Davita Petersburg Dialysis

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(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: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 49355 Based on observation, interviews and document review, it was determined the facility failed to maintain an current updated copy of patients’ treatment orders in the home treatment area evacuation kit. The findings: The facility’s document, “Facility Emergency Management Plan (ICHD, Home),” policy 4-07-01, last revision date October 2024, reads, in part: ... “Emergency Evacuation Kit ... 6. Each evacuation kit(s) should contain: a. Copy of each patient’s treatment orders and medication list. FA or designee will very patient information is updated and replaced at least monthly.” The home treatment evacuation kit, located behind the home area nurses’ desk, was inspected at 10:22 A.M. on June 17, 2025. The patient treatment order list included was dated April 1, 2025. When this surveyor returned to the nursing desk after interviewing a home hemodialysis patient receiving treatment in the facility, EMP21 stated that a new, updated treatment list for current home patients had been printed and was placed in the evacuation kit. On June 17, 2025, at 10:22 A.M., EMP8 and EMP21 agreed a current treatment order list for the home patients should be printed off and included in the kit, at least once monthly.”

“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: 49355 Based on observations, interviews and document review, it was determined the facility failed to follow infection control and prevention practices related to hand hygiene and glove changing. Specifically, hand hygiene (HH) was not performed and gloves were not changed, per policy, in one (1) out of three (3) observations of discontinuation of dialysis with an arteriovenous (AV) fistula. The findings: A review of the facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy: 1-05-01, revision date April 2023, reads, in part: “Hand Hygiene 1. All teammates...will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves, ... d. after patient and dialysis delivery system contact, ... g. before touching clean areas such as supplies, supply car and chairside keyboard/mouse ... PPE ... 7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station.... a. Gloves should be changed when: ... ii. When going from a ‘dirty’ area or take to a ‘clean’ area or task.” A review of the facility’s procedure entitled, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles,” procedure: 1-04-01B, revision date April 2023, reads, in part: ... “1. Perform hand hygiene. Put on PPE. Hand hygiene protects patient and teammate from cross contamination. PPE is worn to protect teammate.” On June 18, 2025, at 9:29 A.M., EMP11 discontinued dialysis via an arteriovenous (AV) fistula on MR19 at station #15. EMP11 never performed hand hygiene or changed gloves throughout the entire discontinuation. During a discussion with EMP1 and EMP22, both agreed that hand hygiene and glove changes should have occurred several times during this process.”

“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: 49355 Based on observations and document review, it was determined the facility failed to ensure dialysis stations and chairs were appropriately and completely disinfected between patients in two (2) out of three (3) observations. The facility also failed to immediately clean up and disinfect two (2) blood drips from beside an occupied dialysis chair. The findings: The facility’s policy entitled, “Termination of Dialysis with All Single Use Dialyzer Types Utilizing Nikkiso DBB-06 Dialysis Delivery System and Nikkiso Conventional Blood Lines,” procedure 1-03-09E, revision date April 2024, reads, in part: ... “Procedure ... 18. Once the patient has vacated the dialysis station: * Empty priming container if needed * Clean exterior surface of dialysis delivery system * Clean interior and exterior surface of reusable priming container with appropriate disinfectant.” The facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy 1-05-01, revised date April 2023, reads, in part: ... “Disinfection 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials.... a. Prior to routine disinfection, remove all visible blood i. For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized ii. After all visible blood is cleaned with the 1:10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time. iii. Cleaning of visible blood should be performed when first observed. ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g. control panel; top, front and sides of dialysis machine; touchscreens; countertops). ... ii. Priming containers are to be emptied prior to disinfection.” On June 16, 2025, at 11.28 A.M., EMP11 failed to empty the prime waste receptacle at station #13, thereby failing to disinfect the internal and external surfaces of the container, per policy. EMP11 failed to disinfect the dialysis chair underneath each side tray and did not disinfect the television touchscreen surface. On June 16, 2025, at 11:39 A.M., this surveyor noticed two (2) blood drips, each approximately 1.5 to 2 inches in diameter, beside an occupied dialysis chair at station #9. The surveyor does not know whether the blood was that of the seated patient or the prior patient. On June 18, 2025, at 9:55 A.M., EMP5 failed to completely disinfect the outside of the the dialysis chair at station #2, failing to clean the area under each chairside table. EMP5 also laid a dirty blood pressure cuff on the disinfected dialysis chair. During a discussion with SM1 and SM22 on June 18, 2025, both agreed that blood drips should be cleaned up and disinfected immediately. Both employees also indicated dialysis chairs and non-disposable items at the station should be completely disinfected prior to the next patient being seated.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 49355 Based on observation, interviews and document review, it was determined the facility failed to ensure aseptic technique when preparing and administering medications and maintaining a safe environment for dialysis patients and staff by: 1) not wiping the medication rubber septum of a multidose vial prior to each needle insertion; 2) not keeping a sterile prefilled syringe of saline flush capped until immediately ready for use; 3) not removing expired medications from the treatment floor; 4) and not labeling predrawn medication. The findings: In the facility policy entitled, “Preparation and Administration of Parenteral Medications (Non-ESA, Non-Parsabiv),” procedure 1-06-01A, last revised April 2024, reads, in part: ... “Preparation of Parenteral Medications (Non-ESA, Non-Parsabiv) ... 7. If the medication is in a vial, remove the vial cap, and clean vial stopper with an alcohol prep pad. A new alcohol prep pad is used prior to each time a vial is entered. ... 16. Label the syringe with the patient’s name, name of the prescribed medication, dose, date, time and initials of licensed teammate preparing the dose.” In the facility policy entitled, “Infection Control for Dialysis Facilities,” policy 1-05-01, last revised April 2023, reads, in part: ... “Supplies 8. Supplies will be stored in a manner that maintains their integrity. ... c. Supplies will not be opened until time of use.” In the facility document entitled, “Medication Policy,” policy 1-06-01, revised date November 2023, reads, in part: ... “8. All teammates administering medications must utilize aseptic technique ... 21. An aseptic environment and aseptic technique is used when preparing medications.” ... 30. All medications in the facility are checked monthly. ... All medications are checked monthly for expiration dates. ... 32. Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations.” On June 16, 2025, at 9:13 A.M., this surveyor witnessed EMP7 prefilling syringes with heparin. EMP7 was using a multidose vial and did not swab the rubber septum of the vial prior to each needle puncture. On June 16, 2025, at 11:41 A.M., EMP6 was preparing to administer medication to MR14 at station #18. EMP6 unwrapped and uncapped a syringe of pre-filled saline flush and laid it on the chairside table until it was time to inject it. On June 16, 2025, at 11:45 A.M., this surveyor removed an expired unopened vial of Nitroglycerin (NTG) SL (Sublingual) tablets 0.4 mg/tablet, NDC #68462-0639-01, from the treatment floor. The vial had expired April, 2025. On June 16, 2025, at approximately 11:42 A.M., this surveyor observed approximately twenty (20) unattended prefilled syringes of a clear liquid, lying on a countertop. None of the syringes were labeled, but there were heparin labels adjacent to the syringes on the counter. The labels did not have the initials of the staff that prepared them, the date or the time. During a discussion on June 18, 2025, EMP1 and EMP22 indicated all medications should be reviewed monthly for expiration dates and all expired medications are to be removed from the treatment floor. EMP1 and EMP22 also indicated the rubber septum of the multidose vial of heparin should have been swabbed with an alcohol pad prior to each needle insertion and that all prefilled syringes should be labeled immediately, to include the initials of the staff that prepared them, the date and time. EMP1 and EMP22 agreed that a sterile prefilled syringe of saline should not be uncapped and placed on the chairside table prior to use. The syringe should be uncapped and used immediately.