Davita Harbour View Dialysis

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 41450 Based on staff interviews and facility documentation review, the facility staff failed to maintain documentation of emergency preparedness training for five (5) staff members in a survey sample of seven (7) staff members (SM), SM #2, SM #3, SM #4, SM #5, and SM #6. The findings include: On 7/23/24 at approximately 2:00 PM, an interview was conducted with Staff Member (SM) #1 regarding the facility’s emergency preparedness (EP) training for all staff members and documentation was requested. On 7/24/24 at approximately 10:30 AM, review of the provided the facility’s EP training documentation revealed no evidence of SM #2, SM #3, SM #4, SM #5, and SM #6’s facility specific EP training. An interview with SM #1, on 7/24/24 at approximately 10:30 AM, confirmed the findings and stated, “It is my expectation that all staff members receive training on facility-specific emergency procedures and that participation in and completion of the training is documented”. Review of the facility’s policy titled, “Facility Emergency Management Plan (ICHD, Home)”, revision date April 2024, page 25, subtitle “Training and Education...Emergency Management Plan [EMP]”, item 1, read, “The FA [Facility Administrator], or designee, is responsible to provide training of EMP: a. Teammates: i. Annually...4. Facility specific emergency response procedures...v. Document training in teammate file, 1. Training/In-service Documentation Form”.”

“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 observations, document review and interview, it was determined that the facility failed to ensure hand hygiene was performed before and after glove removal and after touching masks for two (2) of seven (7) Staff Members (SM), SM # 13 and # 14. The findings include: On July 24, 2024 between 8:30 AM and 11:00 AM, the following was observed during initiation and termination of treatments: At 9:05 AM, SM # 14 was observed wearing the mask below the chin at the nursing station. SM # 14 pulled the mask off by touching the front of the mask. SM # 14 then balled the mask up in hand before throwing in the trash. SM # 14 failed perform hand hygiene before going to Station # 15 to perform patient care. At 9:12 AM, SM # 14 was observed at Station # 14 wearing the mask below the nose. SM # 14 then pulled the mask up above nose by touching the front of the mask. SM # 14 failed to perform hand hygiene before continue patient care at Station # 15. At 10:06 AM, SM # 13 was observed at Station # 18. SM # 13 removed dirty gloves and failed to perform hand hygiene before assisting a patient with a weight at the scale. Center for Disease Control (CDC) guidelines include: “Hands should be washed before applying mask and after removing the mask”. On July 24, 2024 at 2:30 PM, a review of the facility’s policy titled “Infection Control” reads in part “Hand Hygiene: All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene prior to gloving and immediately after removal of gloves”. Facility guidance for face masks included “How to put on your mask: secure ties or elastic bands around ears or at middle of head and neck depending on style, fit flexible band to bridge of nose, and fit mask snug to face and around chin. How to remove PPE (personal protective equipment): the front of your mask is considered dirty. If hands become contaminated during the removal, perform hand hygiene. Remove your surgical mask by the ear loops.” On July 24, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 16 and # 17 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 facility staff wear face masks correctly for one (1) of seven (7) SM, SM # 14; and transport staff in the treatment area wear gowns for one (1) of two (2) transport staff, transport staff # 1. The findings include: On July 24, 2024 between 8:30 AM and 11:00 AM, the following observations were made during the initiation and termination of dialysis treatment: At 9:05 AM, SM # 14 was observed wearing the mask below the chin at the nursing station. At 9:12 AM, SM # 14 was observed at Station # 14 wearing the mask below the nose. At 9:53 AM, Transport Staff # 1 was observed walking through the treatment area while treatments were being initiated and terminated with no gown. While at Station # 11, Transport Staff # 1 put on a gown but failed to button the gown leaving self exposed in the front. Transport Staff # 1 walked back through the treatment area while treatments were being initiated and terminated. Staff Members did not ask Transport Staff to wear PPE correctly. On July 24, 2024 at 2:30 PM, a review of the Facility guidance for face masks included “How to put on your mask: secure ties or elastic bands around ears or at middle of head and neck depending on style, fit flexible band to bridge of nose, and fit mask snug to face and around chin. How to remove PPE (personal protective equipment): Remove your surgical mask by the ear loops. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physician (NPP) and visitors when in the treatment area.” On July 24, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 16 and # 17 during the exit interview.”

