Bellaire Dialysis

“RO-MEETS AAMI/MONITORED, RECORDED ON LOG CFR(s): 494.40(a) 5.2.7 Reverse osmosis: meets AAMI/monitored/recorded on log Refer to RD62:2001, 4.3.7 Reverse osmosis: When used to prepare water for hemodialysis applications, either alone or as the last stage in a purification cascade, reverse osmosis systems shall be shown to be capable, at installation, of meeting the requirements of Table 1, when tested with the typical feed water of the user, in accordance with the methods of [AAMI] 5.2.2. 5.2.7 Reverse osmosis Users should carefully follow the manufacturer’s instructions for feed water treatment and monitoring to ensure that the RO is operated within its design parameters. 6.2.7 Reverse osmosis All results of measurements of RO performance should be recorded daily in an operating log that permits trending and historical review. This Standard is not met as evidenced by:”

“PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility’s interdisciplinary team consists of, at a minimum, the patient or the patient’s designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient’s treatment plan and expectations for care. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review the facility interdisciplinary team failed to complete comprehensive interdisciplinary patient assessment on patients in 1 of 5 sampled patients; #s 5 Findings Patient #5 On 05/6/2024 at 1:40 p.m. Patient #5 was observed on the facility’s hemodialysis unit at station # 3. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mls/ minute and dialysis flow rate of 500 mls/ minute left double lumen central venous catheter. Review of Patient #5’s clinical record (patient information) revealed the patient was admitted to the facility on 3/25/2024 with diagnosis hypertension, and end stage renal disease on in center hemodialysis three times weekly. Review of an interdisciplinary comprehensive assessment provided by the Facility’s Administrator revealed there was no assessment completed by the Registered Nurse. On 05/06/2024 the Surveyor reviewed the record with the Facility’s Administrator, she said the registered nurse did not complete her portion of the interdisciplinary comprehensive assessment.”

“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: 10802 Based on record review and interview, facility’s interdisciplinary team failed to complete annual comprehensive interdisciplinary assessment on patient in 1 of 5 sampled patients. Patient #3 Findings: Patient #3 On 05/06/2024 at 7:29 a.m. Patient #3 was observed on the treatment floor of the facility at station # 4. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysate flow rate of 500 mls/ minute via left upper arm vascular access. Review of the patient’s clinical record revealed the patient was admitted to the facility on 09/03/2018 with diagnosis of systemic lupus erythematosus, osteoporosis, bilateral hip replacement and end stage renal disease on in center hemodialysis three times weekly. Review of the patient’s clinical record revealed no current annual interdisciplinary comprehensive assessment completed on the patient. On 05/06/2024 the Surveyor requested from the Facility’s Administrator an annual interdisciplinary comprehensive assessment on the patient. She states, “ I did it but cannot locate it.””

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, the facility failed to ensure the interdisciplinary team complete comprehensive interdisciplinary care plan on patients in 1 of 5 sampled patients; Patient #5 Findings Patient #5 On 05/6/2024 at 1:40 p.m. Patient #5 was observed on the facility’s hemodialysis unit at station # 3. The patient was receiving hemodialysis treatment at a blood flow rate of 400 mls/ minute and dialysis flow rate of 500 mls/ minute left double lumen central venous catheter. Review of Patient #5’s clinical record (patient information) revealed the patient was admitted to the facility on 3/25/2024 with diagnosis hypertension, and end stage renal disease on in center hemodialysis three times weekly. Review of an interdisciplinary comprehensive assessment provided by the facility’s Administrator revealed there was no interdisciplinary care plan developed by the interdisciplinary team. On 05/06/2024 the Surveyor reviewed the record with the Facility’s Administrator, she said it was not done.”

“QAPI-QAPI-IMMEDIATELY CORRECT ANY IJ ISSUES CFR(s): 494.110(c) The facility must immediately correct any identified problems that threaten the health and safety of patients. This Standard is not met as evidenced by: 10802 Based on record review and interview, the facility’s quality assessment performance improvement team failed to address deficiencies cited during its Medicare Recertification Survey conducted. (A) Based on observation, and interview, the facility’s staff failed to maintain an uncluttered, clean, and sanitary environment. This was not addressed in its quality assessment performance Improvement committee meeting. (B) Based on observation, interview and record review, the facility failed to implement its policy to ensure patients’ attending nephrologists complete two weekly comprehensive visits on patients and document this visit to include patient’s progress notes patients addressing adequacy, vascular access, anemia management, nutritional status, bone mineral metabolism and treatment response. in 5 of 5 sampled patients: Patient #s 5, 3, 4, 1 and 2. This was not addressed in its quality assessment performance Improvement committee meeting. (C) Based on record review and interview Facility’s quality assessment performance Improvement committee failed to analyze data on on upward trend in patients’ hospitalizations and develop and implement a plan to address same. Findings: Observation on 05/6/2024 at 2:45 p.m. of a storage room adjacent to the administration office revealed the following: One large white concentrate mixing tank, food, expired supplies, supplies in use and patients records commingled and stored directly on the floor of the room. One Large white Rockwell concentrate mixing tank. Signage for ambulance parking only One box of 66 Parle G cookies expired 10/2020 Two boxes BYD surgical mask Lot number HL200718 expired 7/17/2022. Two boxes of 20 N95 masks Lot # 6200713 expired 7/12/2022. One box of 20 N95 masks Lot # 6200422 expired 4/21/2022. One box of 20 N95 masks Lot # 6200428 expired 4/27/2022. One bottle Calrite14.0 standard solution Lot # 24031323A expired 3/28/2024. One bottle Calrite 7.0 standard solution Lot # 11032123A expired 3/28/2024. One clear plastic bag with multiple hypodermic injection needles with various expiration date of 12/19/2023 Three opened boxes of patients’ clinical records labeled 2018- 2020. One box of opened gloves stored directly on the floor Interview on 05/06/ 2024 with the facility’s Regional Administrator he states “ I am tired of this s---. “ He said he has being trying to get the environment clean and the expired supplies which came from another facility removed but he is getting push back from the facility’s Medical Director. Review of the facility’s quality assessment performance improvement meeting minutes dated 04/30/2024 revealed no evidence that the committee addressed deficiencies cited during the Recertification survey of 3/22/2024. Environment Observation during the Recertification survey revealed deficiencies were cited for unsanitary, cluttered environment. Observation on 05/6/2024 at 2:45 p.m. of a storage room adjacent to the administration office revealed the following: One large white concentrate mixing tank, food, expired supplies, supplies in use and patients records commingled and stored directly on the floor of the room. Review of the quality assessment performance improvement meeting minutes revealed no root cause or plan was developed and implemented to address the cluttered, unsanitary environment. Physician visit Record review and interview during the Recertification survey revealed deficiencies were cited for the facility failure to implement its policy to ensure patient’s attending nephrologists complete two weekly comprehensive visits on patients and document this visit to include patient’s progress notes patients addressing adequacy, vascular access, anemia management, nutritional status, bone mineral metabolism and treatment response. Review on 05/06/2024 of a sample of patients’ clinical records revealed documentation which indicated physicians visited were documented on 5/12/2024. Documentation in the patients’ clinical records ( physician’s progress notes) revealed physician’s visits were not documented completed every two weeks as stated in the facility’s policy. This was not addressed in the facility’s quality assessment improvement meeting minutes conducted on 04/30/2024 Hospitalizations: Review of the facility’s hospitalization data revealed the facility had 6 patients’ admissions to the hospital in January 2024 and 10 patients’ admissions to the hospital in February 2024. Some patients had multiple admissions. There was no documentation that the facility’s QAPI analyze the data, conducts a root cause, or develops and implements a plan to address the upward trend in hospitalizations. Review of the meeting minutes dated 4/30/2024 revealed the following documented plan the plan for hospitalization of patients: “ Hospitalization log completed in a timely manner. “ On 05/06/2024 the Surveyors reviewed the quality assessment performance improvement meeting minutes with the Facility’s Administrator and Regional Director who confirmed these deficient practices were not addressed in the minutes of the meeting. 48020 Patient #1 Observation on 05/06/2024 at 7:33 a.m., revealed Patient #1 was observed at station #12, hemodialysis machine #3 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 04/01/2020 with diagnosis of hypertension, diabetes mellitus on insulin, and end stage renal disease, on in-center hemodialysis three times weekly. Review of the patient’s clinical record (Physician Progress Note) revealed the most recent physician progress note was documented on 04/12/2024. Patient #2 Observation on 05/06/2024 at 7:49 a.m., revealed Patient #2 was observed at station #15, hemodialysis machine #20 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of 500 mL/min via a left lower arm vascular access. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 07/24/2020 with diagnosis of hypertension, diabetes mellitus on insulin, and end stage renal disease, on in-center hemodialysis three times weekly. Review of the patient’s clinical record (Physician Progress Note) revealed the most recent physician progress note was documented on 04/12/2024.”

