Davita Great Bridge Dialysis Center

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 41450 Based on staff interview and facility documentation review, the facility staff failed to conduct exercises to test the facility’s emergency preparedness plan annually. The findings include: On 1/29/25 at approximately 11:00 AM, a review of the facility’s emergency preparedness plan was conducted. There was no evidence of exercises or testing of the facility’s emergency preparedness plan to include but not limited to community-based exercises, individual facility-based functional exercises, mock disaster drills, or tabletop exercises/workshops. A fire drill was conducted on June 23, 2023. At approximately 11:30 AM, an interview was conducted with Staff Member (SM) #1 who confirmed the findings. Review of the facility’s policy titled, “Facility Emergency Management Plan (ICHD, Home)”, revision date April 2024, page 4, subtitle “Purpose”, item 1, read, “The goal of the Emergency Management Plan is to verify that mitigation, preparedness, response, and recovery actions exist so patient and teammate welfare and safety is preserved” Page 4 of the Facility Emergency Management Plan, subtitled “Authority and Responsibility”, item 2, read, “The leadership team is committed to: a. Preventing, mitigating the consequences of, preparing for, responding to, maintaining continuity during, and recovering from events that may occur, b. Support the development, implementation, and maintenance of the program, c. Provide necessary resources to support the program, d. Review and evaluate as needed to verify program effectiveness, e. Support corrective action to address deficiencies in the plan, f. Adhere to policies, execute plans, and follow procedures developed to support the program”. Page 26 of the Facility Emergency Management Plan, subtitled “Emergency Drills”, item 2a, read, “The purpose is to test the effectiveness of the facility’s emergency plan, emergency response, hazard and risk assessment, and the support of the patient population served” and item 2e, read, “Frequency: i. The facility will conduct and/or participate in one (1) exercise to test the facility EMP [Emergency Management Plan] at least ANNUALLY...”. Under subtitle “Emergency Drills”, page 26, item 3, read, “Fire safety drills:...b. Required on a QUARTERLY basis, c. One drill to be conducted for each shift of patients...”.”

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure staff provided annual Emergency training for Patients as defined by facility policy to include informing patients of what to do, where to go, and how to disconnect themselves from the dialysis machine if an emergency occurs for one (1) of eleven (11) Patients (P), P # 2. The findings include: On January 29, 2025 and January 30, 2025, Clinical Record reviews revealed the following for P # 2: There was no current documentation of Emergency Preparedness (EP) training from 2022 to the survey date to include what to do, where to go, and how to disconnect self from the dialysis machine. The last EP training was documented as September 29, 2021. The facility policy titled “Facility Emergency Management Plan (EMP)” reads in part “Emergency Management Plan. The FA (Facility Administrator) or designee, is responsible to provide training on EMP. Patients: Annually: Policy and facility Emergency Management Plan, Emergency diet, per dietitian and facility specific emergency response procedures.” On January 30, 2025 at approximately 11:00 AM, Staff Member (SM) # 25 stated there was no updated EP training for [P # 2].”

“IC-SANITARY ENVIRONMENT CFR(s): 494.30 The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to provide a sanitary environment to minimize infections for Patients by having tears in chairs for three (3) of six (6) stations, Stations # 5, # 7 and # 8. The findings include: On January 29, 2025, during observations in the treatment area, the following were observed: At 9:55 AM, Station # 5 was observed during cleaning of the station post treatment. The chair at Station # 5 had a tear approximately 5 - 6 inches down the center of the chair. Torn or damaged surfaces expose a porous surface that can’t be disinfected. At 10:20 AM, Station # 7 was observed during cleaning of the station post treatment. The chair at Station # 7 had a tear approximately 4 - 5 inches down the center of the chair. Torn or damaged surfaces expose a porous surface that can’t be disinfected. At 10:23 AM, Station # 8 was observed during cleaning of the station post treatment. The chair at Station # 8 had tear approximately 4 - 5 inches down the center of the chair. Torn or damaged surfaces expose a porous surface that can’t be disinfected. On January 30, 2025 at approximately 10:30 AM, a review of the facility’s policy titled “Infection Control” reads in part “At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaced 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)”. On January 30, 2025 at approximately 12:00 PM, an interview with Staff Member (SM) # 25 revealed “we know what stations they are and are working on getting them repaired.””