“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 seven (7) staff members (SM), SM #4. The findings include: On 7/24/24 at approximately 11:00 AM, staff record reviews were conducted and revealed that Staff Member (SM) #4, hired on 11/7/22, had no documentation of Hepatitis B immunization, to include current Hepatitis B vaccination or antibody status. At approximately 1:30 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”.”

“PERSONNEL-TRAINING PROGRAM/PERIODIC AUDITS CFR(s): 494.40(a) 9 Personnel: training program/periodic audits A training program that includes quality testing, the risks and hazards of improperly prepared concentrate, and bacterial issues is mandatory. Operators should be trained in the use of the equipment by the manufacturer or should be trained using materials provided by the manufacturer. The training should be specific to the functions performed (i.e., mixing, disinfection, maintenance, and repairs). Periodic audits of the operators’ compliance with procedures should be performed. The user should establish an ongoing training program designed to maintain the operator’s knowledge and skills. This Standard is not met as evidenced by: 34452 Based on document review and interview, it was determined that the facility failed to ensure audits of water room duties to include collecting samples, performing water testing and dialysate mixing was completed at least annually. The findings include: On July 23, 2024 at 11:00 AM, a review of water room documents revealed no audits from January to June 2024. On July 24, 2024 at 11:30 AM, an interview with Staff Member (SM) # 16 revealed the facility had no documentation of any audits conducted on water room duties. On July 24, 2024 at 2:30 PM, a review of the facility’s policy titled “Auditing of Clinical practice requirements for water and dialysate concentrate” reads in part “Periodic audits of the teammates’s compliance with procedures should be performed. These audits should be completed at least annually or more frequently if needed.” On July 24, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 16 and # 17 during the exit interview.”