“CFC-PHYSICAL ENVIRONMENT CFR(s): 494.60 This Condition is not met as evidenced by: 10802 Based on observation, and interview, the facility’s staff failed to maintain an uncluttered, clean, and sanitary environment. (B) Based on observation, interview and record review, facility staff failed to ensure preventative maintenance are performed on ancillary equipment. (C) Based on observation, interview, 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. Findings: Observation of the facility’s examination room revealed chairs were stacked on each other, and lamps cluttered the examination room. The chairs were stored directly beside the examination table. Observation of the facility’s water treatment room revealed the catchment sink below the outlets for collection of product water for testing of total chlorine/ chloramines had an accumulation of mold and mildew. The wall adjacent to the water treatment holding tank and acid holding tank were smeared with black residue. The outside of both carbon tanks had black residue on its side. The hoses leading from the acid storage tank were covered with large white icicle like residue of buildup dried acid solution. The drains from the bicarbonate tank and water holding tanks had accumulation of mold and mildew. The bicarbonate mixing and holding tanks and equipment had an accumulation of dust and dirt to the back of the machine and in between each tanks. On 03/20/24 at 2:20 p.m. The Surveyor observed the water treatment room environment with the facility’s chief biomedical technician. He states, “ we will take care of it.” Cross reference V401 Observation on 03/2024 of the following ancillary equipment located and in use on the facility’s hemodialysis unit revealed stickers on equipment in use for patient care have the following dated that they were preventative maintained: One cardiac science AED One suction machine One Ascend Laboratory centrifuge model 35, located in the laboratory; One scale used for weighing patients One DeVilbiss 5 Liter Oxygen Concentrator: Everflow Concentrator #2 oxygen concentrator: stickers indicate most current preventative maintenance were done February 2021 with recommended reinspection due August 2021. Observation during the survey on 03/20/2024 - 03/22/2024 revealed facility’s staff were observed using the scale to weigh patient pre and post hemodialysis treatment. Patient #8 On 03/21/2024 at 07:48 a.m., revealed Patient #8 was observed receiving supplemental oxygen from the DeVilbiss 5 Liter Oxygen Concentrator at 4 liters via a nasal cannula. Expired supplies Observation on 03/20/2024 at 8:45 a.m. of the facility’s water treatment room revealed a container of residual chlorine strips( Lot number H 9240 ), expired on 1/2024 Observation on 03/2024 at 8:47 a.m. of the facility’s stock room revealed multiple BD safety Glide #22 gauge expired 1/31/2024 Observation of the Treatment Floor on 03/20/2024 at 08:47 a.m. revealed the following: “ A supply cart with multiple Tempa DOT oral thermometers Lot # 06976 expired 01-2021 Observation of the Water Room on 03/20/2024 at 09:12 a.m. revealed the following: “ CalRite QC Standard Solutions 150 us/cm Conductivity Solution, Opened Date 11/14/2023, Lot #19022723A, expired 02/28/2024 “ CalRite QC Standard Solutions 1500 ppm 2060 us/cm Fresh Water TDS Solution, Opened Date 11/14/2023, Lot #33020923B, expired 02/28/2024 “ CalRite QC Standard Solutions 15 ppm 23.8 us/cm Fresh Water TDS Solution, Opened Date 11/14/2023, Lot #33021323A, expired 02/28/2024. On 03/20/24 at at 12:50 p.m. the surveyor accompanied the Facility’s Chief Biomedical Technician to the water room and showed him the expired supplies. He states “ok” Cross reference V 403”

“CFC-QAPI CFR(s): 494.110 This Condition is not met as evidenced by: 10802 Based on observation, interview and record review, the facility’s quality assessment performance improvement committee failed to develop a robust comprehensive quality assessment improvement program, which identifies deficient areas of care and services of dialysis patients, conduct root cause analysis, and develop and implement plans to address all aspect of care and services of patients who receive hemodialysis treatment. Findings: Review of the facility’s quality assessment performance improvement plan/data and meeting minutes for November 2023, December 2023, and January 2024 revealed no documentation of that the facility monitored and developed a plan to improve outcomes in fluid management, mortality, hospitalization, Infections: NHSN BSI rates, influenza vaccination, rehabilitation status, missed treatments, involuntary discharges, transfers, KDQOL and lack of physician’s visit Fluid Balance Monitoring of fluid management on the quality assessment performance improvement plan was blank. Hospitalizations: Review of the facility’s hospitalization data revealed the facility had 6 patients’ admissions to the hospital in January 2024 and 10 patients’ admissions to the hospital in February 2024. Some patients had multiple admissions. There was no documentation that the facility’s QAPI analyzes the data, conducts a root cause, or develops and implements a plan to address hospitalizations. Mortality There no documentation of the facility’s gross mortality. There was no root cause analysis of the patients’ mortality, nor a plan developed and implemented to address patients’ mortality. Infections: NHSN BSI Rates There was no no documentation of the facility’s NHSN BSI Rates. The category has “N/A” documented for each month in the Quality Assessment Performance (QAPI) Tracking document. Influenza Vaccination Review of the facility’s influenza vaccination tracker on 03/21/2024 revealed 2 patients who have no documented vaccination or refusal of the vaccination. There was no documentation of the facility’s Influenza Vaccination monitored in the Quality assessment performance improvement data and meeting minutes. The category has “N/A” documented for each month in the Quality Assessment Performance (QAPI) Tracking document. Lack of Physician’s visits Review of patients’ clinical records revealed documentation which indicated that certain physicians were not seeing their patients based on regulatory requirements This was not included in the facility’s quality assessment performance improvement plan. Cross reference V 628”

“Plan Based on All Hazards Risk Assessment CFR(s): §403.748(a)(1)-(2), §416.54(a)(1)-(2), §418.113(a)(1)-(2), §441.184(a)(1)-(2), §460.84(a)(1)-(2), §482.15(a)(1)-(2), §483.73(a)(1)-(2), §483.475(a)(1)-(2), §484.102(a)(1)-(2), §485.68(a)(1)-(2), §485.542(a)(1)-(2), §485.625(a)(1)-(2), §485.727(a)(1)-(2), §485.920(a)(1)-(2), §486.360(a)(1)-(2), §491.12(a)(1)-(2), §494.62(a)(1)-(2) [(a) Emergency Plan. The [facility] must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following:] (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach.* (2) Include strategies for addressing emergency events identified by the risk assessment. * [For Hospices at §418.113(a):] Emergency Plan. The Hospice must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach. (2) Include strategies for addressing emergency events identified by the risk assessment, including the management of the consequences of power failures, natural disasters, and other emergencies that would affect the hospice’s ability to provide care. *[For LTC facilities at §483.73(a):] Emergency Plan. The LTC facility must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least annually. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing residents. (2) Include strategies for addressing emergency events identified by the risk assessment. *[For ICF/IIDs at §483.475(a):] Emergency Plan. The ICF/IID must develop and maintain an emergency preparedness plan that must be reviewed, and updated at least every 2 years. The plan must do the following: (1) Be based on and include a documented, facility-based and community-based risk assessment, utilizing an all-hazards approach, including missing clients. (2) Include strategies for addressing emergency events identified by the risk assessment. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s staff failed to evaluate hazard/risk of its facility and develop and implement a plan to address identified hazard/risk based on the assessment. Findings: Interview with the Facility Administrator on 03/20/2024 during the entrance conference revealed she said the facility has 26 patients who receive hemodialysis treatment in the facility on two shifts from 7:00 a.m. - 3:00 p.m. on Monday - Saturday. Observation on 03/20/2024 - 03/22/2024 during the survey of the facility revealed, patients were observed receiving hemodialysis treatment on two shifts Wednesday - Friday. Review of the facility’s emergency plan provided by the Facility’s Administrator revealed no evidence that the facility’s staff evaluate hazard/risk to facility or develop and implement plans to address identified hazard/risk. Interview with Facility Administrator (G) on 03/22/2024 at 8:33 a.m.: the Surveyor requested evidence that the facility’s staff evaluate hazard/risk to facility, develop and implement plans to address identified hazard/risk. Facility Administrator (G) said, “Okay, I will have to get one done.””