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to wear disposable gloves when touching Patient equipment at the dialysis station for three (3) of four (4) Staff Members (SM), SM # 6, # 8, and # 18. The findings include: On January 28, 2025, during observations in the treatment area, the following were observed: At 12:29 PM, SM # 8 was observed touching the dialysis machine at Station # 11 while wearing one glove. At 12:31 PM, SM # 18 was observed touching the dialysis machine at Station # 12 while wearing one glove. At 1:08 PM, SM # 6 was observed touching the dialysis machine at Station # 11 while wearing one glove. On January 30, 2025 at approximately 10:30 AM, a review of the facility’s policy titled “Infection Control” reads in part “Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station.” On January 30, 2025 at approximately 12:00 PM, an interview with SM # 25 revealed “staff know they should be wearing two gloves.””

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to clean and disinfect contaminated surfaces at the dialysis station for three (3) of six (6) stations, Stations # 5, # 8 and # 21. The findings include: On January 29, 2025, during observations in the treatment area, the following were observed: At 9:55 AM, Station # 5 was observed during cleaning of the station post treatment. There was a blood pressure cuff on the counter during the treatment. The staff failed to clean and disinfect the counter behind the chair. At 10:00 AM, Station # 21 was observed during cleaning of the station post treatment. There were Patient belongings on the counter behind the chair during the treatment. The staff failed to clean and disinfect the counter behind the chair. At 10:23 AM, Station # 8 was observed during cleaning of the station post treatment. There were Patient belongings on the counter behind the chair during the treatment. The staff failed to clean and disinfect the counter behind the chair. On January 30, 2025, at approximately 10:30 AM, a review of the facility’s policy titled “Infection Control” reads in part “At the end of each treatment, the dialysis station will be cleaned and disinfected. Surfaced 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)”. On January 30, 2025 at approximately 12:00 PM, an interview with SM # 25 revealed “staff know they should be cleaning the counters.””

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 41450 Based on staff interview and facility documentation review, the facility staff failed to provide Hepatitis B vaccines for one (1) of five (5) staff members (SM), SM #13. The findings include: On 1/29/25 at approximately 2:30 PM, staff record reviews were conducted and revealed that Staff Member (SM) #13, hired on 2/26/24, had no documentation of Hepatitis B immunization, to include Hepatitis B vaccination or antibody status. On 1/29/25 at approximately 3:30 PM, SM #1 confirmed the findings and stated, “It is my expectation for all personnel to be screened for HBV [Hepatitis B Virus] at the time of hire as part of our onboarding process”. Review of the facility’s policy titled, “Teammate Hepatitis B Monitoring and Follow-Up Guidance”, revision date April 2024, subtitle, “Policy”, item 1, read, “New teammates ...will be screened for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) within 10 days and offered the vaccination as indicated by their results”.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure the Patient’s treatment blood flow rate (BFR) was as prescribed by the Physician for one (1) of eleven (11) Patients (P), P # 8. The findings include: On January 30, 2025, the clinical record review for P # 8 revealed the following: The flowsheet dated January 27, 2025 revealed the BFR was 250 the duration of treatment (4:18 PM to 8:06 PM). The Physician ordered BFR was 400. There was no documentation that the Physician and/or Registered Nurse (RN) was notified of the decreased BFR. On January 30, 2025 at approximately 10:30 AM, a review of the facility’s policy titled “Pre Intra Post Treatment Data collection, monitoring and nursing assessment” reads in part “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.” On January 30, 2025 at approximately 12:00 PM, an interview with Staff Members # 1, # 24 and # 25 revealed “staff are expected to follow the policy.””

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure: the Registered Nurse (RN) verified the treatment prescription within one (1) hour of the treatment initiation per facility policy for two (2) of eleven (11) Patients (P), P # 7 and # 8; the RN performed and documented the nursing assessment within one (1) hour of the treatment initiation for two (2) of eleven (11) Patients, P # 7 and # 8; and a standing blood pressure (BP) was obtained for one (1) of eleven (11) Patients P # 5. The findings include: On January 30, 2025, clinical record reviews revealed the following: P # 5- The flowsheet dated January 24, 2025 revealed there was no standing BP on the pre treatment assessment. Mobility was documented as “ambulates - no assistance needed”. The post treatment BP was documented as 115/70. P # 7- The flowsheet dated January 16, 2025 revealed the treatment was initiated at 6:07 AM and ended at 9:40 AM. The RN assessment was completed and documented at 8:32 AM (more than one (1) hour after the start of the treatment). The flowsheet dated January 18, 2025 revealed the treatment was initiated at 5:47 AM and ended at 9:17 AM. The RN assessment was completed and documented at 12:45 PM (more than one (1) hour after the start of the treatment). The RN verified the treatment prescription at 7:52 AM (more than one (1) hour after the start of the treatment). P # 8- The flowsheet dated January 24, 2025 revealed the treatment was initiated at 4:15 PM and ended at 6:51 PM. The RN assessment was completed and documented at 6:06 PM (more than one (1) hour after the start of the treatment). The RN verified the treatment prescription at 5:40 PM (more than one (1) hour after the start of the treatment). On January 30, 2025 at approximately 10:30 AM, a review of the facility’s policy titled “Pre Intra Post Treatment Data collection, monitoring and nursing assessment” reads in part “The nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse... the assessment includes the following components ... verification of prescription including machine parameters. 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. Patient data will be obtained and documented by the patient care technician (PCT) or a license nurse. Data collection includes... Sitting and standing BP required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flowsheet.” On January 30, 2025 at approximately 12:00 PM, an interview with Staff Members # 1, # 24 and # 25 revealed “staff are expected to follow the policy.””

