Rai-Riverside Rmc-Newport News

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure adequate number of qualified personnel are present during dialysis treatments to ensure Patient needs are meet on 34 of 62 days from October 2 to December 2, 2023 for sixty four (64) of one hundred five (105) Patients (P # 1 - 64); and failed to submit requested information regarding Patients to the Network for one (1) of one (1) Patients, P # 1. See Tags # 757 and # 772 for specific findings.”

“Names and Contact Information CFR(s): §403.748(c)(1), §416.54(c)(1), §418.113(c)(1), §441.184(c)(1), §460.84(c)(1), §482.15(c)(1), §483.73(c)(1), §483.475(c)(1), §484.102(c)(1), §485.68(c)(1), §485.542(c)(1), §485.625(c)(1), §485.727(c)(1), §485.920(c)(1), §486.360(c)(1), §491.12(c)(1), §494.62(c)(1). [(c) The [facility must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following:] (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [facilities]. (v) Volunteers. *[For Hospitals at §482.15(c) and CAHs at §485.625(c)] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians (iv) Other [hospitals and CAHs]. (v) Volunteers. *[For RNHCIs at §403.748(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Next of kin, guardian, or custodian. (iv) Other RNHCIs. (v) Volunteers. *[For ASCs at §416.45(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For Hospices at §418.113(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Hospice employees. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Other hospices. *[For HHAs at §484.102(c):] The communication plan must include all of the following: (1) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Patients’ physicians. (iv) Volunteers. *[For OPOs at §486.360(c):] The communication plan must include all of the following: (2) Names and contact information for the following: (i) Staff. (ii) Entities providing services under arrangement. (iii) Volunteers. (iv) Other OPOs. (v) Transplant and donor hospitals in the OPO’s Donation Service Area (DSA). This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to have a current list of facility names and contact information available to Patients for one hundred forty five (145) of one hundred forty five (145) Patients (P), P # 1 through # 145. The findings include: On December 4, 2023 at approximately 1:00 p.m., observation in the front lobby for in center and home Patients revealed the following: There was a form in a locked case in the front lobby of the facility titled “Important Numbers”. The form read in part “Please first contact your clinical Manager or Facility Administrator (no name provided) and number for the clinic. Next level Supervisor [Name of person no longer employed by the Company]. Your Regional Vice President [Name of person no longer at this clinic].” A copy of the form was requested from Staff Member (SM) # 2. SM provided an updated copy not the copy requested from the case in the front lobby. On December 5, 2023 at approximately 9:00 a.m., the same form was in the front lobby with outdated information for Facility Staff contacts. On December 6, 2023 at approximately 9:00 a.m., the same form was in the front lobby with outdated information for Facility Staff contacts. On December 6, 2023 at approximately 1:00 p.m., the findings were discussed with SM # 3, # 4, # 5 and # 6 during the exit interview.”

“EP Training and Testing CFR(s): §403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d). *[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, “Organizations” under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. *[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually. *[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i). *[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years. This Standard is not met as evidenced by: 34452 Based on document review and interviews, it was determined that the facility failed to have documentation that Patients were trained in Emergency Preparedness (EP) for ten (10) of ten (10) In Center Hemodialysis (ICHD) Patients (P), P # 1, # 2, # 3, # 4, # 5, # 6, # 7, # 8, # 9 and # 10. The findings include: On December 5, 2023 at approximately 1:00 p.m., Clinical Record reviews revealed there was no documented EP training for ICHD Patients. On December 6, 2023 at approximately 12:00 p.m., Staff Member (SM) # 3 stated “we can’t find any EP training for in center Patients.” On December 6, 2023, a review of the facility policy titled “Emergency Preparedness” reads in part “Semi annually, in conjunction with fire drills, facility staff will hold disaster drills. Patients should be able to verbalize how they would disconnect themselves from the machine and evacuate the facility, or if unable, how they will be evacuated. Patients who are absent during drills shall be provided with a verbal review of disaster drill procedures. Documentation of the review should be done.” On December 6, 2023 at approximately 1:00 p.m., the findings were discussed with SM # 3, # 4, # 5 and # 6 during the exit interview.”