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, facility’s governing body failed to ensure all staff providing care and services in the facility contact information are kept on an updated emergency contact list in 3 of 9 staff personnel files reviewed: Patient Care Technician (C), (E), and (F) Findings: On 03/20/2024 - 03/22/2024 during the survey Patient Care Technician (C), (E), and (F) were observed providing care and services in the facility. Review of the facility’s current emergency contact list of staff, provided by Facility’s Administrator revealed Patient Care Technician (C), (E), and (F) names and contact information were not included on the list. Interview with Facility Administrator (G) on 03/22/2024 at 8:30 a.m.: the Surveyor notified Facility Administrator (G) of the missing personnel from the emergency contact list. Facility Administrator (G) said, “I will have to get it updated.””

“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: 10802 Based on record review and interview, the facility’s governing body: failed to ensure staff hired to the facility to provide care and services to patients are provided with emergency management training in 4 of 9 personnel files reviewed: Social Worker (J), Registered Dietician (I), Biomedical Technician (H) and Clinical Nurse Manager (A) B) failed to ensure newly admitted patients participate in the emergency management drill in the facility in 1 of 9 sampled patients: Patient #8 Findings: Review of the facility’s current policy and procedure: Natural Disaster Plans - Fire Drills, directs the staff as follows: “Fire Drill Procedure To prepare the staff for a safe and orderly evacuation in the event of a fire or other disaster, the following procedures will be followed: 1. When a Fire Drill or Natural Disaster Drill is sounded, all personnel should proceed immediately to the treatment area ... 9. Fire Drills will be held quarterly on each patient shift.” Review of the Facility’s Governing Body Meeting Minute dated 2/29/2024 revealed documentation which indicated that the social worker was hired to the facility on February 14, 2024 On 03/22 /2024 at 8:03 a.m. during an interview with the facility’s social worker revealed she stated that she started working as a contract staff on 02/15/2024 and did two visits to the facility on 02/15/2024 and 03/15/24 where she saw patients. Interview with the Facility’s Social worker reveal she said she did not participate in fire drill or emergency management training since hired. Registered Dietician (I) Review of Facility’s REgistered Dietician (I’s) personnel and training file on 03/21/2024 revealed no documentation that the Registered Dietician participated in a fire drill, emergency management tabletop exercise or community-based drill. On 03/21/2024 at 11:20 a.m. during an interview with the Facility’s Administrator, the Surveyor requested evidence that the Registered Dietician participated in in a fire drill, emergency management tabletop exercise or community-based drill. None was provided. 48020 Biomedical Technician (H) On 03/20/2024 Biomedical Technician (H) was observed in the facility’s water room monitoring the equipment. Review of Biomedical Technician (H’s) personnel and training file on 03/21/2024 at 10:21 a.m. revealed no documentation that the Biomedical Technician participated in a fire drill, emergency management tabletop exercise or community-based drill. Review of the Facility’s Fire Drill Checklist & Emergency Evacuation Review on 03/22/2024, revealed documentation which indicated fire drill was last held at the facility on February 13-14, 2024. The log did not include Biomedical Technician (H’s) signature. Review of the Facility’s Emergency Management binder revealed no documentation of a tabletop exercise or community-based drill being conducted. Clinical Nurse Manager (A) On 03/20/20204 - 03/22/2024, Clinical Nurse Manager (A) was observed on the treatment floor providing care to patients. Review of Clinical Nurse Manager (A’s) personnel and training file on 03/22/2024 at 10:03 a.m., revealed no documentation Clinical Nurse Manager (A) participated in an emergency management tabletop exercise or community-based drill. Review of the Facility’s Emergency Management binder revealed no documentation of a tabletop exercise or community-based drill being conducted. Interview with Clinical Nurse Manager (A) on 03/22/2024 at 10:36: the Surveyor asked Clinical Nurse Manager (A) about participating in an emergency management tabletop exercise or community-based drill. Clinical Nurse Manager (A) said, “I did not know we were supposed to have one.” Patient #8 Observation on 03/21/2024 at 7:48 a.m., revealed Patient #8 was observed at station #2, hemodialysis machine #12 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of 500 mL/min via a left arm vascular access. Review of the patient’s clinical record revealed the patient was admitted to the facility on 10/17/2023 and there was no documentation of him participating in an emergency management drill. Review of the Facility’s Emergency Preparedness binder on 03/22/2024 revealed documentation which indicated a hurricane/disaster drill was last held at the facility on October 13, 2023. Interview with Facility Administrator (G) on 03/22/2024 at 8:33 a.m.: the Surveyor requested evidence that the patient participated in an emergency management drill. Facility Administrator (G) said, “We did not do a drill with the patient.””

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s direct care staff failed to: wash/sanitize hands after removal of contaminated gloves: 2 of 3 staff observed: Patient Care Technician (C) and (B) Findings: Review of the facility’s current policy and procedure: Hand Washing, directs the staff as follows: “Purpose: To instruct and guide health workers of the important of hand washing in preventing cross-contamination of disease-causing microorganisms 6. Never use the same gloves on more than one patient. Remember to always wash your hands after removing gloves and after each patient contact.” Patient Care Technician (C) Observation on 03/20/2024 at 8:51 a.m., revealed Patient Care Technician (C) touch the hemodialysis machine screen at station #11 machine #4 to show the Surveyor the patient’s hemodialysis prescription. Patient Care Technician (C) then touch the hemodialysis machine screens at station #12 machine #3, station #13 machine #17, and station #15 machine #15 in succession, without removing his contaminated gloves, handwashing/hand sanitizing his hands, and donning clean gloves before touching the next hemodialysis machine. The Surveyor notified Patient Care Technician (C) at 08:53 a.m. that he moved from machine to machine without removing his contaminated gloves, handwashing/hand sanitizing his hands, and donning clean gloves before touching the next hemodialysis machine. Patient Care Technician (C) said, “Yes, I am supposed to change my gloves and wash my hands in between touching the machines.” Patient Care Technician (C) failed to remove contaminated gloves and perform hand hygiene to prevent cross contamination: 1) Subsequent observation at 11:05 a.m. revealed Patient Care Technician (C) at station #13 and machine #17 preparing to remove the vascular access needles of a patient post hemodialysis treatment. Patient Care Technician (C) moved the Sharps disposable container sitting on the floor away from the side of the chair, remove the venous needle, pull tape hanging on the side of the chairside table, and apply the tape to the patient’s vascular access with the contaminated gloves. 2) Subsequent observation at 11:50 a.m. revealed Patient Care Technician (C) at station #15 and machine #15 setting up a new hemodialysis blood tubing set and dialyzer for the next patient. Patient Care Technician (C) touched his face shield to adjust it and then he continued attaching the clean bloodlines to the dialyzer with the contaminated gloves. 10802 Patient Care Technician (B) On 03/20/2024 at 10:40 a.m. Patient Care Technician (B) was observed at station #4, hemodialysis machine #1. The patient care technician was terminally cleaning the unit post hemodialysis treatment of a patient. Observation revealed the patient care technician wearing a pair of gloves removed the used external blood lines from the hemodialysis machine, removed his contaminated gloves then picked up clean gloves from a box of gloves with his unwashed/ unsanitized hands, then rinse the prime bucket under the tap with running water. The patient care technician did not wash/ sanitize his hands after removing his contaminated gloves, prior to picking up clean gloves from the box of gloves. Patient Care Technician (B) Patient #9 On 03/20/2024 at 1:42 p.m. Patient Care Technician was observed at station # 4. The patient care technician was initiating hemodialysis treatment on Patient #4. Observation revealed Patient Care Technician (B) with his ungloved hands lowered the footrest of the patient’s chair, then picked up a pair of clean gloves stored on the windowsill adjacent to the patient’s chair, donned the pair of gloves with his unwashed hands and cannulate the patient’s left upper arm vascular access. After cannulating the patient’s vascular access, the patient care technician removed his contaminated gloves, and picked up clean gloves from a box of clean gloves. The patient care technician did not wash or sanitize his hands after removing the contaminated gloves. On 03/202024 at 1:53 p.m., the Surveyor informed Patient Care Technician (B) that she observed that he did not wash/ sanitize his hand after lowering the patient’s footrest and that he did not wash/ sanitize his hands after removing his contaminated gloves post cannulation of the patient’s vascular access. Patient Care Technician ( B) states “ I will correct that habit.””