“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: 34452 Based on document review and interview, it was determined that the facility failed to ensure the Patient’s plan of care was completed and signed by the interdisciplinary team (Physician, Registered Nurse (RN), Social Worker (SW), Registered Dietitian (RD) and the Patient) for one of eleven (11) Patients (P), P # 4. The findings include: On January 30, 2025, the clinical record review for P # 4 revealed the following: The plan of care dated September 18, 2024 lacked the SW signature to reflect participation in the plan of care meeting. On January 30, 2025 at approximately 10:30 AM, a review of the facility’s policy titled “Interdisciplinary team (IDT) Patient Assessment and plan of care” reads in part “The patient’s plan of care will be completed by the facility’s interdisciplinary team, including the Patient or personal representative and be signed by the team members including the patient”. On January 30, 2025 at approximately 12:00 PM, an interview with Staff Members # 1, # 24 and # 25 revealed “staff are expected to follow the policy.””

“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: 41450 Based on staff record review, staff interview and facility documentation review, the medical director failed to ensure that facility staff implemented the facility’s health and safety policy for tuberculosis (TB) monitoring for four (4) of twenty (20) staff members (SM), SM #4, #9, #15, and #16. The findings include: On 1/29/25 at approximately 1:15 PM, staff record reviews were conducted and revealed the following: SM #4, hired on 4/22/24, had no documentation of TB screening, to include a TB risk assessment and/or symptom evaluation. SM #9, hired on 12/12/94, had no documentation of TB screening, to include a TB risk assessment and/or symptom evaluation since 10/15/18. SM #15, hired on 11/18/24, had no documentation of TB screening, to include a TB risk assessment and/or symptom evaluation. SM #16, hired on 10/14/24, had no documentation of TB screening, to include a TB risk assessment and/or symptom evaluation. On 1/29/25 in an interview at approximately 2:45 PM, SM #1 confirmed the findings and stated, “It is my expectation for all personnel to be screened for TB at the time of hire as well as annually, that is our facility’s policy”. Review of the facility’s policy titled, “Tuberculosis Monitoring and Follow-Up”, revision date April 2020, page 1, read, “Baseline new hire requirements ...teammates will complete the following: 1. TB-Risk Assessment and Symptom Evaluation Questionnaire ...” and page 3, read “Annual teammate requirements ...All teammates will complete the TB Individual Risk Assessment and Symptom Evaluation”. Review of facility policy #COMP-DD-017 entitled “Medical Director Qualifications and Responsibilities”, effective date 12/09/2016, page 2, item 4.2.1, read, “Medical Director responsibilities include, but are not limited to...oversight of 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...”.”

“GOV-RESPONDS TO NW REQUEST/WORKS TOWARD GOALS CFR(s): 494.180(i) The governing body receives and acts upon recommendations from the ESRD network. The dialysis facility must cooperate with the ESRD network designated for its geographic area, in fulfilling the terms of the Network’s current statement of work. Each facility must participate in ESRD network activities and pursue network goals. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to documentation of cooperation with ESRD Network from June 2024 to present. The findings include: On January 29, 2025 at 2:00 PM, a review of the facility’s Quality meetings revealed there was no documentation of the ESRD Quality Improvement Report discussions from June 2024 to present. On January 29, 2025 at 2:30 PM, an interview with Staff Member (SM) # 25 revealed the facility has not been accessing the ESRD Quality Improvement Report nor have they been discussing the information during the Quality meetings. On January 29, 2025 at 2:45 PM, a review of the facility’s policy titled “General Statement on Clinical Policies” reads in part “Facility and facility teammates will operate and furnish services in compliance with applicable Federal, State, local laws and regulations pertaining to licensure and any other relevant health and safety requirements including individual ESRD network requirements”. “Governing Body Bylaws” read in part “Ensure that the Facility provides to the ESRD network any information that may be required, and that the Facility receive and act on recommendations of the ESRD network.” On January 30, 2025 at approximately 12:00 PM, an interview with SM # 24 revealed “the FA’s (facility administrator) email address was incorrect.””