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 49355 Based on medical record reviews, documentation review and interview, it was determined the facility failed to document a monthly nursing note to evaluate a patient’s current health status and medical condition, per policy, in one (1) out of nine (9) medical records reviewed, patient (MR) 9. The findings: The facility’s document entitled, “Progress Note Policy,” policy 3-02-17, last revised October 2024, reads, in part: “Purpose: To verify progress notes are documented by the Physician, Nurse, Dietitian and Social Worker. Documentation needs to include treatment given or planned, patients encounters and the condition of the patient. Policy: ... Nurse: Nurses are required to record patient progress notes at least monthly and for any clinical event, which must be recorded in a time frame that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times. ... All progress notes are to be dated and signed at the time they are written or entered electronically.” A review of the medical record for MR9 on June 17, 2025, with the assistance of EMP22, revealed the last documented nursing note was dated April 7, 2025. During an interview with EMP22 and EMP23 on June 17, 2025, both employees indicated that a nursing note should be documented for each patient once monthly, at the minimum.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 49355 Based on medical record reviews, document review and interviews, it was determined the facility failed to document abnormal findings and notification to the charge nurse or physician of: 1) unmet target weights (TW) compared to post treatment weights (PTW) in six (6) out of nine (9) medical records reviewed; 2) blood pressure (BP) measurements outside of facility guidelines in three (3) out of nine (9) medical records reviewed; 3) and documentation of completed pre-treatment nursing assessments by the policy-specified time in five (5) out of nine (9) medical records reviewed. The findings: The facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy 1-03-08, revision date April 2024, reads, in part: ... “Pre-Treatment Data Collection/Assessment ... 5. The assessment is a nursing responsibility. ... 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation.... ... 11. Abnormal finding or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. ... 13. All findings, interventions and patient response will be documented in the patient’s medical record. ... Abnormal Findings Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. ... Fluid Status: ... Post-treatment: If patient is above or below 1 kg from the target weight ... Blood Pressure-Intradialytic: * Systolic greater than 180 mm/Hg or less than 90 mm/Hg * Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg” A review of the following medical records revealed: Patient (MR) 2: Flowsheet dated June 9, 2025: PTW was documented as 98.7 kg, TW was 96.5, a deviation of 2.2 kg. No documentation was noted on the flowsheet. Flowsheet dated June 12, 2025: PTW was documented as 99.4 kg, TW was 96.5, a deviation of 2.9 kg. No documentation was noted on the flowsheet. MR3: Flowsheet dated June 11, 2025: PTW was documented as 65.0 kg, TW was 67.0, a deviation of 2.0 kg. No documentation was noted on the flowsheet. MR4: Flowsheet dated June 5, 2025: treatment start time was 11:21 A.M., documented nursing pre-assessment note completion was 1:00 P.M., a difference of 1 hour 39 minutes. MR5: Flowsheet dated June 2, 2025: PTW was documented as 59.9 kg, TW was 57.5, a deviation of 2.4 kg. No documentation was noted on the flowsheet. Flowsheet dated June 4, 2025: PTW was documented as 59.0 kg, TW was 57.5, a deviation of 1.5 kg. No documentation was noted on the flowsheet. Flowsheet dated June 9, 2025: PTW was documented as 58.6 kg, TW was 57.5, a deviation of 1.1 kg. No documentation was noted on the flowsheet. Flowsheet dated June 12, 2025: PTW was documented as 59.6 kg, TW was 57.5, a deviation of 2.1 kg. No documentation was noted on the flowsheet. MR6: Flowsheet dated June 3, 2025: PTW was documented as 90.3 kg, TW was 87.0, a deviation of 3.3 kg. No documentation was noted on the flowsheet. Flowsheet dated June 10, 2025: treatment start time was 6:19 A.M., documented nursing pre-assessment note completion was 7:25 A.M., a difference of 1 hour 6 minutes. MR7: Flowsheet dated June 6, 2025: treatment start time was 11:20 A.M., documented nursing pre-assessment note completion was 12:22 P.M., a difference of 1 hour 2 minutes. Flowsheet dated June 9, 2025: treatment start time was 11:14 A.M., documented nursing pre-assessment note completion was 12:25 P.M., a difference of 1 hour 11 minutes. Flowsheet dated June 11, 2025: treatment start time was 11:15 A.M., documented nursing pre-assessment note completion was 