“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: 10802 Based on observation, interview and record review facility’s direct care staff failed to clean and disinfect intravenous pole, clipboard, prime bucket, Hansen connectors, sides and back of hemodialysis machines, stethoscope, chase, wall boxes and water hoses in 3 of 3 direct care staff observed terminally cleaning 5 of 5 hemodialysis stations. Patient Care Technician B, D and C Findings: Review of the facility’s current policy and procedure: Dialysis Machine Exterior & Patient Station Disinfection, directs the staff as follows: “Procedure: 2. After removing the bloodlines and other disposables, use a cloth dampened with 1:100 Bleach Solution to clean the entire exterior of the dialysis machine and patient station area, including the back of the wall and drain.” 3. Wipe the blood pressure cuff, the clipboard, individual televisions, patient chair, individual trash can and writing pen with the 1:100 Bleach Solution.” Review of the Center for Disease Control (CDC) Dialysis Safety: Dialysis Wall Boxes and Drains states: “ wall boxes need to be cleaned, disinfected, and properly maintained to decrease risk of patient infections. Wall boxes are part of the immediate patient care environment and are considered contaminated or dirty.” Patient Care Technician (B); Station 4 hemodialysis machine # 1. On 03/20/2024 at 10:40 a.m. Patient Care Technician (B) was observed on the hemodialysis unit at station # 4 hemodialysis machine #1. The patient care technician was terminally cleaning the hemodialysis machine post hemodialysis treatment of a patient. During terminal cleaning of the unit, the patient care technician rinse the prime bucket under running water from the tap but did not disinfect the prime bucket. The patient care technician did not clean and disinfect, the intravenous pole, Hansen connectors, left side of the hemodialysis machine, chase, water box and hoses. After terminally cleaning the unit, the Patient Care Technician (B) removed his contaminated gloves, walked over to clean supply cupboard and picked up clean blood lines and dialyzer from the storage area. The patient care technician did not wash or sanitize his hands after removing the contaminated gloves. Subsequent observation at 12:38 a.m. Patient Care Technician (D) was observed, taking a patient temperature in preparation for initiation of hemodialysis treatment. The Surveyor requested of the patient to wait in the lobby for some time. Interview with Patient Care Technician (D) after the observation revealed she said the patient was going to station #4 for hemodialysis treatment. Interview on 03/20/2024 at 12:40 p.m. with Patient Care Technician (B), the surveyor notified Patient Care Technician (B), that during terminal cleaning of the hemodialysis unit he did not clean and disinfect prime bucket, the intravenous pole, Hansen connectors, left side of the hemodialysis machine, chase, water box and hoses. Patient Care Technician (B) states “ ok, I will clean it.” Patient Care Technician (D); Station 2 hemodialysis machine #12 On 03/20/2024 at 11:28 a.m. Patient Care Technician (D) was observed on the hemodialysis unit at station # 2, hemodialysis machine #12. The patient care technician was terminally cleaning the hemodialysis machine post hemodialysis treatment of a patient. Observation revealed during terminal cleaning of the unit, the patient care technician rinse the prime bucket under running water from the tap but did not disinfect the prime bucket. Patient Care Technician (D) did not clean and disinfect, the intravenous pole, stethoscope, Hansen connectors, sides and back of the hemodialysis machine, chase, water box and hoses. On 03/20/2024 at 11:35 a.m. Patient Care Technician (D) was observed setting up clean blood lines and dialyzer in preparation for an oncoming patient. During an interview on 03/20/2024 at 12:36 p.m. The Surveyor informed Patient Care Technician (D) that she did not clean and disinfect the intravenous pole, stethoscope, Hansen connectors, sides and back of the hemodialysis machine, chase, water box and hoses. Patient Care Technician (D) states “I don’t know why I did not clean everything.” Patient Care Technician (B); Station 1 hemodialysis machine #s 23 On 03/20/2024 at 11:45 a.m. Patient Care Technician (B) was observed on the hemodialysis unit at station # 1, hemodialysis machine #23. The patient care technician was terminally cleaning the hemodialysis machine post hemodialysis treatment of a patient. During terminal cleaning of the unit, the patient who had previously utilized the station for hemodialysis treatment was sitting in the chair tethered to the blood pressure cuff attached to the hemodialysis machine that was been terminally clean. During terminally cleaning of the unit Patient Care Technician (D) did not clean and disinfect the prime bucket, back and sides of the hemodialysis machine, chase, wall boxes and hoses. The patient remained tethered to the blood pressure cuff on the machine that was terminally cleaned. After terminally cleaning the hemodialysis machine Patient Care Technician ( B) set up clean blood line and dialyzer in preparation for an oncoming patient, while the current patient remained tethered to the blood pressure cuff attached to the hemodialysis machine. The patient’s blood pressure was not with in normal range and required monitoring prior to discharge. On 03/20/2024 at 11:50 a.m, the Surveyor informed Patient Care Technician (B) that the patient was tethered to the hemodialysis machine while he terminally cleaned it which cross contaminated the hemodialysis machine terminally cleaned for an on coming patient, and that he did not clean and disinfect the prime bucket, back and sides of the hemodialysis machine, chase, wall boxes and hoses. Patient Care Technician (B) states “ I will try to do better.” 48020 Patient Care Technician (C) Station #12 - hemodialysis machine #3 Observation on 03/20/2024 at 10:40 a.m. revealed Patient Care Technician (C) terminally cleaning station #12 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #3 at station #12, Patient Care Technician (C) failed to clean and disinfect the prime bucket, intravenous pole, clipboard, back of the hemodialysis machine, dialysate lines, wall box and chase cabinet. Station #15 - hemodialysis machine #15 Subsequent observation on 03/20/2024 at 11:37 a.m. revealed Patient Care Technician (C) terminally cleaning station #15 post hemodialysis treatment of a patient. During terminal cleaning of the hemodialysis machine #15 at station #15, Patient Care Technician (C) failed to clean and disinfect the prime bucket, intravenous pole, clipboard, back of the hemodialysis machine, dialysate lines, wall box and chase cabinet. The Surveyor notified Patient Care Technician (C) at 12:50 p.m. that he failed to clean and disinfect the prime bucket, intravenous pole, clipboard, back of the hemodialysis machine, dialysate lines, wall boxes and chase cabinets at stations #12 and #15. Patient Care Technician (C) said, “Okay.””

“IC-CATHETERS:GENERAL CFR(s): 494.30(c)(2) (2) The “Guidelines for the Prevention of Intravascular Catheter-Related Infections” entitled “Recommendations for Placement of Intravascular Catheters in Adults and Children” parts I - IV; and “Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients,” Morbidity and Mortality Weekly Report, volume 51 number RR-10, pages 16 through 18, August 9, 2002. The Director of the Federal Register approves this incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR Part 51. This publication is available for inspection as the CMS Information Resource Center, 7500 Security Boulevard, Central Building, Baltimore, MD or at the National Archives and Records Administration (NARA). Copies may be obtained at the CMS Information Resource Center. For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_regulations/ibr_locations.html This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, facility’s direct care staff failed to encourage patients to wash vascular access sites prior to initiation of hemodialysis treatment in 3 of10 sampled patients Patient #s 6, 7 and 8 in 2 of 2 staff observed: Patient Care Technician (F) and (E) Findings: Review of the facility’s current policy and procedure: AV Graft Cannulation, directs the staff as follows: “PROCEDURE ... 2. Explain procedure to the patient. Patients are required to wash access extremity with soap and water upon arrival to dialysis, if able. If patient is unable to wash access site, patient care staff will clean access extremity with alcohol-based hand disinfectant.” Patient #6 On 03/21/2024 at 7:10 a.m. observation revealed Patient #6 walked into the station after the patient’s temperature was taken and weighed by Patient Care Technician (F). Observation revealed the patient with a left upper arm vascular access. Observation revealed the patient care technician did not direct the patient to wash her vascular access prior to cannulation of the patient’s vascular access. Subsequent observation at 07:15 a.m. revealed the Patient Care Technician (F) cannulating the patient’s vascular access. The patient was not instructed to wash her vascular access site prior to cannulation of her vascular access. Patient #7 On 03/21/2024 at 7:50 a.m. observation revealed Patient Care Technician (E) accompanying Patient #7 to the hemodialysis station #1, after the patient’s temperature was taken and weighed by the Patient Care Technician (E). Observation revealed the patient with a left lower arm vascular access. Observation revealed the patient care technician did not direct the patient to wash her vascular access prior to cannulation of the patient’s vascular access. Subsequent observation at 08:00 a.m. revealed the Patient Care Technician (E) was observed cannulating the patient’s vascular access. On 03/21/2024 at 8:10 a.m. the Surveyor informed patient Care Technician (E) and the Facility’s Clinical Coordinator that staff are not encouraging patients to wash their vascular access site prior to cannulation of the vascular access. The Clinical Coordinator states “ you are right.’ 48020 Patient Care Technician (F) Patient #8 Observation on 03/21/2024 at 7:29 a.m., revealed Patient Care Technician (F) weighing Patient #8 prior to hemodialysis treatment. Patient Care Technician (F) failed to encourage Patient #8 to wash his hands and vascular access before leading patient to the hemodialysis station. The Surveyor notified Patient Care Technician (F) at 07:31 a.m. that she failed to encourage Patient #8 her to wash her hands and access prior to the hemodialysis treatment. Patient Care Technician (F) said, “Okay.””

