Usrc Ashland

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 42042 Based on observations, interview, and document review, it was determined the facility failed to maintain emergency equipment by not securing the emergency evacuation bin and emergency code cart with breakaway locks and not having two (2) sets of defibrillation pads present on the emergency code cart. The findings include: On July 22, 2024, at 10:01 AM, the surveyor inspected the contents of both the emergency code cart and emergency evacuation bin located on the treatment floor. The surveyor observed that neither the cart nor bin were secured with breakaway locks despite the contents of both emergency equipment apparatuses containing sensitive contents such as the protected health information (PHI) found within the patient treatment orders of the emergency evaluation bin. Additionally, the surveyor confirmed that there was only one (1) set of sealed defibrillation pads present on the emergency code cart. In the afternoon of July 22, 2024, the surveyor discussed the observational findings to Staff Member #1 during interview who verbalized understanding. The surveyor was provided copies by Staff Member #3 of the most recent Emergency Evacuation Supply Checklist which indicated that that the emergency equipment is checked daily by staff to ensure that the equipment and supplies are locked and secured. Additionally, the “AED/Emergency Cart Daily Checklist” form revealed that the two (2) sets of sealed defibrillation pads should be present on the emergency code cart at all times. On July 24, 2024, at approximately 9:15 AM, the surveyor re-inspected the emergency code cart and evacuation bins and confirmed that both were still not secured with breakaway locks, nor contained a second set of defibrillation pads. In the afternoon of July 24, 2024, the surveyor met again with Staff Member #1 to reiterate the findings and reviewed the facility policy titled, “Emergency Evacuation Supplies” (Policy # C-EM-0014) which stated that the emergency evaluation bin and emergency cart should be securely maintained with lock and contain all contents outlined in the aforementioned emergency checklist.”

“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: 42042 Based on interview and facility document review, it was determined the facility failed to conduct annual testing of the emergency plan with emergency exercises for the past three (3) calendar years. The finding include: In the afternoon of July 23, 2024, the surveyor initiated review of the Emergency Preparedness (EP) Program found within the EP binder. The surveyor was unable to locate any documentation of any emergency-based exercise or drill being performed for the past three (3) years outside of quarterly fire drills that indicated it had attempted to test the emergency plan. On July 23, 2024, at 1:00 PM, the surveyor met with Staff Member #1 for interview who acknowledged the lack of EP testing. The surveyor verified with Staff Member #1 that there were no other available documentation of its staff being involved with any community or facility-based full-scale or tabletop exercise or drill based on the “all-hazards” risk assessment. The surveyor was provided with the facility policies titled, “Emergency Preparedness: Documentation of Emergency Exercises” (Policy # C-EM-0007a) and “Conduction of Emergency Preparedness Exercises” (Policy # C-EM-0007) that stated that the facility must conduct an emergency preparedness exercise once every twelve months based on the facility’s risk assessment. The policy continued to state that the EP exercise must have appropriate documentation indicating the type of exercise performed (i.e. full-scale community or facility-based mock, tabletop or actual) with opportunities for after exercise evaluations and review with corresponding staff signoffs.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 42042 Based on observations, interviews, and document review, it was determined the facility staff failed to maintain a safe environment by not appropriately wearing face masks. The finding include: During observations of the treatment floor conducted on July 22, 2024, from 9:15 AM until 10:35 AM, the surveyor observed Staff Member # 2, 3, 5, 14 utilizing Personal Protective Equipment (PPE) inappropriately by wearing facemasks below the nose. The surveyor shared the observational findings with Staff Member #1 in the afternoon of July 24, 2024, who demonstrated understanding, and provided the surveyor with the facility policy titled, “Personal Protective Equipment (PPE)” (Policy # C-IC-0025). On page two, the policy states “ensure facemask covers nose and mouth”.”

“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: 42042 Based on observations, interviews, and document review, it was determined the facility failed to maintain a safe environment by not including the necessary label components on opened multidose vials of medication. The findings include: On July 22, 2024, at 12:53 PM, the surveyor inspected the contents of the medication refrigerator located at Nurse’s Station #1 while performing treatment floor observations. The surveyor identified an opened, multi-dose vial of Tuberculin (Mantoux) medication without any label indicating date and time opened and staff responsible. The surveyor informed Staff Member #1 of the observation during interview in the afternoon of July 22, 2024. The staff member demonstrated understanding and provided the surveyor with the facility policy titled, “Preparation and Administration of IV/SubQ/IM Medications” (Policy # C-MA-0070). The policy stated, in part, “For multi-dose vials (MDV), label vial with date and initials when first opened; for previously opened vials, check date to ensure vial is not outdated”.”

