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“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the facility’s social worker failed to complete the patients initial Kidney Disease Quality of Life (KDQOL)-36 survey by the 90 day Plan of Care (POC) meeting per the facility’s policy in 2 of 7 sampled patients: Patient #s 4, 6 Findings: Review of the facility’s current policy and procedure on Social Work Services, published 04/04/2012 directs staff as follows: “Documentation ... Information obtained by the qualified social worker related to the patient’s psychosocial needs should be entered promptly in the patient’s current medical record for example: “ Individual or team discussion with members of the interdisciplinary team regarding the patient’s KDQOL 36 results and any resulting changes to the plan of care. “ Changes to the plan of care should be recorded at the time of the 90 day and annual POC meetings or at other intervals when the KDQOL 36 has been administered. Documentation shall be in accordance with federal and state rules and regulations. For example, some state ESRD regulations may require the social workers to provide assessment and contact notes on a monthly or quarterly basis this would be in addition to ongoing documentation that is required whenever there is a contact with more about the patient status.” Patient #4 Observation of Patient #4 in Training Room #1 on 05/07/2025 at 2:03 p.m. revealed she was sitting in the dialysis chair receiving a foot check. Review of the patient’s clinical record on 05/07/2025 revealed the patient was admitted to the facility on 12/04/2024 with diagnoses of end stage renal disease and type 2 diabetes, on peritoneal dialysis five times weekly. Review of the patient’s 90 day interdisciplinary plan of care revealed the meeting was held on 04/09/2025. The patient’s KDQOL-36 scores were not discussed with the Interdisciplinary Team (IDT) during the POC meeting. The KDQOL-36 tool was not completed until 05/08/2025. Patient #6 Review of the patient’s clinical record on 05/07/2025 revealed the patient was admitted to the facility on 12/16/2024 with diagnoses of end stage renal disease, cerebrovascular accident, hypertension and type 2 diabetes, on home hemodialysis five times weekly. Review of the patient’s initial KDQOL-36 survey revealed the tool was completed on 05/08/2025. The following score was flagged: Mental Component Summary (MCS) Score: 35.9 Average Range: 39.8 to 61.2 Results: The Current Score is below the average risk range. Review of the patient’s 90 day interdisciplinary plan of care revealed the meeting was held on 04/21/2025. The patient’s KDQOL-36 scores were not discussed with the Interdisciplinary Team (IDT) during the POC meeting. The KDQOL-36 tool was not completed until 05/08/2025. Interview with Social Worker (G) on 05/08/2025 at 4:17 p.m. confirmed that the KDQOL-36 surveys for Patient #s 6 and 4 were completed on 05/08/2025 and the scores were not available for discussion during the 90 day IDT POC meeting.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 48020 Based on observation and interview, the facility’s interdisciplinary team failed to ensure participation by the patient in the interdisciplinary care plan in 1 of 7 sampled patients: Patient #4 Findings: Review of the facility’s current Policy and Procedure on Comprehensive Interdisciplinary Assessment and Plan of Care; Policy #45283, published 07/03/2023 directs staff as follows: “Comprehensive Assessment Participation and Plan of Care Review “ The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record.” Patient #4 Observation of Patient #4 in Training Room #1 on 05/07/2025 at 2:03 p.m. revealed she was sitting in the dialysis chair receiving a foot check. Review of the patient’s clinical record on 05/07/2025 revealed the patient was admitted to the facility on 12/04/2024 with diagnoses of end stage renal disease and type 2 diabetes, on peritoneal dialysis five times weekly. Review of the patient’s initial interdisciplinary Plan of Care (POC) dated 01/08/2025 revealed approval signatures for the physician on 01/09/2025, registered nurse and social worker on 01/08/2025 and registered dietitian on 01/10/2025. The “Patient Approval Signature” and the “Patient chooses not to sign plan of care” check box were left blank. Review of the patient’s 90 day interdisciplinary Plan of Care (POC) dated 04/09/2025 revealed approval signatures for the physician and registered nurse on 04/09/2025, social worker on 04/10/2025 and registered dietitian on 04/14/2025. The “Patient Approval Signature” and the “Patient chooses not to sign plan of care” check box were left blank. Interview with Area Administrator (K) on 05/08/2025 at 3:04 p.m. confirmed that Patient #4 did not participate in her initial and 90 day plan of care as evidence by her acknowledgement signature.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, facility failed to ensure all patients create a treatment record for every dialysis treatment according to policy 1 of 7 sampled patients: Patient #5 Findings Review of the facility’s current policy and procedure: Review and Documentation of Home Therapies Patient Health Data reference number 23557 directs the staff as follows: “Policy The patient will create a treatment record for every dialysis treatment according to policy and regulatory requirements. Treatment data will be reviewed by the home therapies nurse in order to identify trends, determine if patients are following their treatment plans or having problems with their dialysis at home. Data Transmission Interruptions In instances in which the patient is not transmitting any data electronically or via portable device (i.e., IQ card, ProCard), whether intermittently due to patient choice or as the result of connectivity issues, they may be required to document treatment data via paper flowsheets and regularly provide the flowsheets for review by the home therapies nurse. The home therapies staff will assist the patient in troubleshooting equipment, technology or other data transmission errors as needed, and notify the patient when completion of paper flowsheets may be necessary until electronic data submission can be restored.” Patient #5 Observation of Patient #5 in Training Room #5 on 05/07/2025 at 2:30 p.m. revealed the patient sitting the in dialysis chair receiving a foot check. Review of the patient’s clinical record revealed the patient was admitted to the facility on 07/24/2024 with diagnoses of end