“MIXING SYSTEMS-PERM RECORD/VERIF TEST CFR(s): 494.40(a) 5.4.4.1 Mixing systems: perm record/verification testing In addition to container labeling, there should be permanent records of batches produced. These records should include the concentrate formula produced, the volume of the batch, the lot numbers of powdered concentrate packages, the manufacturer of the powdered concentrate, the date and time of mixing, any test results, the person performing the mixing, the person verifying mixing and test results, and the expiration date (if applicable). 6.4.1 Mixing systems Acid and bicarbonate concentrates may be tested by using conductivity or by using a hydrometer. Concentrates should not be used or transferred to holding tanks or distribution systems until all tests are completed. The test results and verification that they meet all applicable criteria should be recorded and signed by the individuals performing the tests. This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the facility failed to document the bicarbonate concentrate mixing: time of preparation, bleach residual, water quantity, number of bags used, lot number, and specific gravity, according to policy. Findings: Review of the facility’s policy and procedure on Bi-Carb Mixing Procedure Policy # T-120.01 revised 01/18/2016 directs staff as follows: “Document procedure in Bicarb Concentrate Mixing Log.” Observation of the water treatment room on 03/20/2024 - 03/22/2024 revealed a Mar Cor Purification Bicarb system dual tank with bicarbonate concentration in use for the hemodialysis treatments. Review of the Facility’s Bicarb Concentrate Mixing Log on 03/21/2024 revealed the log is used for bicarb concentrate mixing documentation. The time of preparation, bleach residual, water quantity, number of bags used, lot number, and specific gravity documentation was missing for the following dates: 03/07/2024, 11/02/2023, 11/09/2023, 11/16/2023, 11/28/2023, 11/30/2024, 10/05/2023, 10/12/2023, 10/19/2023, 10/26/2023, and 10/28/2023. Several of the missing dates fall on a Thursday. Interview with Clinical Nurse Manager (A) on 03/20/2024 at 03:32 p.m. confirmed the facility mixes bicarbonate concentrate daily. Clinical Nurse Manager (A) said, “Patient Care Technician (B) mixes bicarbonate on Monday, Wednesday, Friday and if we don’t have anyone for Tuesday, Thursday, Saturday, Biomedical Technician (H) does it.” Interview with Biomedical Technician (H) on 03/22/2024 at 07:00 a.m. revealed he confirmed the facility mixes bicarbonate concentrate daily and the time of preparation, bleach residual, water quantity, number of bags used, lot number, and specific gravity were not documented for the dates in question.”

“MIXING SYSTEMS-CLEANING CFR(s): 494.40(a) 6.4.1 Mixing systems: cleaning Concentrate mixing equipment should be either: (1) completely emptied, cleaned, and disinfected according to the manufacturer’s instructions; or (2) cleaned and disinfected using a procedure demonstrated by the facility to be effective in routinely producing concentrate meeting [these regulations related to allowable bacterial and endotoxin levels]. The disinfection data should be recorded for each ...disinfection cycle using a dedicated log. This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the facility staff failed to document disinfection of the bicarbonate concentrate system according to its policy. Findings: Review of the facility’s policy and procedure on Bi-Carb System Disinfection Policy # T-120.02 revised 01/18/2016 directs staff as follows: “Document procedure in bicarb system disinfection log.” Observation of the water treatment room on 03/20/2024 - 03/22/2024 revealed a Mar Cor Purification Bicarb system dual tank with bicarbonate concentration in use for the hemodialysis treatments. Review of the Facility’s Bicarb Mixer Clean/Disinfect Log on 03/21/2024 revealed the log is used for weekly bleach documentation. Documentation for March 2024 revealed the weekly bleach disinfection occurred on March 7th and 14th. Subsequent review of the Facility’s Bicarb Mixer Clean/Disinfect Log revealed missing documentation of the weekly bleach for the following days: 02/22/2024, 01/11/2024, 01/18/2024, 01/25/2024, 12/21/2023 and 12/28/2023. There was no documentation of the weekly bleach for the months of October 2023, June 2023, and March 2023. Interview with Biomedical Technician (H) on 03/22/2024 at 07:00 a.m. revealed he confirmed the weekly bleach was not documented for the dates and months in question.”

“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: 10802 Based on observation, and interview, the facility’s staff failed to maintain an uncluttered, clean, and sanitary environment. Findings: Observation on 03/2024 at 8:05 a.m. of the area provided as a workstation for surveyors which lead to the examination room revealed, the egress were obstructed with 23 boxes containing dialysate concentrates stored directly on the floor. Observation of the facility’s examination room revealed chairs were stacked on each other, and lamps cluttered the examination room. The chairs were stored directly beside the examination table. Observation of the facility’s water treatment room revealed the catchment sink below the outlets for collection of product water for testing of total chlorine/ chloramines had an accumulation of mold and mildew. The wall adjacent to the water treatment holding tank and acid holding tank were smeared with black residue. The outside of both carbon tanks had black residue on its side. The hoses leading from the acid storage tank were covered with large white icicle like residue of buildup dried acid solution. The drains from the bicarbonate tank and water holding tanks had accumulation of mold and mildew. The bicarbonate mixing and holding tanks and equipment had an accumulation of dust and dirt to the back of the machine and in between each tanks. On 03/20/24 at 2:20 p.m. The Surveyor observed the water treatment room environment with the facility’s chief biomedical technician. He states, “ we will take care of it.””

