2023 with a diagnosis of end stage renal disease (ESRD) and is receiving HD three times per week. Further review of the record revealed the patient’s current dialysis prescription order is for a dialysate flow rate (DFR) of 800 milliliter/minute (ml/min) and a blood flow rate (BFR, the speed that the patient’s blood is moving through the dialysis tubing) of 500 ml/min. Review of the dialysis treatment flow sheets revealed that Patient ID #1 received his/her treatment with a BFR less than the ordered 500 ml/min on the following dates: - 4/10/2025 with a BFR of 425 ml/min and 480 ml/min - 4/12/2025 with a BFR of 350 ml/min - 4/19/2025 with a BFR of 450 ml/min. Further review of the record failed to reveal evidence that the physician was notified that Patient ID #1 did not receive his/her dialysis treatments as ordered, a rationale as to why the BFR was adjusted, or what action was taken to address the inadequate blood flow. 2. Record review revealed Patient ID #3 was admitted to the facility in March of 2025 with a diagnosis of ESRD and is receiving HD three times per week. Further review of the record revealed the patient’s current dialysis prescription order is for a DFR of 800 ml/min and BFR of 500 ml/min. Review of the dialysis treatment flow sheets revealed that Patient ID #3 received his/her treatment with a BFR less than the ordered 500 ml/min on the following dates: - 4/15/2025 with a BFR of 490 ml/min - 4/17/2025 with a BFR of 475 ml/min - 4/22/2025 with a BFR of 470 ml/min Further review of the record failed to reveal evidence that the physician was notified that Patient ID #3 did not receive his/her dialysis treatments as ordered, a rationale as to why the BFR was adjusted, or what action was taken to address the inadequate blood flow. 3. Record review revealed that Patient ID #5 was admitted to the facility in February of 2023 with a diagnosis of ESRD and is receiving HD three times per week. Further review of the record revealed a current dialysis prescription order for a DFR of 800 ml/min and BFR of 500 ml/min. Review of the dialysis treatment flow sheets revealed that Patient ID #5 received his/her treatment with a BFR less than the ordered 500 ml/min on the following dates: - 4/15/2025 with a BFR of 450 ml/min - 4/10/2025 with a BFR of 490 ml/min, 480 ml/min, and 470 ml/min Further review of the record failed to reveal evidence that the physician was notified that Patient ID #5 did not receive his/her dialysis treatments as ordered, a rationale as to why the BFR was adjusted, or what action was taken to address the inadequate blood flow. 4. Record review revealed that Patient ID #6 was admitted to the facility in October of 2017 with a diagnosis of ESRD and is receiving HD three times per week. Further review of the record revealed a current dialysis prescription order for a DFR of 800 ml/min and a BFR of 500 ml/min. Review of the dialysis treatment flow sheets revealed that Patient ID #6 received his/her treatment with a BFR less than the ordered 500 ml/min on the following dates: - 3/13/2025 with a BFR of 450 ml/min - 3/15/2025 with a BFR of 450 ml/min - 3/18/2025 with a BFR of 350 ml/min - 3/20/2025 with a BFR of 350 ml/min, 390 ml/min, and 400 ml/min - 3/22/2025 with a BFR of 380 ml/min and 420 ml/min - 3/25/2025 with a BFR of 400 ml/min - 3/27/2025 with a BFR of 450 ml/min - 3/29/2025 with a BFR of 450 ml/min - 4/3/2025 with a BFR of 400 ml/min and 430 ml/min - 4/5/2025 with a BFR of 450 ml/min - 4/8/2025 with a BFR of 300 ml/min, 350 ml/min, and 400 ml/min Further review of the record failed to reveal evidence that the physician was notified that Patient ID #6 did not receive his/her dialysis treatments as ordered, a rationale as to why the BFR was adjusted, or what action was taken to address the inadequate blood flow. 5. Record review revealed that Patient ID #10 was admitted to the facility in February of 2022 with a diagnosis of ESRD and is receiving HD three times per week. Further review of the record revealed a current dialysis prescription order for a DFR of 800 ml/min and a BFR of 500 ml/min. Review of the dialysis treatment flow sheets revealed that Patient ID #10 received his/her treatment with a BFR less than the ordered 500 ml/min on the following dates: - 4/11/2025 with a BFR of 450 ml/min - 4/14/2025 with a BFR of 350 ml/min, 400 ml/min, and 450 ml/min - 4/16/2025 with a BFR of 350 ml/min, 400 ml/min, 410 ml/min, and 450 ml/min - 4/18/2025 with a BFR of 200 ml/min, 400 ml/min, and 450 ml/min - 4/21/2025 with a BFR of 400 ml/min, 425 ml/min and 450 ml/min - 4/23/2025 with a BFR of 400 ml/min Further review of the record failed to reveal evidence that the physician was notified that Patient ID #10 did not receive his/her dialysis treatments as ordered, a rationale as to why the BFR was adjusted, or what action was taken to address the inadequate blood flow. 6. Record review revealed that Patient ID #12 was admitted to the facility in July of 2018 with a diagnosis of ESRD and is receiving HD three times per week. Further review of the record revealed a current dialysis prescription order for a DFR of 800 ml/min and a BFR of 500 ml/min. Review of the dialysis treatment flow sheets revealed that Patient ID #12 received his/her treatment with a BFR less than the ordered 500 ml/min on the following dates: - 4/11/2025 with a BFR of 350 ml/min, 400 ml/min, and 450 ml/min - 4/14/2025 with a BFR of 400 ml/min and 425 ml/min - 4/16/2025 with a BFR of 400 ml/min and 425 ml/min - 4/18/2025 with a BFR of 450 ml/min - 4/21/2025 with a BFR of 450 ml/min - 4/23/2025 with a BFR of 400 ml/min and 430 ml/min Further review of the record failed to reveal evidence that the physician was notified that Patient ID #12 did not receive his/her dialysis treatments as ordered, a rationale as to why the BFR was adjusted, or