stage renal disease, congestive heart failure, other cardiac disease, peripheral vascular disease, hypertension, amputation, diabetes on insulin and diabetic retinopathy, on peritoneal dialysis seven times weekly. Review of the Patient Summary report from 01/13/2025 - 04/15/2025 revealed the patient completed 82 treatments. There was blood pressure documentation on 02/25/2025, 03/21/2025 and 03/26/2025. There was no other blood pressures documented for the 3 months. There were no heart rates documented for the 3 months. The patient did not create a treatment record for every dialysis treatment according to policy. The nurse documented “Patient will write in separate sheet/input in cycler. Reviewed with patient.” and initialed the note at the bottom of the first page of the Patient Summary report. The patient reported for the monthly clinic visit on 02/10/2025, 03/18/2025 and 4/15/2025 but the nurse did not document the review of the missing vital signs with the patient until 04/15/2025. Interview with Home Therapy Program Manager (H) on 05/08/2025 at 4:15 p.m. confirmed the above findings.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 48020 Based on observation, record review and interview: the facility’s nurses failed to review and address actionable health data per the facility’s policy in 2 of 7 sampled patients: Patient #s 1, 3 B) the facility’s governing body failed to ensure expired supplies are not stored, and in use in the facility for care and services of patients per policy. Findings: Review of the facility’s current policy and procedure on Review and Documentation of Home Therapies Patient Health Data; Policy #23557 directs staff as follows: “Review and Documentation of Health Data Electronically transmitted data will be reviewed in CareTeamHub by the home therapies nurse or appropriate staff member on a routine and ongoing basis between clinic visits. Actionable health data will be reviewed and addressed by the home therapies nurse or appropriate staff member in a timely manner. Follow up communication with the patient, including interventions or instructions as needed, would be documented in the patient’s medical record.” Review of the facility’s current policy and procedure on Emergency Medications, Equipment and Supplies, published 02/03/2025 directs staff as follows: “Emergency Cart “ An itemized log must be kept indicating the contents and expiration dates of contents. Items approaching expiration must be reordered and replaced prior to the actual expiration date.” Review of the facility’s current policy and procedure on Storage of Supplies, published 04/05/2021 directs staff as follows: “Background Proper storage conditions are necessary to provide a safe environment and to ensure supplies are not expired, contaminated and damaged. Policy “ Supplies must be rotated First in-First Out (FIFO) to ensure products maintain quality and do not expire. Appropriately dispose of items that have reached the expiration date.” Review of the facility’s current policy and procedure Expiration Dates Sterile Supplies, published 07/04/2012 directs staff as follows: “Sterile items will be checked before use to ensure that they have not expired. Appropriately dispose of sterile items that have reached the expiration date.” Nurse review and address Patient #1 Review of the patient’s clinical record on 05/07/2025 revealed the patient was admitted to the facility on 02/23/2024 with diagnoses of end stage renal disease and hypertension, on peritoneal dialysis seven times weekly. Review of treatment flowsheet dated 03/08/2025 revealed the following documentation: Blood pressure of 182/103 mmHg Review of Clinical Nurse Report revealed a nurse note on 03/06/2025 and 03/10/2025. There were no nurse notes documented on 03/08/2025 or 03/09/2025 in the patient’s medical record to address the patient’s elevated blood pressure. Review of the patient’s Peritoneal Dialysis Admission and Standing Orders signed by the physician on 01/02/2025 reveals the following order: “Notify MD if BP is greater than: 180/100 mmHg of BP is less than: 90/60 mmHg” Patient #3 Review of the patient’s clinical record on 05/07/2025 revealed the patient was admitted to the facility on 02/02/2022 with diagnoses of end stage renal disease, other cardiac disease, hypertension and diabetes on oral medications, on peritoneal dialysis seven times weekly. Review of treatment flowsheet dated 03/04/2025 revealed the following documentation: Blood pressure of 87/74 mmHg and pulse of 112 beats per minute Review of Clinical Nurse Report revealed a nurse note on 03/04/2025 at 12:02 p.m. with the following documentation: “He called and reported that he never received the email from __. Patient aware about the appointment for 3/6/25 for Dr. __. Reported to __, RN.” There was no mention of the elevated pulse. There were no other nurse notes documented on 03/04/2025 in the patient’s medical record to address the patient’s low blood pressure and elevated pulse. Review of Clinical Nurse Report revealed a nurse note on 03/04/2025 at 12:45 p.m. with the following documentation: “Patient reported that he have a question about the new PD prescription using the USB drive. Reported to __, RN. There was no mention of the elevated pulse. There were no other nurse notes documented on 03/05/2025 in the patient’s medical record to address the patient’s low blood pressure and elevated pulse. Review of the patient’s Peritoneal Dialysis Admission and Standing Orders signed by the physician on 01/02/2025 reveals the following order: “Notify MD if BP is greater than: 180 mmHg of BP is less than: 100 mmHg systolic; Pulse >100 or pulse <50” Interview during record review with Home Therapy Program Manager (H) on 05/07/2025 starting at 1:30 p.m. confirmed the above findings. Expired Supplies Observation during a tour of the facility on 05/06/2025 beginning at 09:12 a.m. revealed the following expired supplies: Emergency cart: 1 - Bemis Hydrophobic 800 cc suction canister in the bottom drawer, Ref# 424410, expiration date 2021-07-01 Notification to Home Therapy Program Manager (H) on 05/06/2025 at 9:48 a.m. revealed she said about Home Therapy Registered Nurse (A) who completed the checklist, “She didn’t look at this one”. Training Room #5: 16 - NxStage Master Guard Plus TwinPack+ Hemodialysis Fistula Needle Sets 17GX1”, Lot# 220125F6, expiration date 2025-01-31 Interview during observation with Area Technical Manager (C) on 05/06/2025 at 10:54 a.m. verified the above findings.”