1:22 P.M., a difference of 2 hour 7 minutes. MR8: Flowsheet dated June 2, 2025: between 11:09 A.M. and 3:09 P.M., blood pressure readings ranged from 177/115 mm/Hg to 199/122 mm/Hg throughout the 225 minute treatment cycle. No documentation was noted on the flowsheet. Flowsheet dated June 3, 2025: PTW was documented as 98.1 kg, TW was 97.0, a deviation of 1.1 kg. No documentation was noted on the flowsheet. Flowsheet dated June 5, 2025: PTW was documented as 98.3 kg, TW was 97.0, a deviation of 1.3 kg. No documentation was noted on the flowsheet. : treatment start time was 10:48 A.M., documented nursing pre-assessment note completion was 12:38 P.M., a difference of 1 hour 50 minutes. Flowsheet dated June 7, 2025: PTW was documented as 98.3 kg, TW was 97.0, a deviation of 1.3 kg. No documentation was noted on the flowsheet. Flowsheet dated June 10, 2025: treatment start time was 10:51 A.M., documented nursing pre-assessment note completion was 12:10 P.M., a difference of 1 hour 19 minutes. : at 1:21 P.M., BP reading was 199/100 mm/Hg. No documentation was noted on the flowsheet. MR9: Flowsheet dated June 2, 2025: treatment start time was 6:38 A.M., documented nursing pre-assessment note completion was 8:09 A.M., a difference of 1 hour 31 minutes. Flowsheet dated June 13, 2025: PTW was documented as 58.6 kg, TW was 57.5, a deviation of 1.1 kg. No documentation was noted on the flowsheet. During an interview on June 17, 2025, EMP22 and EMP23 indicated that pre-assessment nursing notes should be completed within one (1) hour from the start of treatment and any unmet target weights or abnormal BP readings should be documented in the flowsheet and the charge nurse notified.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 49355 Based on medical record reviews, interviews and document review, it was determined the facility failed to follow physician’s orders and failed to document the reason for the deviation for: 1) prescribed blood flow rate (BFR) and/or dialysate flow rate (DFR) for five (5) out of nine (9) records reviewed 2) and/or decreased length of treatment times shorter than the prescribed duration without documentation and/or a completed Against Medical Advice form in four (4) out of nine (9) medical records reviewed. The findings: The facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy 1-03-08, revision date April 2024, reads, in part: ... “3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour.... Prescription components include but are not necessarily limited to: ... b. Treatment time ... f. Blood flow rate g. Dialysate flow rate ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. ... 12. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record. ... 17. Licensed nurse will use their clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility.” The facility’s policy entitled, “Prescribed Treatment Time Not Met, policy 1-01-09, revision date April 2024, reads, in part: ... “A. Completion of the Early Termination of Treatment Against Medical Advice Form 1. The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. ... 3. The RN will obtain the patient’s signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient’s signature prior to rinse-back, the RN will obtain the patient’s signature on the form prior to the patient’s departure from the facility. 4. A RN must countersign all Early Termination of Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 5. If a patient refuses to sign the Early Termination of Treatment Against Medical Advice form, the RN will document the patient’s refusal with the words “patient refused” in the patient signature box along with the date. Under such circumstances, the RN will sign the form and will also obtain a witness’ signature on the form. 6. This applies only to shortened treatments. ... B. Prescribed Treatment Time Not Met 1. If the shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs. NOTE: Shortened/Early Termination of dialysis treatment includes all reasons the prescribed dialysis time is not met by 30 or more minutes. ... 3. If a patient’s treatment is shortened/early terminated, the RN will document the event in the patient’s electronic health record. Documentation will include, as appropriate: * The amount of time by which the treatment was shortened * A description of why the treatment was shortened * Whether the patient’s nephrologist was notified * A description of the follow-up medical orders provided by the patient’s attending nephrologist (if any) * A description of all other interventions planned to address the shortened treatment, including recommendation to the patient. ... 5. Additionally, if the patient’s dialysis treatment is terminated 30 or more minutes prior to the ordered treatment length, the reason must be documented in the patient electronic health record at the time the treatment was terminated while reconciling the treatment times. ... 