“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: 34452 Based on document review and interview, it was determined that the facility failed to have documentation of fire drills per facility policy from January 1, 2023 to present. The findings include: On December 6, 2023 at approximately 10:00 a.m., a review of the facility’s Emergency Preparedness (EP) Plan revealed there were no documented fire drills for 2023. On December 6, 2023 at approximately 10:00 a.m., an interview with Staff Member (SM) # 2 revealed “we do not have any fire drill for in-center.” On December 6, 2023 at approximately 10:00 a.m., a review of the facility’s policy titled “Fire Drill Procedure” reads in part “Quarterly, all [Name of Facility] shall perform a fire drill for each shift of patients and staff including Home Therapies patients present in the facility and Nocturnal shifts. In addition to the drill, activation of the fire alarm once per staff shift shall occur. Patients should be able to verbalize how they would disconnect themselves from the machine and evacuate the facility or if unable, how they will be evacuated. Document patient participation in fire and disaster drills. Document fire drills, alarms and signal received by the monitoring services or fire department and patient and staff participation.” On December 6, 2023 at approximately 1:00 p.m., the findings were discussed with SM # 3, # 4, # 5 and # 6 during the exit interview.”

“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 and monitor the facility for sanitary environment to minimize the transmission of infections by having corrugated boxes in the treatment area for one hundred five (105) of one hundred five (105) ICHD Patients (P), P # 1 through #105. The findings include: On December 5, 2023 at approximately 9:55 a.m., three (3) corrugated boxes were observed in the treatment area at the nursing station. One (1) box contained dialyzers, one (1) box contained syringes, and one (1) box contained lab specimen bags. According to Center for Disease Control (CDC) guidelines, corrugated boxes are susceptible to moisture and humidity and attractive many types of bugs. On December 5, 2023 at approximately 2:00 p.m., a review the facility’s policy titled “Infection Control” reads in part “All areas must be kept clean and organized, including but not limited to the treatment area.” On December 6, 2023 at approximately 1:00 p.m., the findings were discussed with Staff Members (SM) # 3, # 4, # 5 and # 6 during the exit interview.”

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to ensure Staff wear footwear that meet safety requirements for one (1) of six (6) Staff Members (SM), SM # 7 The findings include: On December 5, 2023 at approximately 11:05 a.m., SM # 7 was observed in the treatment area during initiation and termination of treatments for Patients wearing shoes with holes and no back to cover heels (crocs). On December 6, 2023 at approximately 9:30 a.m., a review of the facility policy titled “Employee Dress Code” reads in part “When in a patient care area, foot wear must be worn that meets the following safety requirements: has a solid foot-box (no holes or vents). On December 6, 2023 at approximately 1:00 p.m., the findings were discussed with SM # 3, # 4, # 5 and # 6 during the exit interview.”

