Fresenius Kidney Care Sugarland Home

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 48020 Based on observation, record review and interview, the facility’s interdisciplinary team failed to ensure participation by the patient in the Plan of Care in 2 of 9 sampled patients and 6 closed records: Patient #s 1, 8 Findings: Review of the facility’s current Policy and Procedure on Comprehensive Interdisciplinary Assessment and Plan of Care; Policy #45283, published 07/03/2023 directs staff as follows: “Comprehensive Assessment Participation and Plan of Care Review “ The patient’s level of participation is determined by the patient. The patient must sign the plan of care meant to acknowledge the information in the plan. If the patient chooses not to sign their plan of care, the reason for refusal must be documented in the patient’s medical record.” Patient #1 Review of the patient’s clinical record on 06/30/2025 revealed the patient was admitted to the facility on 04/09/2024 with the diagnoses of end stage renal disease, hypertension, diabetes mellitus and hyperlipidemia, on home peritoneal dialysis seven times a week. Review of the patient’s current Plan of Care revealed it was signed by the physician, registered nurse, registered dietitian, and social worker on 07/15/2024. The Plan of Care was not signed and dated by the patient. During the record review, surveyor requested documentation that the patient participated in the plan of care meeting. There was no documentation provided. Patient #8 Review of the patient’s clinical record on 06/30/2025 revealed the patient was admitted to the facility on 07/02/2024 with the diagnoses of end stage renal disease, diabetes mellitus and hyperlipidemia, on home hemodialysis five times a week. Review of the patient’s current Plan of Care revealed it was signed by the registered nurse, registered dietitian, and social worker on 10/29/2024. The Plan of Care was signed by the physician on 11/04/2024. The Plan of Care was not signed and dated by the patient. During the record review, surveyor requested documentation that the patient participated in the plan of care meeting. There was no documentation provided. Interview with Home Therapies Area Team Lead (H) on 06/30/2025 at 4:25 p.m. confirmed the Plan of Care for the patients above were not signed.”

“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: 48020 Based on observation, interview and record review, patients’ attending nephrologists failed to complete monthly comprehensive progress notes on patients addressing adequacy, dialysis access, anemia management, nutritional status, bone mineral metabolism and treatment response in 4 of 9 sampled patients and 6 closed records: Patient #s 2, 6, 8, 9 Findings: Patient #2 Observation on 06/30/2025 at 11:09 a.m. revealed Patient #2 was seated in the hemodialysis chair being interviewed by Registered Nurse (B). Review of the patient’s clinical record revealed the patient was admitted to the facility on 11/27/2024 with the diagnoses of end stage renal disease and hypertension, on home peritoneal dialysis seven times a week. Review of the patient’s clinical record revealed the most current monthly physician progress note was dated 04/17/2025. There were no monthly comprehensive progress notes documented for May 2025 or June 2025. Patient #6 Review of the patient’s clinical record on 06/30/2025 revealed the patient was admitted to the facility on 09/20/2019 with the diagnoses of end stage renal disease, hypertension, hyperlipidemia on peritoneal dialysis seven times a week. Review of the patient’s clinical record revealed the most current monthly physician progress note was dated 06/16/2025. There was no monthly comprehensive progress notes documented for April 2025. Patient #8 Review of the patient’s clinical record on 06/30/2025 revealed the patient was admitted to the facility on 07/02/2024 with the diagnoses of end stage renal disease, diabetes mellitus and hyperlipidemia, on home hemodialysis five times a week. Review of the patient’s clinical record revealed the most current monthly physician progress note was dated 06/23/2025. There was no monthly comprehensive progress notes documented for April 2025. Patient #9 Review of the patient’s clinical record on 06/30/2025 revealed the patient was admitted to the facility on 02/18/2025 with the diagnoses of end stage renal disease and hypertension, on home hemodialysis five times a week. Review of the patient’s clinical record revealed the most current monthly physician progress note was dated 03/31/2025. There were no monthly comprehensive progress notes documented for April 2025 - June 2025. Interview with Clinical Manager (A) on 06/30/2025 at 4:10 p.m. confirmed the findings above.”