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, facility staff failed to ensure preventative maintenance are performed on ancillary equipment. (B) Based on observation, interview, 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. Findings: Observation on 03/2024 of the following ancillary equipment located and in use on the facility’s hemodialysis unit revealed stickers on equipment in use for patient care have the following dated that they were preventative maintained: One cardiac science AED stored on the emergency cart; sticker indicates most current preventative maintenance was done February 2021 with recommended reinspection due August 2021. One suction machine stored on the emergency cart; sticker indicates most current preventative maintenance was done February 2021 with recommended reinspection due August 2021. One Ascend Laboratory centrifuge model 35, located in the laboratory; sticker indicates most current preventative maintenance was done February 2021 with recommended reinspection due August 2021. One scale used for weighing patients; sticker indicates most current preventative maintenance was done February 2021 with recommended reinspection due August 2021. Observation during the survey on 03/20/2024 - 03/22/2024 revealed facility’s staff were observed using the scale to weigh patient pre and post hemodialysis treatment. Interview on 03/20/24 at 2:10 p.m. with the Facility’s Administrator when asked for documentation indicating preventative maintenance were done on the following ancillary machines revealed she said “I have no documentation I have a check for 2022. The company is no longer in business.” Review on 03/22/2024 of the facility’s agreement log revealed a Ascend centrifuge Mechanical Safety Inspection Certificate for Model # 755ES serial # 19105AE077 which indicated an inspection was done on the centrifuge on 1/28/2021 and that the next calibration was due 1/28/22023. Review of a certificate of Inspection issued by the company ( --) responsible for inspection of ancillary equipment dated 3/11/2021 - 3/2022 revealed the following : “The Medical Equipment in This Facility Has Been Inspected For Patient Safety And Is IN Compliance With OSHA Requirements and Recommended Procedures. “ Date inspected 3/11/2021. Next Inspection Due 3/22.” Expired Supplies Observation on 03/20/2024 at 8:45 a.m. of the facility’s water treatment room revealed a container of residual chlorine strips( Lot number H 9240 ), expired on 1/2024 Observation on 03/2024 at 8:47 a.m. of the facility’s stock room revealed multiple BD safety Glide #22 gauge expired 1/31/2024 On 03/20/24 at at 12:50 p.m. the surveyor accompanied the Facility’s Chief Biomedical Technician to the water room and showed him the expired supplies. He states “ok” 48020 Oxygen Concentrators: Observation on 03/20/2024 at 09:01 a.m. of the facility’s oxygen concentrators revealed: 1)DeVilbiss 5 Liter Oxygen Concentrator: Observation of the preventative maintenance sticker on the equipment revealed documentation that safety inspection by Legacy Biomedical was last done February 2021. The sticker indicated the next safety inspection was due in August 2021. There was no indication that preventative maintenance was done in August 2021 or currently. 2)Everflow Concentrator #2 oxygen concentrator: Observation of the preventative maintenance sticker on the equipment revealed documentation that safety inspection by Legacy Biomedical was last done February 2021. The sticker indicated the next safety inspection was due in August 2021. There was no indication that preventative maintenance was done in August 2021 or currently. Patient #8 Subsequent observation on 03/21/2024 at 07:48 a.m., revealed Patient #8 was observed at station #2, hemodialysis machine #12 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of 500 mL/min via a right arm vascular access. Patient #8 was receiving supplemental oxygen from the DeVilbiss 5 Liter Oxygen Concentrator at 4 liters via a nasal cannula. Interview with Clinical Nurse Manager (A) on 03/21/2024 at 07:59 a.m.: the Surveyor notified Clinical Nurse Manager (A) the DeVilbiss oxygen concentrator was past due for the preventative maintenance. Clinical Nurse Manager (A) said the Biomedical Technician was responsible for the preventative maintenance of the equipment. Interview with Biomedical Technician (H) on 03/22/2024 at 06:44 a.m.: the Surveyor notified Biomedical Technician (H) the DeVilbiss and Everflow oxygen concentrators were past due for the preventative maintenance. Biomedical Technician (H) said, “Okay.” Expired supplies Review of the facility’s current policy and procedure: TDS Myron L directs the staff as follows: Review of manufacturer’s instruction for use product insert for use revealed “Storage and Handling: “ Do not use the solution (from an opened or unopened bottle) after the expiration date Observation on 03/20/2024 during tour of the facility revealed the following expired supplies were observed co-mingled with supplies in use for patient care: Treatment Floor Observation of the Treatment Floor on 03/20/2024 at 08:47 a.m. revealed the following: “ A supply cart with multiple Tempa DOT oral thermometers Lot # 06976 expired 01-2021 Interview with Patient Care Technician (B) on 03/20/2024 at 8:57 a.m. revealed that the facility uses the Tempa DOT oral thermometers to take the temperature of patients before and after hemodialysis treatments. Water Room Observation of the Water Room on 03/20/2024 at 09:12 a.m. revealed the following: “ CalRite QC Standard Solutions 150 us/cm Conductivity Solution, Opened Date 11/14/2023, Lot #19022723A, expired 02/28/2024 “ CalRite QC Standard Solutions 1500 ppm 2060 us/cm Fresh Water TDS Solution, Opened Date 11/14/2023, Lot #33020923B, expired 02/28/2024 “ CalRite QC Standard Solutions 15 ppm 23.8 us/cm Fresh Water TDS Solution, Opened Date 11/14/2023, Lot #33021323A, expired 02/28/2024 Interview with Patient Care Technician (B) on 03/20/2024 at 03:30 p.m. revealed that the facility uses the CalRite QC Standard Solutions. Interview with Biomedical Technician (H) on 03/22/2024 at 06:42 a.m.: the Surveyor notified Biomedical Technician (H) the CalRite QC solutions were expired. Biomedical Technician (H) said, “Okay.””

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 10802 Based on observation, interview and record review patient’s attending nephrologists failed to complete monthly comprehensive progress notes on patients addressing adequacy, vascular access, anemia management, nutritional status, bone mineral metabolism and treatment response in 5 of 10 sampled patients: Patient #s 5, 6, 4, 3 and 2 Findings: Review of the facility’s Policy and procedure on Attending Physician Orientation Program revised 1-01-2020 directed staff as follows:” At a minimum each patient receiving dialysis in the facility shall be seen by a Physician once every two weeks or once by the physician and approximately two weeks later by His/ Her Boarded and licensed Physician Extender.” “The record of these contacts shall include evidence of assessment for new and recurrent problems and review of dialysis adequacy each month as well as documentation of A comprehensive assessment once monthly.” Patient #6 On 03/21/2024 at 7:40 a.m. Patient #6 was observed on the facility’s hemodialysis unit at station 11. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/minute and dialysate flow rate of 500 mls/ minute via a left upper arm vascular access. Review of the patient’s clinical record (patient’s history and physical) revealed the patient was admitted to the facility on 6/27/2023 with diagnosis of diabetes type 1, hypertension, diabetic complication and end stage renal disease on in center hemodialysis three times weekly. The record revealed the most current patient’s nephrologist progress notes were dated 2/10/2024 and 2/17/2024. There was no progress notes for March 2024. revealed the following findings: 03/21/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 55.7 kg, post treatment weight 53.4 kg. 03/19/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 55.8 kg, post treatment weight 53.9 kg. 03/16/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 54.7 kg, post treatment weight 52.6 kg. 03/14/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 54.7 kg, post treatment weight 52.1 kg. 03/12/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 56 kg, post treatment weight 52.9 kg. 03/9/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 55.2 kg, post treatment weight 53. kg. 03/7/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 55.5 kg, post treatment weight 53 kg. 03/5/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 56.3 kg, post treatment weight 53 kg. 03/2/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 54 kg, post treatment weight 52.1 kg. 02/29/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 54.3 kg, post treatment weight 51.3 kg. 02/27/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 55.3 kg, post treatment weight 52.1 kg. 02/24/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 54.8 kg, post treatment weight 52 kg. 02/22/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 54.9 kg, post treatment weight 52 kg. 02/20/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 55.1 kg, post treatment weight 52.4 kg. 02/17/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 54.9 kg, post treatment weight 52.1 kg. 02/15/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 54.5 kg, post treatment weight 52.9 kg 02/13/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 55.4 kg, post treatment weight 52.7 kg. 02/10/2024; Patient’s ordered target weight 49 kg, pre hemodialysis treatment weight 54.8 kg, post treatment weight 52.3 kg. The records revealed the patient had an encounter with her Attending Nephrologist 2/10/2024 and 2/17 2024. The patient’s weight was not addressed by the patient’s Attending Nephrologist. Patient #5 On 03/20/2024 at 8:40 a.m. Patient #5 was observed on the facility’s hemodialysis unit at station # 2. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysis flow rate of 500 mls/ minute via a right upper arm vascular access. Review of Patient #5’s clinical record (patient information) revealed the patient was admitted to the facility on 9/4/2023 with diagnosis of diabetes mellitus, hypertension, early dementia and end stage renal disease on in center hemodialysis three times weekly. Review of the patient’s clinical record revealed the patient’s had no documentation of a nephrologist progress notes for the months of November 2023 and December 2023. The record revealed the most current patient’s nephrologist progress notes was dated 2/12/2024. There was no progress notes for March 2024. Patient #4 On 03/20/2024 at 8:27 a.m. patient #4 was observed on the hemodialysis unit of the facility at station #1, hemodialysis #3. The patient was alert and oriented to person, place, time and situation. The patient was receiving hemodialysis treatment at a blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute via a right upper arm vascular access. Review of the patient’s clinical record (patient’s history and physical) revealed the patient was admitted to the facility on 4/15/2022 with diagnosis of diabetes mellitus, hypertension, peripheral vascular disease end stage renal disease, on in center hemodialysis three times weekly. The record revealed the most current patient’s nephrologist progress notes was dated 2/14 2024. There were no physician progress notes for November 2023, December 2023 and March 2024. On 03/21/2024 and 03/22/2024 the Surveyor requested missing physician’s progress notes from the Facility’s Administrator. She said there were none. 48020 Patient #3 Observation on 03/20/2024 at 8:32 a.m., revealed Patient #3 was observed at station #13, hemodialysis machine #17 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 07/24/2020 with diagnosis of hypertension and diabetes mellitus on insulin, on in-center hemodialysis three times weekly. Review of the patient’s clinical record (Physician Progress Note) revealed no documentation of a physician progress note for the current month of March 2024. There was no documentation of a physician progress note for the months of November 2023 and December 2023. The most recent physician progress note was documented on 02/12/2024. Patient #2 Observation on 03/20/2024 at 8:36 a.m., revealed Patient #2 was observed at station #12, hemodialysis machine #3 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Review of the patient’s clinical record (demographic record) revealed the patient was admitted to the facility on 04/01/2020 with diagnosis of hypertension and diabetes mellitus on insulin, on in-center hemodialysis three times weekly. Review of the patient’s clinical record (Physician Progress Note) revealed no documentation of a physician progress note for the current month of March 2024. There was no documentation of a physician progress note for the months of November 2023 and December 2023. The most recent physician progress note was documented on 02/12/2024. On 03/21/2024 at 02:58 p.m. the Surveyor notified the nephrologist caring for Patient #3 and #2 of the missing physician progress notes. The nephrologist confirmed that the progress notes were not completed.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 48020 Based on observation, interview and record review, the facility’s quality assessment performance improvement committee failed to develop a robust comprehensive quality assessment improvement program, which identifies deficient areas of care and services of dialysis patients, conduct root cause analysis, and develop and implement plans to address all aspect of care and services of patients who receive hemodialysis treatment. Findings: Fluid Management: Review of the facility’s quality assessment performance improvement plan/ data for November 2023, December 2023, and January 2024 revealed no documentation of the facility’s fluid management. The category was left blank. There was no documentation that the facility’s QAPI analyzes the data, conducts a root cause, or develops and implements a plan to address fluid management. Hospitalizations: Review of the facility’s hospitalization data revealed the facility had 6 patients’ admissions to the hospital in January 2024 and 10 patients’ admissions to the hospital in February 2024. Some patients had multiple admissions. There was no documentation that the facility’s QAPI analyzes the data, conducts a root cause, or develops and implements a plan to address the upward trend in hospitalizations. Mortality: Review of the facility’s quality assessment performance improvement plan/ data for November 2023, December 2023, and January 2024 revealed no documentation of the facility’s gross mortality. There was no root cause analysis of the patients’ mortality, nor a plan developed and implemented to address patients’ mortality. Infections: NHSN BSI Rates Review of the facility’s quality assessment performance improvement plan/data for November 2023, December 2023, and January 2024 revealed no documentation of the facility’s NHSN BSI Rates. The category has “N/A” documented for each month in the Quality Assessment Performance (QAPI) Tracking document. There was no documentation that the facility’s QAPI analyzes the data, conducts a root cause, or develops and implements a plan to address NHSN BSI Rates. Review of the facility’s influenza vaccination tracker on 03/21/2024 revealed 2 patients who have no documented vaccination or refusal of the vaccination. Review of the facility’s quality assessment performance improvement plan/data for November 2023, December 2023, and January 2024 revealed no documentation of the facility’s Influenza Vaccination. The category has “N/A” documented for each month in the Quality Assessment Performance (QAPI) Tracking document. There was no documentation that the facility’s QAPI analyzes the data, conducts a root cause, or develops and implements a plan to address Influenza Vaccination. Physicians Visit of In-center Hemodialysis Patients: Review of patients’ clinical records revealed documentation which indicated that certain physicians were not seeing their patients as required. Review of the facility’s quality assessment performance improvement plan/data for November 2023, December 2023, and January 2024 revealed no documentation of the missed physician visits. There was no documentation that the facility’s QAPI analyzes the data, conducts a root cause, or develops and implements a plan to address missed physician visits. Review of a sample of patients’ clinical record revealed documentation which indicated the following: “ 1 sampled patient’s most current visit documented by the patient’s Nephrologist was dated February 17th “ 1 sampled patient’s most current visit documented by the patient’s Nephrologist was dated February 14th “ 3 sampled patient’s most current visit documented by the patient’s Nephrologist was dated February 12th Interview with the Facility’s Vice President of Operations during review of the meeting minutes on 03/22/2024 revealed, one Nephrologist is responsible for the missed physician visits. The Facility’s Vice President of Operations also confirmed that this deficiency is not included in the quality assessment performance plan. Social Worker Involvement: Review of the facility’s quality assessment performance improvement plan/data for November 2023 revealed the Social Worker signed the Sign-In sheet but the documentation completed for the modality, rehabilitation status, missed treatments, restart/involuntary discharges, transfers, or KDQOL tracking categories in the meeting minutes was not completed. Review of the facility’s quality assessment performance improvement plan/data for December revealed the Social Worker did not sign the Sign-In sheet nor was the documentation completed for the modality, rehabilitation status, missed treatments, restart/involuntary discharges, transfers, or KDQOL tracking categories in the meeting minutes. Review of the facility’s quality assessment performance improvement plan/data for January revealed the Social Worker did not sign the Sign-In sheet nor was the documentation completed for the modality, rehabilitation status, missed treatments, restart/involuntary discharges, transfers, or KDQOL tracking categories in the meeting minutes. Interview with the Facility’s Administrator during review of the meeting minutes on 03/22/2024 revealed the facility was without a Social Worker for the months of December and January.”