“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 have a Registered Nurse (RN) verify the treatment prescription for six (6) of ten (10) In Center Hemodialysis (ICHD) Patients (P), P # 2, # 3, # 6, # 8, # 9 and # 10; have an RN assessment completed and documented within one (1) hour of initiation of treatment for three (3) of ten (10) ICHD Patients, P # 5, # 8, and # 9; assess and document at least every 45 minutes treatment data to include blood pressures for nine (9) of ten (10) ICHD Patients, P # 1, # 2, # 3 # 5, # 6, # 7, # 8, # 9 and # 10. The findings include: On December 5, 2023, during clinical record reviews the following was revealed: P # 1- The flowsheet dated November 21, 2023 revealed no documentation of treatment data to include blood pressure between 4:04 p.m. and 5:11 p.m. P # 2- The flowsheet dated November 21, 2023 revealed no documentation of treatment data to include blood pressure between 9:33 a.m. and 10:38 a.m. There was no documentation that the RN verified the treatment prescription. The flowsheet dated November 27, 2023 revealed there was no documentation that the RN verified the treatment prescription. The flowsheet dated November 29, 2023 revealed there was no documentation that the RN verified the treatment prescription. The flowsheet dated December 4, 2023 revealed no documentation of treatment data to include blood pressure between 9:00 a.m. and 10:17 a.m. P # 3- The flowsheet dated November 29, 2023 revealed no documentation of treatment data to include blood pressure between 10:05 a.m. and 11:10 a.m. The flowsheet dated December 4, 2023 revealed there was no documentation that the RN verified the treatment prescription. There was no documentation of treatment data to include blood pressure between 9:30 a.m. and 10:43 a.m. The flowsheet dated November 24, 2023 revealed no documentation of treatment data to include blood pressure between 10:02 a.m. and 10:05 a.m. P # 5- The flowsheet dated November 27, 2023 revealed the treatment was initiated at 6:47 a.m. and the RN assessment was completed at 8:08 a.m. (greater than one (1) hour). The flowsheet dated December 1, 2023 revealed no documentation of treatment data to include blood pressure between 6:34 a.m. and 8:52 a.m. The flowsheet dated December 4, 2023 revealed no documentation of treatment data to include blood pressure between 5:59 a.m. and 6:49 a.m. P # 6- The flowsheet dated November 29, 2023 revealed there was no documentation that the RN verified the treatment prescription. The flowsheet dated December 1, 2023 revealed there was no documentation that the RN verified the treatment prescription. There was no documentation of treatment data to include blood pressure between 4:33 p.m. and 5:36 p.m. P # 7- The flowsheet dated November 30, 2023 revealed no documentation of treatment data to include blood pressure between 8:07 a.m. and 9:03 a.m. The flowsheet dated December 2, 2023 revealed no documentation of treatment data to include blood pressure between 5:49 a.m. and 7:07 a.m. P # 8- The flowsheet dated November 20, 2023 revealed there was no documentation that the RN verified the treatment prescription. The flowsheet dated November 28, 2023 revealed there was no documentation that the RN verified the treatment prescription. The flowsheet dated November 30, 2023 revealed no documentation of treatment data to include blood pressure between 10:49 a.m. and 11:44 a.m. The treatment was initiated at 10:49 a.m. and the RN assessment was completed at 12:41 p.m. (greater than one (1) hour). The flowsheet dated December 2, 2023 revealed no documentation of treatment data to include blood pressure between 10:35 a.m. and 11:47 a.m. P # 9- The flowsheet dated November 20, 2023 revealed there was no documentation that the RN verified the treatment prescription. The flowsheet dated November 22, 2023 revealed there was no documentation that the RN verified the treatment prescription. The flowsheet dated November 28, 2023 revealed no documentation of treatment data to include blood pressure between 3:03 p.m. and 4:27 p.m. The flowsheet dated December 2, 2023 revealed there was no documentation that the RN verified the treatment prescription. There was no RN assessment documented. P # 10- The flowsheet dated November 20, 2023 revealed there was no documentation that the RN verified the treatment prescription. The flowsheet dated November 30, 2023 revealed there was no documentation that the RN verified the treatment prescription. The flowsheet dated December 2, 2023 revealed there was no documentation that the RN verified the treatment prescription. There was no documentation of treatment data to include blood pressure between 2:33 p.m. and 3:36 p.m. On December 6, 2023, the facility’s policy titled “Pre-intra-post treatment data collection, monitoring and nursing assessment” reads in part “The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment. Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes.” On December 6, 2023 at approximately 1:00 p.m., the findings were discussed with Staff Members (SM) # 3, # 4, # 5 and # 6 during the exit interview.”