what action was taken to address the inadequate blood flow. 7. Record review revealed that Patient ID #13 was admitted to the facility in October of 2021 with a diagnosis of ESRD and is receiving HD three times per week. Further review of the record revealed a current dialysis prescription order for a DFR of 800 ml/min and BFR of 500 ml/min. Review of the dialysis treatment flow sheets revealed that Patient ID #13 received his/her treatment with a BFR less than the ordered 500 ml/min on the following dates: - 4/11/2025 with a BFR of 300 ml/min, 375 ml/min, 400 ml/min, and 450 ml/min - 4/23/2025 with a BFR of 450 ml/min Further review of the record failed to reveal evidence that the physician was notified that Patient ID #13 did not receive his/her dialysis treatments as ordered, a rationale as to why the BFR was adjusted, or what action was taken to address the inadequate blood flow. 8. Record review revealed that Patient ID #14 was admitted to the facility in October of 2020 with a diagnosis of ESRD and is receiving HD three times per week. Further review of the record revealed a current dialysis prescription order for a DFR of 800 ml/min and BFR of 500 ml/min. Review of the dialysis treatment flow sheets revealed that Patient ID #14 received his/her treatment with a BFR less than the ordered 500 ml/min on the following dates: - 4/14/2025 with a BFR of 475 ml/min - 4/23/2025 with a BFR of 450 ml/min Further review of the record failed to reveal evidence that the physician was notified that Patient ID #14 did not receive his/her dialysis treatments as ordered, a rationale as to why the BFR was adjusted, or what action was taken to address the inadequate blood flow. During a surveyor interview with the Clinical Nurse Manager, on 4/25/2025 at 9:34 AM, he revealed that staff are titrating the blood flow rates without notifying the provider. Additionally, he acknowledged that the staff are not documenting what action was taken to address the inadequate blood flow or why the BFR was adjusted. Furthermore, he acknowledged that the dialysis prescription orders were not followed for the above-mentioned patients on the above-mentioned dates and would expect the physician to be notified and for staff to document the interventions and the rationales for adjusting the BFRs.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 41729 Based on record review and staff interview, it has been determined that the facility failed to maintain complete and accessible records on all patients, including home patients whose care is under the supervision of the facility for 1 of 3 patients that is receiving peritoneal dialysis (PD, a treatment for kidney failure that uses the lining of the abdomen, or belly, to filter the blood and remove waste products and excess fluids from the blood) at home, Patient ID #4. Findings are as follows: Review of a facility policy titled “Clinic Visits for Home Dialysis Patients” dated 11/1/2021 states in part, “...Review home treatment records, self-monitoring data and other information recorded by the patient or designated care partner for completeness and trends. Manually recorded treatment related documentation shall be collected from the patient/care partner and maintained in the patient’s medical record...” Record review revealed the patient was admitted to the facility in July of 2024 with a diagnosis of end stage renal disease (a severe condition where the kidneys are unable to filter waste and excess fluid from the blood requiring dialysis) and is receiving PD at home. Record review revealed a physician’s order dated 1/28/2025 for PD seven days a week with dialysate (a dialysis cleansing solution used during dialysis to remove waste and excess fluids from the blood) 1.5%, 2.5%, and 4.5% dextrose (a type of sugar, used as a primary agent in the PD dialysis solution to help filter waste, and excess fluid from tiny blood vessels in the lining of the abdomen), cycle therapy time of seven hours and five minutes and an average dwell time (the duration the dialysate stays in the abdomen to allow waste products and excess fluid to move from the blood stream into the dialysate) of one hour and fifteen minutes. Record review failed to reveal evidence of a medical record that was maintained by the facility that included documentation of home treatments, self- monitoring data, including but not limited to; pre and post dialysis vital signs, weights and the type of dialysate used for his/her PD treatments. During a surveyor interview on 4/24/2025 at 1:04 PM with Home Therapy Registered Nurse (RN), Staff D, she indicated that the patient receives PD at home seven days a week. Staff D, further indicated that the patient documents his/her treatments including his/her vital signs in a notebook and not in the electronic records that are transmitted to the facility. Staff D, acknowledged that the patient’s treatments and vital signs are not recorded or transcribed in the patient’s record at the facility. During a surveyor interview on 4/25/2025 at 10:43 AM with the Clinical Nurse Manager, he indicated that he would expect copies of the patient’s home treatment records to be kept at the facility. Additionally, he was unable to provide evidence that the patient’s home treatment records and self-monitoring data was manually recorded or collected from the patient and maintained in his/her medical record per the facility’s policy. During a surveyor interview on 4/25/2025 at 12:26 PM with the patient’s Physician, Staff E, he indicated that the patient records his/her treatment record in a notebook at his/her home. Additionally, he indicated that he would expect the staff to follow the facility’s policy related to medical records and was unable to provide evidence that the facility maintained a copy of the patient’s treatment records.”