“ENVIRONMENT-SECURE & RESTRICTED CFR(s): 494.40(a) 8 Environment: secure & restricted The water purification and storage system should be located in a secure area that is readily accessible to authorized users. The location should be chosen with a view to minimizing the length and complexity of the distribution system. Access to the purification system should be restricted to those individuals responsible for monitoring and maintenance of the system. This Standard is not met as evidenced by: 42042 Based on observations, interview, and document review, it was determined the facility failed to secure the water purification area by propping open the doors located at the water room rear entrance, rear facility exit, and door separating the biomed maintenance area and patient treatment area. The findings include: During facility flash tour conducted on July 22, 2024, at approximately 11:00 AM, the surveyor observed all access areas surrounding the water treatment and purification area were propped opened. More specifically, the water room rear entrance, rear facility exit, and door separating the biomed maintenance area and patient treatment area were all left opened without access restrictions. In the evening of July 22, 2024, the surveyor discussed the observations with Staff Member #1 during interview, who verbalized understanding. The surveyor was provided by Staff Member #1 the facility policy titled, “Facility Space/Design and Safety Requirements” (Policy # C-AD-0380). The policy states, “No doors, including the rear doors, fire doors, water treatment doors, IT closet, medical records room or treatment area doors will be propped opened [sic] at any time”.”

“PE-HD PTS IN VIEW DURING TREATMENTS CFR(s): 494.60(c)(4) Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement). This Standard is not met as evidenced by: 42042 Based on observations and facility policy review, it was determined the facility failed to ensure the access sites for patients were visible during the dialysis treatment. The findings include: The surveyor conducted observations of patient receiving in-center hemodialysis on the treatment floor on July 22, 2024, and July 24, 2024. On July 22, 2024, at 1:57 PM, the surveyor observed Patient #10 being dialyzed at hemodialysis station #7 with their access covered with a blanket throughout treatment. On July 24, 2024, at 9:23 AM, the surveyor identified the three (3) patients located at hemodialysis station #6, 10, and 14 with their dialysis accesses fully covered. The surveyor continued to maintain ongoing observations of the aforementioned patients, and confirmed that the patients’ accesses remained covered without visible or audible staff intervention. The surveyor discussed the observations with Staff Member #1 during on both July 22, 2024, and July 24, 2024. Staff Member #1 expressed the challenges posed to the facility in maintaining ongoing visibility of patient accesses but verified it was consistent with facility intradialytic procedures. The surveyor was provided the facility policy titled, “Intradialytic Monitoring of Patient” (Policy #C-ID-0010). Under “Monitoring” section, the policy stated, in part. the following: “... 5. ENSURE PATIENT’S ACCESS BLOOD LINES AND FACE ARE VISIBLE AT ALL TIMES. ... a. During every 30 minute monitoring, the access and visualization of the face must be observed. ... b. If the patient refuses to keep access or face uncovered at all times (including eye shades or hats/caps), the charge nurse will be notified.””

“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: 42042 Based on document review and interview, it was determined the facility failed to ensure that Plan of Care (POC) Assessments were performed within thirty (30) days of admission for two (2) of five (5) patients reviewed. The finding include: On July 24, 2024, at 10:50 AM, the surveyor reviewed the medical records of Patient # (4, 6, 7, 8, 9) to include the Plan of Care (POC) Assessments. The surveyor identified the following POC Assessment documentation were not completed within the required timeframe following admission: Patient #8: Date of Admission: May 6, 2024, Initial POC completion date: July 10, 2024. Patient #9: Date of Admission: March 18, 2024, Initial POC completion date: April 26, 2024. In the afternoon of July 24, 2024, the surveyor was provided with the facility policy titled, “Comprehensive Interdisciplinary Patient Assessment/Plan of Care (CIPA/POC)” (Policy # C-AD-0480). Under “Frequency of CIPA/POC completion” section, the policy stated that the initial plan of care must be completed “within the latter of 30 calendar days or 13 treatments beginning with admission for all new patients” In the evening of July 24, 2024, the surveyor conducted interview with Staff Member #1. The surveyor requested clarification whether the aforementioned patients had received thirteen treatments prior to the initial Care Plan completion dates. Staff Member #1 confirmed they were outside of the mandated completion timeframe for newly admitted patients, and provided additional comment indicating they were delayed related to the availability of the medical director for review.”

“PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility’s staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility’s staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This Standard is not met as evidenced by: 42042 Based on interview and document review, it was determined the facility failed to ensure that clinical staff were tested for colorblindness for one (1) of three (3) staff reviewed. The findings include: In the afternoon of July 23, 2024, the surveyor initiated personnel file review of Staff Member #2, 3, and 4. During review of Staff Member #4, the surveyor was unable to find documentation that the employee was tested for colorblindness. On July 23, 2024, at 3:40 PM, the surveyor met with Staff Member #1 regarding the employees testing for colorblindness. Staff Member #1 confirmed during interview that the employee did perform chlorine testing and was therefore required to be tested for colorblindness. Staff Member #1 stated to surveyor that they believed the employee was tested for colorblindness but that the results were not readily available at facility and were present “at other clinic”. Staff Member #1 provided the surveyor with the job description pertaining to Staff Member #4 which indicated under “Qualifications/Requirements” [sic] section, that the employee is required to have “confirmation of ability to distinguish all primary colors”. At the time of exit conference on July 24, 2024, at 2:40 PM, the surveyor was not provided any evidence that Staff Member #4 had been tested for colorblindness.”

“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: 42042 Based on interview and document review, it was determined the facility failed to perform pre-dialysis nursing assessments within one (1) hour of dialysis initiation for four (4) of five (5) patients reviewed. The findings include: On July 24, 2024, at 10:50 AM, the surveyor reviewed the most recent two (2) weeks’ worth of treatment flowsheets for Patient # (4, 6, 7, 8, and 9). The surveyor identified the following patients as having pre-dialysis nursing assessments being performed beyond the required one hour timeframes. Patient #4: On treatment date of 07/15/2024, the patient’s treatment was initiated at 7:00 AM. The pre-dialysis nursing assessment was documented as not having been performed until 8:30 AM. The surveyor was unable to locate any documentation in the medical record providing clarification or rationale for the late patient assessment. Patient #6: On treatment date of 06/28/2024, the patient’s treatment was initiated at 2:09 PM. The pre-dialysis nursing assessment was documented as not having been performed until 5:55 PM. The surveyor was unable to locate any documentation in the medical record providing clarification or rationale for the late patient assessment. Patient #8: On treatment date of 07/10/2024, the patient’s treatment was initiated at 11:54 AM. The pre-dialysis nursing assessment was documented as not having been performed until 1:41 PM. The surveyor was unable to locate any documentation in the medical record providing clarification or rationale for the late patient assessment. Patient #9: On treatment date of 07/19/2024, the patient’s treatment was initiated at 10:43 AM. The pre-dialysis nursing assessment was documented as not having been performed until 12:18 PM. The surveyor was unable to locate any documentation in the medical record providing clarification or rationale for the late patient assessment. In the afternoon of July 24, 2024, the surveyor reviewed the facility policy titled, “Pre-Treatment Assessment of Patient,” (Policy #C-PT-0010) which clearly stated that the pre-dialysis nursing assessment will occur within the first hour of patient contact The surveyor shared the findings with Staff Member #1 on July 24, 2024, at approximately 2:20 PM who verbalized understanding.”

“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: 42042 Based on document review and interview, it was determined the facility failed to fulfill its agreement with the local End-Stage-Renal-Disease (ESRD) network by: a) Not accessing and reviewing the Dialysis Facility Report (DFR) on a monthly basis; b) Not providing updates to the network regarding patient quality data; and c) Not participating in patient engagement activities or projects set forth by the network. The findings include: On July 23, 2024, at 11:20 AM, the surveyor contacted the local ESRD Network #5 Quality Insights, Patient Engagement Specialist by email for supplemental facility information. On July 24, 2024, at 8:56 AM, the surveyor received an email response from the Patient Engagement Specialist that stated that the facility was not enrolled in any network projects and had not provided any communication with the network regarding what its QAPI program was doing to meet the network goals. The Patient Engagement Specialist communicated that the facility had not provided any updates to the network for “over a year”, and that they were not accessing the DFR on a monthly basis as outlined within the network agreement. The same email sent by the Patient Engagement Specialist advised that reminder notifications were made to the Facility Administrator, Social Worker, and Medical Director “each time the data updates”. On July 24, 2024, at 12:44 PM, the surveyor met with Staff Member #1 to request the facility policy corresponding to collaboration with the local ESRD Network. Staff Member #1 was unable to produce said policy but provided the surveyor with the Renal Network #5 Quality Insights “Membership Agreement” (acknowledgement date of 06/18/2024). The network agreement set forth the agreed terms in which the facility had agreed to abide by including ongoing cooperation and participation with the network activities and goals. The surveyor requested supporting documentation and evidence of the facility’s compliance with the network terms and conditions. At the time of exit conference on July 24, 2024, at 2:40 PM, no such documentation was provided to the surveyor.”