“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, interview, 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. Findings: Review of the facility’s current policy and procedure: TDS Myron L directs the staff as follows: Review of manufacturer’s instruction for use product insert for use revealed “Storage and Handling: “ Do not use the solution (from an opened or unopened bottle) after the expiration date Observation on 03/20/2024 during tour of the facility revealed the following expired supplies were observed co-mingled with supplies in use for patient care: Treatment Floor Observation of the Treatment Floor on 03/11/2024 at 08:47 a.m. revealed the following: “ A supply cart with multiple Tempa DOT oral thermometers Lot # 06976 expired 01-2021 Interview with Patient Care Technician (B) on 03/20/2024 at 8:57 a.m. revealed that the facility uses the Tempa DOT oral thermometers to take the temperature of patients before and after hemodialysis treatments. Water Room Observation of the Water Room on 03/11/2024 at 09:12 a.m. revealed the following: “ CalRite QC Standard Solutions 150 us/cm Conductivity Solution, Opened Date 11/14/2023, Discard Date 11/14/2023, Lot #19022723A, expired 02/28/2024 “ CalRite QC Standard Solutions 1500 ppm 2060 us/cm Fresh Water TDS Solution, Opened Date 11/14/2023, Discard Date 11/14/2023, Lot #33020923B, expired 02/28/2024 “ CalRite QC Standard Solutions 15 ppm 23.8 us/cm Fresh Water TDS Solution, Opened Date 11/14/2023, Discard Date 11/14/2023, Lot #33021323A, expired 02/28/2024 Interview with Patient Care Technician (B) on 03/20/2024 at 03:30 p.m. revealed that the facility uses the CalRite QC Standard Solutions. Interview with Biomedical Technician (H) on 03/22/2024 at 06:42 a.m.: the Surveyor notified Biomedical Technician (H) the CalRite QC solutions were expired. Biomedical Technician (H) said, “Okay.””