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- (1) At least annually for stable patients; This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure the Registered Nurse (RN) completed a comprehensive nursing assessment (CIA) and revision of the plan of care for one (1) of ten (10) In Center Hemodialysis (ICHD) Patients (P # 1), and one (1) of four (4) Home Patients (P # 106). The findings include: On December 5, 2023 at approximately 2:00 p.m., clinical record reviews revealed the following: P # 1’s annual stable Plan of Care meeting was held on August 16, 2023. There was no documented RN or Social Worker (SW) CIA at least 15 days prior to the Plan of Care Meeting. The last RN CIA was completed July 13, 2022 and the last SW CIA was completed on July 15, 2022. P # 106’s annual stable Plan of Care meeting was held on March 30, 2023. There was no documented RN CIA at least 15 days prior to the Plan of Care Meeting. The last RN CIA was completed on February 22, 2021. On December 6, 2023 at approximately 9:30 a.m., the facility’s policy titled “Comprehensive Interdisciplinary Assessment and Plan of Care” reads in part “The patient’s Plan of Care will be guided and developed based on the findings identified in the Comprehensive Interdisciplinary Assessment (CIA). CIA must be conducted 12 months after the completion of the 3 month assessment and then reassessed annually thereafter on all stable patients. The Plan of Care must be implemented within 15 days of the reassessment.” On December 6, 2023 at approximately 1:00 p.m., the findings were discussed with Staff Members (SM) # 3, # 4, # 5 and # 6 during the exit interview.”

“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 Interdisciplinary Team (IDT) signed the Patient Plan of Care at the meeting when attending in person for eight (8) of ten (10) Patients (P), P # 1, # 2, # 3, # 4, # 6, # 7, # 9 and # 10. The findings include: On December 6, 2023 at approximately 1:00 p.m., Clinical record reviews revealed the following: P # 1- The Plan of Care meeting was held on August 16, 2023. The Plan of Care was signed by the Physician on August 28, 2023 (attended in person). There was no signature by the Patient. Signature dates do not reflect participation in the Plan of Care meeting. P # 2- The Plan of Care meeting was held on June 26, 2023. There was no signature by the Patient. No signature to reflect participation in the Plan of Care meeting. P # 3- The Plan of Care meeting was held on August 28, 2023. The Plan of Care was signed by the Registered Nurse (RN) on September 7, 2023 (attended in person). There was no signature by the Patient. Signature dates do not reflect participation in the Plan of Care meeting. P # 4- The Plan of Care meeting was held on April 26, 2023. The Plan of Care was signed by the RN on April 27, 2023 (attended in person) and there was no signature by the Patient. Signature dates do not reflect participation in the Plan of Care meeting. P # 6- The Plan of Care meeting was held on September 21, 2023. The Plan of Care was signed by the RN on September 25, 2023 (attended in person) and Registered Dietician (RD) on October 2, 2023 (attended in person) and there was no signature by the Patient. Signature dates do not reflect participation in the Plan of Care meeting. P # 7- The Plan of Care meeting was held on November 22, 2023. The Plan of Care was signed by the RN on November 28, 2023 (attended in person). There was no signature by the Patient. Signature dates do not reflect participation in the Plan of Care meeting. P # 9- The Plan of Care meeting was held on November 22, 2023. The Plan of Care was signed by the RN on November 28, 2023 (attended in person) and there was no signature by the Patient. Signature dates do not reflect participation in the Plan of Care meeting. P # 10- The Plan of Care meeting was held on November 22, 2023. There was no Patient signature to reflect participation in the Plan of Care meeting. On December 6, 2023 at approximately 10:00 a.m., a review of the facility policy titled “Comprehensive interdisciplinary assessment and plan of care” reads in part “The plan of care should be signed at the time of the interdisciplinary team meeting for those attending in person”. On December 6, 2023, the findings were discussed with Staff Members (SM) # 3, # 4, # 5 and # 6 during the exit interview.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to maintain complete and accurate clinical records for two (2) of ten (10) ICHD Patients (P), P # 1 and # 7. The findings include: On December 5, 2023 at approximately 2:00 p.m., Clinical Record reviews revealed the following: P # 1 had a fistulogram on October 26, 2023. There was no report of the fistulogram in the Clinical Record for P # 1 during the review. The report for the fistulogram was requested from Staff Member (SM) # 2. At approximately 3:00 p.m. on December 5, 2023, SM # 2 provided the report for the fistulogram. The report reads in part “I suspect the bleeding has to do with the fact that there is continued access at the apex of the 2 small pseudoaneurysms where the fistula is likely thinner. Proper needle placement should avoid this problem.” On December 6, 2023 at 12:00 p.m., an interview with SM # 8 revealed SM # 8 was not aware of the fistulogram results. SM # 8 was not aware of any education to staff on rotating sites for needle placement on P # 1. P# 7’s clinical record revealed the plan of care in the clinical record was not the plan of care for P # 7. On December 6, 2023 at approximately 12:30 p.m., a review of the facility policy titled “Medical Record” reads in part “Each Medical record whether hard copy, electronic or a combination of both should include complete pertinent information about the condition of the patient. The facility must maintain a complete and accurate medical record that is unique for each patient. Information in the medical record should clearly portray that patient, the care provided by facility staff and the outcomes of that care.” On December 6, 2023 at approximately 1:00 p.m., the findings were discussed with SM # 3, # 4, # 5 and # 6 during the exit interview.”

