Liberty Dialysis Huntsville

“COMPLIANCE WITH FED/STATE/LOCAL LAWS CFR(s): 494.20 The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements. This Standard is not met as evidenced by: 37322 On record review and interview, the facility’s governing body failed to ensure patients’ physicians (Nephrologist) conduct visits every two weeks on patients, while patients are receiving hemodialysis treatment in the facility in 3 of 7 (Patient ID#s 2,3,6) records reviewed as required by the state regulations. Findings: During medical record review in the facility on 03/03/2025 along with clinic manager, staff ID #B it was noted the physician ID#F failed to document progress notes every 14 days as required. Records Reviewed: Records documented a physician progress notes for the following dates in the patient’s records by physician ID #F that did not meet every 14-day requirement: Patient ID #2 12/18/24-01/08/2025: 21 days 01/08/25-01/23/25: 15 days- Patient ID #3 01/08/25-01/23/2025: 15 days 01/23/2025-02/12/2025: 20 days Patient ID #6 12/02/24-12/18/2024: 16 days 12/18/24-01/08/25: 21 days 01/08/25-01/23/25: 15 days Records documented a physician progress notes for the following dates in the patient’s records by physician ID # F that did not meet every 14-day requirement: Interview in the conference room on 03/03/2025 at 15:00 PM with the clinic manager, staff #B confirmed there was no documentation of every 2-week physician as required. No additional information was received prior to exit of the survey.”

“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: 30124 Based on record review and interview the medical director failed to ensure staff follow their current policy in that registered nurses failed to ensure patient’s hemodialysis prescription was verified within the first hour of initiation of treatment in 3 of 7 records reviewed (patient ID# 1, 2, 3). Policy Reviewed: Review on 03/03/2025 along with staff ID #D of the facility’s current policy tiled “Nursing Supervision and Delegation”, Published 11/06/2023 Reference Number: 45265; Version: 6. Purpose: The purpose of the policy is to provide guidance regarding nurse supervision and delegation of tasks to other licensed and unlicensed staff in the outpatient setting. Policy: The registered nurse must evaluate each patient preferably within an hour or according to state requirements (ex. NY requires an evaluation within 45 minutes of treatment initiation) to: o Confirm identify o Review the patient’s condition. o Review accuracy and completeness of treatment and patient data o Review patient treatment prescription and equipment parameters to verify correct settings, and if dialysis prescription is being followed. o Confirm that the correct vascular access is being used, and that the access is visible. Observe patient’s response to treatment. o Verify machine safety checks have been completed. o Talk to the patient to elicit information such as changes in condition, response to treatment, new injuries, information/education needs or complaints, satisfaction with care. Record Review on 03/03/2025 along with staff ID # D the following was identified in patient records: Patient ID #1 02/11/2025 - hemodialysis treatment initiated at 11:41 AM. No documentation was found that the registered nurse verified the patient was on the correct hemodialysis prescription within the first hour of treatment. 02/13/2025 2025 - hemodialysis treatment initiated at 11:45 AM. No documentation was found that the registered nurse verified the patient was on the correct hemodialysis prescription within the first hour of treatment. Patient ID #2 02/15/2025 - hemodialysis treatment initiated at 007:05 AM. No documentation was found that the registered nurse verified the patient was on the correct hemodialysis prescription within the first hour of treatment. Nursing note documented verification of prescription at 06:55 AM which was prior to initiation of treatment. 02/17/2025 - hemodialysis treatment initiated at 06:10 AM. No documentation was found that the registered nurse verified the patient was on the correct hemodialysis prescription within the first hour of treatment. Nursing note documented verification of prescription at 06:00 AM which was prior to initiation of treatment. 02/17/2025 - hemodialysis treatment initiated at 06:15 AM. No documentation was found that the registered nurse verified the patient was on the correct hemodialysis prescription within the first hour of treatment. Nursing note documented verification of prescription at 06:06 AM which was prior to initiation of treatment. Patient ID #3 02/17/2025 - hemodialysis treatment initiated at 15:25 PM. No documentation was found that the registered nurse verified the patient was on the correct hemodialysis prescription within the first hour of treatment. Interview on 03/03/2025 at 16:30 PM with clinic staff ID #D confirmed the above finding.”