6. The Facility Administrator (FA)/Designee will verify that all shortened treatments are recorded and trended, and the FA/Designee shall verify that such records are reviewed and discussed at the Facility Health Meetings (FHM), as appropriate.” A review of the following medical records revealed: Patient (MR) 2: Flowsheet dated June 12, 2025: prescribed treatment duration 240 minutes, actual treatment duration 197 minutes, a deviation of 43 minutes. A completed AMA form was absent from the medical record. Flowsheet dated June 12, 2025: prescribed treatment duration 240 minutes, actual treatment duration 182 minutes, a deviation of 58 minutes. A completed AMA form was absent from the medical record. MR4: Flowsheet dated June 5, 2025: prescribed treatment duration 150 minutes, actual treatment duration 119 minutes, a deviation of 31 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent from the medical record. Flowsheet dated June 12, 2025: prescribed treatment duration 150 minutes, actual treatment duration 117 minutes, a deviation of 33 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent from the medical record. Prescribed DFR 500 ml/min, actual DFR 700 ml/min for 30 minutes of treatment. No documentation noted in the flowsheet. MR5: Flowsheet dated June 2, 2025: prescribed treatment duration 225 minutes, actual treatment duration 169 minutes, a deviation of 56 minutes. A completed AMA form was absent from the medical record. Flowsheet dated June 12, 2025: prescribed BFR 400 ml/min, actual BFR ranged from 349 ml/min to 3500 ml/min for 162 minutes of the 225 minute treatment. No documentation noted in the flowsheet. MR6: Flowsheet dated June 12, 2025: prescribed BFR 450 ml/min, actual BFR 350 ml/min for 30 minutes of the 225 minute treatment; prescribed DFR 800 ml/min, actual 500 ml/min for 30 minutes of the 225 minute treatment. No documentation noted in the flowsheet. MR7: Flowsheet dated June 6, 2025: prescribed treatment duration 240 minutes, actual treatment duration 150 minutes, a deviation of 90 minutes. A completed AMA form was absent from the medical record. Prescribed BFR 350 ml/min, actual BFR 532 ml/min for 27 minutes of treatment. No documentation noted in the flowsheet. Flowsheet dated June 11, 2025: prescribed treatment duration 240 minutes, actual treatment duration 180 minutes, a deviation of 60 minutes. A completed AMA form was absent from the medical record. MR9: Flowsheet dated June 13, 2025: prescribed BFR 400 ml/min, actual BFR 299 ml/min for 30 minutes of 180 minute treatment. No documentation noted in the flowsheet. During an interview at 10:37 A.M. on June 16, 2025, EMP18 indicated that the expectation is the dialysis prescription will be followed exactly. Any deviation from the prescribed values should be documented and the RN notified. If problems exist, the RN should notify the physician. During an interview on June 17, 2025, EMP22 and EMP23 indicated that any deviation from the prescribed values for BFR, DFR and/or shortened length of treatment should be documented in the flowsheet and the charge nurse notified. EMP23 indicated there may be valid reasons for a deviation from the prescribed values, but that should be documented in the flowsheet and the RN should be notified.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49355 Based on observations, interviews and document review, it was determined the facility failed to properly care for arteriovenous (AV) grafts/fistulas according to the facility’s policy. Specifically, in two (2) out of three (3) observations, facility staff touched the cannulation sites of arteriovenous (AV) fistulas after the areas were prepped with antiseptic and prior to needle insertion. The findings: The facility’s procedure entitled, “AV Fistula or Graft Cannulation with JMS Sysloc (R) Mini Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” procedure 1-04-01D, revision date April 2025, reads, in part: ... “Procedure: ... 13. Do not palpate insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possible allow for the introduction of bacteria during contamination.” On June 16, 2025, at 11:41 A.M., employee (EMP) 6 palpated patient (MR) 14’s AV fistula cannulation site at station #20 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. On June 18, 2025, at 10:24 A.M., EMP7 palpated MR18’s AV fistula cannulation site at station #14 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. During an interview on June 18, 2025, EMP22 indicated that once the fistula insertion sites are cleansed with an antiseptic, the area should not be touched prior to needle insertion, unless the area is recleansed.”