“GOV-STAFF # & RATIO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- (1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients; This Standard is not met as evidenced by: 34452 Based on document review and interviews, it was determined that the facility failed to ensure adequate number of qualified personnel are present during dialysis treatments to ensure Patient needs were meet on 34 of 62 days from October 2, 2023 to December 2, 2023 for sixty four (64) of one hundred five (105) Patients (P # 1 - 64). The findings include: On December 5, 2023, on entrance to the facility, Staff Member (SM) # 1 revealed there were twenty (24) dialysis stations with one (1) isolation station with three (3) shifts Monday, Wednesday, Friday (MWF) and two (2) shifts Tuesday, Thursday, Saturday (TTS). A review of the Patient Schedule revealed the first scheduled Patient for MWF first shift arrived at 5:30 a.m. and the last arrived at 8:00 a.m. for twenty three (23) Patients with one (1) isolation station for twenty four (24) total Patients on the first shift. The first scheduled Patient for TTS first shift arrived at 5:30 a.m. and the last arrived at 8:00 a.m. for twenty (20) total Patients on the first shift. On second shift for TTS, the first scheduled Patient arrived at 9:55 a.m. and the last arrived at 1:15 p.m. for twenty (20) total Patients. On December 5, 2023, a review of “as worked” schedules from October 2, 2023 to December 2, 2023 revealed the following: One RN worked 5:00 a.m. to 6:00 p.m. on October 3, 5, 7, 10, 12, 14, 17, 19, 21, 24, 26, 28, 31, 2023; November 2, 7, 9, 11, 14, 16, 18, 20, 25, 28, 30, 2023; and December 2, 2023. One RN worked 5:00 a.m. to 4:00 p.m. and one RN worked 9:30 a.m. to 10:30 p.m. on October 16, 18, 20, 23, 25, 27, 30, 2023; November 1, 15, 19, 29, 2023. On December 5, 2023, a review of flowsheets for Patient treatments revealed there were at least two (2) days with late or missing RN assessments, November 30, 2023 and December 2, 2023. There were at least three (3) days with no or late RN treatment verifications, November 20, 28 and 29, 2023. (See tag 504 for more details.) On December, 6, 2023 at approximately 1:00 p.m., the findings were discussed with SM # 3, # 4, # 5 and # 6 during the exit interview.”

“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 staff failed to submit requested information regarding Patients to the Network for one (1) of one (1) Patient (P), P # 1. The findings include: On December 6, 2023 at 12:30 p.m., a review of the complainant documentation revealed patient records were requested from the facility and not received. On December 4, 5 and 6, 2023, the information provided to the network for P # 1 was requested. There was no information provided. On December 6, 2023 at 12:30 p.m., an interview with Staff Member (SM) # 4 revealed “we don’t have the information provided to the Network.” On December 6, 2023 at approximately 1:00 p.m., the findings were discussed with SM # 3, # 4, # 5 and # 6 during the exit interview.”