“GOV-ADM RESP FOR FISCAL OPERATIONS CFR(s): 494.180(a)(2) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility’s chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to- (2) Fiscal operations; This Standard is not met as evidenced by: 10802 Based on observation, record review and interview, the facility’s governing body failed to ensure medication included in the standing orders of sampled patients were available in the facility for administration in 5 of 10 sampled patients: Patient #s 4, 5, 6, 3 and 2 Findings: Review of the facility’s current policy and procedure on Attending Physician Orientation Program, revised 1-01-2020 directed staff as follows: “There shall be written /electronic Standing Orders specific to the facility to guide actions to be taken by the nursing staff in the event a patient’s condition deteriorate during treatment.” Patient #4 On 03/20/2024 at 8:27 a.m. patient #4 was observed on the hemodialysis unit of the facility at station #1, hemodialysis machine #3. The patient was alert and oriented to person, place, time and situation. The patient was receiving hemodialysis treatment at a blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute via a right upper arm vascular access. Review of the patient’s clinical record revealed a hemodialysis standing order dated 2/09/2024 for “NTG 1/150 grains sublingual PRN for chest pain. May repeat for a total of three doses if SBP>110. Notify MD prior to giving for SPB<100.” Dextrose 50%:Give 50 mL IV PRN for hypoglycemia. Check blood glucose in 5- 10 minutes for response. Phenergan 25 mg /po q 4 hrs PRN for nausea and vomiting.” The medications were not available in the facility for administration to the patient. Patient #5 On 03/20/2024 at 8:40 a.m. Patient #5 was observed on the facility’s hemodialysis unit at station #2. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysis flow rate of 500 mls/ minute via a right upper arm vascular access. Review of Patient #5’s clinical record (patient information) revealed the patient was admitted to the facility on 9/4/2023 with diagnosis of diabetes mellitus, hypertension, early dementia, and end stage renal disease on in center hemodialysis three times weekly. Review of the patient’s clinical record revealed a hemodialysis standing order dated 2/09/2024, for “NTG 1/150 grains sublingual PRN for chest pain. May repeat for a total of three doses if SBP>110. Notify MD prior to giving for SPB<100.” Dextrose 50%:Give 50 mL IV PRN for hypoglycemia. Check blood glucose in 5- 10 minutes for response. Phenergan 25 mg /po q 4 hrs PRN for nausea and vomiting. “ The medications were not available in the facility for administration to the patient. Patient #6 On 03/21/2024 at 7:40 a.m. Patient #6 was observed on the facility’s hemodialysis unit at station 11. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/minute and dialysate flow rate of 500 mls/ minute via a left upper arm vascular access . Review of the patient’s clinical record revealed hemodialysis standing order dated 2/09/ 2024 for “NTG 1/150 grains sublingual PRN for chest pain. May repeat for a total of three doses if SBP>110. Notify MD prior to giving for SPB<100.” Dextrose 50%:Give 50 mL IV PRN for hypoglycemia. Check blood pressure in 5- 10 minutes for response. Phenergan 25 mg /po q 4 hrs PRN for nausea and vomiting. “ The medications were not available in the facility for administration to the patient. Observation on 03/22/2024 10:30 a.m. with the Facility’s Clinical Coordinator of the facility’s medication storage cabinet revealed no evidence of nitroglycerin, Phenergan, and Dextrose 50 mls present in the facility. Interview on 03/22/2024 at 10:30 a.m. with the Facility’s Clinical Coordinator revealed she said the facility did not have these medication in stock because they had expired and not restocked. 48020 Patient #3 Observation on 03/20/2024 at 8:32 a.m., revealed Patient #3 was observed at station #13, hemodialysis machine #17 receiving hemodialysis treatment at a blood flow rate of 400 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Review of the patient’s clinical record revealed a hemodialysis standing order dated 2/09/2024 for: “NTG 1/150 grains sublingual PRN for chest pain. May repeat x 3 for a total of three doses if SBP>110. Notify MD prior to giving for SPB < 100. Dextrose 50%: Give 50 mL IV PRN for hypoglycemia. Check blood glucose in 5-10 minutes for response. Phenergan 25 mg/p.o. q4hrs PRN for nausea and vomiting.” The medications were not available in the facility for administration to the patient. Patient #2 Observation on 03/20/2024 at 8:36 a.m., revealed Patient #2 was observed at station #12, hemodialysis machine #3 receiving hemodialysis treatment at a blood flow rate of 450 mL/min and dialysate flow rate of 500 mL/min via a left upper arm vascular access. Review of the patient’s clinical record revealed a hemodialysis standing order dated 2/09/2024 for: “NTG 1/150 grains sublingual PRN for chest pain. May repeat x 3 for a total of three doses if SBP>110. Notify MD prior to giving for SPB < 100. Dextrose 50%: Give 50 mL IV PRN for hypoglycemia. Check blood glucose in 5-10 minutes for response. Phenergan 25 mg/p.o. q4hrs PRN for nausea and vomiting.” The medications were not available in the facility for administration to the patient.”

“GOV-RN, MSW, & RD AVAIL TO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs; This Standard is not met as evidenced by: 10802 Based on observation, interview and record review, facility’s direct care staff failed to provide social services intervention to address patient’s needs in 2 of 10 sampled patients and 1 random interview. Patient #s 4, 5, and random Patent #11 Findings: Review of the facility’s current policy and procedure on Social services -Psychosocial Aspects #335 A directs staff as follows: The Dialysis staff will serve as supportive counselors , and resource people or should know where to direct the patients for help in several areas. One of these is financial help. Dialysis has become an expensive proposition. Aside from the cost of treatment ( usually covered by Medicare) there is low salt food, medications, travel costs, etc. the staff need to help patients meet these cost by telling them where that can go to get help or use creative measures, fund raisers personal resources to help. Another area is dietary counseling. Dialysis staff , because they see the patient gain weight , should be able to help them with dietary problems and provide a dietician to whom the patient can turn to. The staff needs to help with supportive counseling to help the patient gain back his self- esteem. The patient may express a desire for this , or it may come from the staff member just talking to the patient. Staff should be aware of a social worker , if there is not one on the team, to which can be referred . It is important for the staff to know what resources the hospital , community and patient’s community may have.” Marital and family problems of dialysis patients can be immense “ “Another problem the dialysis patient may have is his sex life . Due to the uremia present before dialysis most men are at least partly impotent, and most women have decreased sexual desire. After dialysis is initiated, this problem may get better. It may not It is felt that at least part of this is psychological reasons and counseling may help a great deal.” Patient #4 On 03/20/2024 at 8:27 a.m. patient #4 was observed on the hemodialysis unit of the facility at station #1, hemodialysis machine #3. The patient was alert and oriented to person, place, time and situation. The patient was receiving hemodialysis treatment at a blood flow rate of 450 mls/ minute and dialysate flow rate of 500 mls/ minute via a right upper arm vascular access. Interview with the patient during the observation revealed he said he is having financial challenges. He applied for Medicaid but have not heard anything. He is supposed to have surgery on his eyes, but he is waiting on Medicaid approval. He states “we had one before who comes once a year” referring to the facility’s social worker. He said the facility has a new social worker who started last month.” Review of the patient’s nurse’s notes dated 12/13/2023 revealed the following entry by the facility’s licensed nurse “ Pt no show for tx today, contacted pt and spoke to wife, stated D/t no gas money or no transportation. Pt education provided to sodium diet, fluid intake restricted . Dr -notified. “ Interview on 03/22/2024 at 2:45 p.m. with the Facility’s Clinical Coordinator revealed she said she can recall the patient not coming for his hemodialysis treatment. She said she spoke to the patient via the telephone, and he told her that he was not able to attend hemodialysis treatment because he had a problem with his vehicle and did not have money to pay to get to the facility. She said the patient then handed his telephone to his wife who told her that they did not have money to pay for transportation for the patient to get to hemodialysis treatment. She said she could not offer to pay because it would be a conflict of interest. She said this incident happened when the facility was in between having the service of a social worker, but she notified the patient’s physician. Review of the patient’s clinical record revealed no follow up documentation by facility’s social worker addressing the patient’s lack of resources to get to hemodialysis treatment and information provided to obtain necessary resources. Review of the Patient’s clinical record revealed the following social worker’s documentation: 11/16/2023: “ Patient was resting during treatment and shared limited information. No concern at this time. SW will continue to monitor.” 03/15/2023: “ PT has no concerns and is stable. PHQ2 administered and there were no concerns. SW to continue to follow and provide support where needed. The record revealed the patient had no documentation of contact with a Social Worker between 11/16/2023 and 03/15/2023. Review of the patient’s clinical record revealed the most current kidney disease quality of life survey on file which was not dated or scored. Documentation on the Kidney Disease Quality of Life Survey which addresses physical health or emotional problems interfered with social activities indicated this happened most of the time. Definitely true that his kidney disease interferes too much with his life, mostly true too much time is spent dealing with kidney disease, definitely true dealing with his kidney disease and definitely true he feels like a burden on his family. The effect of kidney disease on his daily life indicated that he was extremely bothered about his ability to travel, stress or worries cause by kidney disease and his sex life. Review of the Facility’s Governing Body Meeting Minute dated 2/29/2024 revealed documentation which indicated that the social worker was hired to the facility on February 14, 2024. Interview on 03/22/2023 at 8:03 a.m. via the telephone with the facility’s current social worker revealed she said she started working at the facility in February 2024 and conducted visits to the facility on February 15th, 2024, and March 15th 2024. She said during the visit she was getting to know the patients and was not aware of the patient’s situation. She said she has not received orientation to the facility. Patient #5 On 03/20/2024 at 8:40 a.m. Patient #5 was observed on the facility’s hemodialysis unit at station # 2. The patient was receiving hemodialysis treatment at a blood flow rate of 350 mls/ minute and dialysis flow rate of 500 mls/ minute via a right upper arm vascular access. Review of Patient #5’s clinical record (patient information) revealed the patient was admitted to the facility on 9/4/2023 with diagnosis of diabetes mellitus, hypertension, early dementia and end stage renal disease on in center hemodialysis three times weekly. Review of the Patient’s clinical record revealed the following social worker’s documentation: 11/16/2023: “Pt is stable, no concerns at this time, SW will continue to monitor.” 03/15/2023: “ SW met with patient. Patient is stable and no concern at this time. PHQ2 done. SW to continue to follow patient.” The record revealed the patient had no documentation of contact with a Social Worker between 11/16/2023 and 03/15/2023. Random Patient #11 On 03/20/2024 at 8:48 a.m. revealed random Patient #11 was observed on the hemodialysis treatment unit at station # 4. Interview on 03/20/2024 at 8:48 a.m. with random Patient #11 revealed she stated” I last saw a social worker on approximately May last year.””