“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: 49355 Based on facility document review and interview, it was determined the facility failed to complete the initial plan of care (POC) within thirty (30) calendar days after admission to the dialysis facility, per policy, for one (1) of nine (9) medical records reviewed, patient (MR) 8. The findings: A review of the facility’s policy entitled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” revised October 2024 states, in part: ... “10. An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days.... ... New Patient: Assessment within 30 days of admission to facility....” A review of the medical record for MR8 on March 17, 2025, revealed the patient started dialysis at the facility on December 11, 2024. The patient’s initial POC was written on January 28, 2025. During an interview on June 18, 2025, EMP22 acknowledged MR8’s initial POC was late. The completion date should have been within thirty (30) days of MR8 starting dialysis treatments.”

“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: 49355 Based on review of documentation and interview, it was determined the facility failed to document a monthly physician note to evaluate a patient’s current health status and medical condition, per policy, in one (1) out of nine (9) medical records reviewed, patient (MR) 4. The findings: The facility’s document entitled, “Progress Note Policy,” policy 3-02-17, last revised October 2024, reads, in part: “Purpose: To verify progress notes are documented by the Physician, Nurse, Dietitian and Social Worker. Documentation needs to include treatment given or planned, patients encounters and the condition of the patient. Policy: ... Physician: The attending Nephrologist is required to record patient progress notes at least monthly and for any clinical event, which must be recorded in a time frame that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times.” A review of the medical record for MR4 on June 17, 2025, with the assistance of EMP22, revealed the last documented physician note was dated April 19, 2025. During an interview with EMP22 and EMP23 on June 17, 2025, both employees indicated that a physician note should be documented for each patient once monthly, at the minimum.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 49355 Based on facility document review and interview, it was determined that the facility’s quality improvement program failed to implement effective improvement plans to achieve measurable and sustained improvement in facility focused areas. The findings: A review of facility’s policy entitled “Continuous Quality Improvement Program,” revised April 2021 reads, in part: ... “8. ... Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement, and will track this change in performance over time to verify improvements are sustained.” On June 18, 2025, the facility’s quality improvement program was reviewed with the assistance of EMP22. Three (3) of the facility’s top quality indicators were reviewed, consisting of: missed treatments, excessive interdialytic weight gain and post treatment weight versus (vs) target weight disparities. Data from the October 2024, quality meeting was reviewed for these indicators. The missed treatment at the facility percentage was 11.8% vs the company standard of 5.8%; excessive interdialytic weight gain was documented at 33.3% vs. the company standard of 28%; and post treatment weight vs target weight was 43.1% vs the company standard of 28%. The next data documented, from January 2025, revealed missed treatments of 13.6% vs 5.8%; excessive interdialytic weight gain at 34.8% vs 28%; and post treatment vs target weight disparities of 58% vs 25%. The action plans for each of these indicators had not changed, despite the documented decline in outcomes. During an interview on June 18, 2025,, EMP22 indicated that the quality improvement program for this facility was a recognized area of improvement. EMP22 indicated agreement that action plans needed to be reviewed monthly and updated, as needed, to achieve quality improvement and obtain meaningful data to be track and trend.”