“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 reviews and interviews, it was determined that the facility staff failed to evaluate and ensure the dialysis prescription was administered as ordered by the Physician for five (5) of eight (8) ICHD (incenter hemodialysis) Patients (P), P # 1, # 3, # 4, # 8 and # 10. The findings include: On July 24, 2024 between 1:00 PM and 3:00 PM, clinical record reviews revealed the following: P # 1- The flowsheet dated June 27, 2024 revealed the Physician ordered blood flow rate (BFR) was 400. Documentation from 11:03 AM through 1:24 PM revealed the BFR was between 200 and 350. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. The flowsheet dated July 6, 2024 revealed the Physician ordered blood flow rate (BFR) was 400. Documentation from 11:39 AM through 2:33 PM revealed the BFR was between 200 and 300. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. P # 3- The flowsheet dated July 10, 2024 revealed the Physician ordered blood flow rate (BFR) was 450. Documentation from 12:22 PM through 1:45 PM revealed the BFR was 230. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. The flowsheet dated July 12, 2024 revealed the Physician ordered blood flow rate (BFR) was 450. Documentation from 11:00 AM through 2:08 PM revealed the BFR was 400. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. The flowsheet dated July 17, 2024 revealed the Physician ordered blood flow rate (BFR) was 450. Documentation from 10:25 AM through 1:28 PM revealed the BFR was 400. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. The flowsheet dated July 22, 2024 revealed the Physician ordered blood flow rate (BFR) was 450. Documentation from 10:48 AM through 1:50 PM revealed the BFR was 400. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. P # 4- The flowsheet dated July 17, 2024 revealed the Physician ordered blood flow rate (BFR) was 400. Documentation from 1:03 PM through 3:23 PM revealed the BFR was between 200 and 300. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. The flowsheet dated July 19, 2024 revealed the Physician ordered blood flow rate (BFR) was 400. Documentation from 1:33 PM through 2:18 PM revealed the BFR was between 200 and 350. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. P # 8- The flowsheet dated July 19, 2024 revealed the Physician ordered blood flow rate (BFR) was 400. Documentation from 7:14 AM through 9:37 AM revealed the BFR was between 300 and 350. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. The flowsheet dated July 22, 2024 revealed the Physician ordered blood flow rate (BFR) was 400. Documentation from 6:51 AM through 9:52 AM revealed the BFR was between 200 and 300. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. P # 10- The flowsheet dated July 19, 2024 revealed the Physician ordered blood flow rate (BFR) was 400. Documentation from 11:02 AM through 1:39 PM revealed the BFR was 300. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. On July 24, 2024 at 2:30 PM, a review of the facility’s policy titled “Pre-Intra-Post treatment” reads in part “blood flow rate is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one hour of treatment initiation. 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 July 24, 2024 at 3:00 PM, the findings were discussed with Staff Members # 1, # 16 and # 17 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 observation, document reviews and interviews, it was determined that the facility failed to ensure: patient weights were obtained by staff pre and post treatment for three (3) of three (3) ICHD (InCenter Hemodialysis) Patients (P), P # 11, # 12 and # 13; standing blood pressure were obtained pre and post treatment for three (3) of eight (8) ICHD Patients, P # 4, # 5 and # 9; treatment data to include blood pressures were documented every 30 minutes during the treatment for three (3) of eight (8) ICHD Patients, P # 3, # 4 and # 9; the Registered Nurse (RN) assessed and documented the patient assessment within 1 hour of the initiation of the treatment for four (4) of eight (7) ICHD Patients, P # 1, # 4, # 6 and # 10; and the RN verified the treatment prescription within 1 hour of the initiation of the treatment for five (5) of eight (8) ICHD Patients, P # 1, # 3, # 6, # 9 and # 10. The findings include: On July 24, 2024 between 8:30 AM and 11:00 AM the following were observed during initiation and termination of treatments: At 10:30 AM, P # 8 was observed weighing self before exit from the treatment area with no Staff Member (SM) present. At 9:42 AM, P # 11 was observed weighing self with no Staff Member present. At 9:43 AM, P # 12 was observed weighing self with no Staff Member present. At 9:53 AM, P # 13 was observed being weighed by Transport Staff with no Staff Member present. On July 24, 2024 between 12:00 PM and 2:30 PM, clinical record reviews revealed the following: P # 1- The flowsheet dated June 29, 2024 revealed the treatment was initiated at 10:48 AM and ended at 1:50 PM. The RN prescription verification was documented at 12:49 PM (greater than one (1) hour). The RN pre treatment assessment was documented at 12:50 PM (greater than one (1) hour). P # 3- The flowsheet dated July 12, 2024 revealed there was no treatment data to include blood pressure (BP) between 1:04 PM and 2:08 PM (greater than 30 minutes). The flowsheet dated July 15, 2024 revealed there was no treatment data to include BP between 10:16 AM and 11:02 AM (greater than 30 minutes). The flowsheet dated July 22, 2024 revealed the treatment was initiated at 11:08 AM and ended at 1:31 PM. The RN prescription verification was documented at 12:18 PM (greater than one (1) hour). The RN pre treatment assessment was documented at 12:19 PM (greater than one (1) hour). P # 4- The flowsheet dated July 15, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “124/80”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 15, 2024 revealed there was no treatment data to include BP between 1:32 PM and 2:32 PM (greater than 30 minutes). The flowsheet dated July 17, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “126/82”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 19, 2024 revealed the treatment was initiated at 10:45 AM and ended at 2:18 PM. The RN pre treatment assessment was documented at 2:01 PM (greater than one (1) hour). P # 5- The flowsheet dated June 18, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “161/93”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 17, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “N/A”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 17, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “N/A”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 19, 2024 revealed the pre treatment standing blood pressure documented as “169/95”. The post treatment standing blood pressure was documented as “N/A”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 22, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “N/A”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. P # 6- The flowsheet dated May 22, 2024 revealed the treatment was initiated at 10:38 AM and ended at 1:43 PM. The RN prescription verification was documented at 12:22 PM (greater than one (1) hour). The RN pre treatment assessment was documented at 12:23 PM (greater than one (1) hour). The flowsheet dated June 28, 2024 revealed the treatment was initiated at 11:29 AM and ended at 1:02 PM. The RN prescription verification was documented at 1:12 PM (greater than one (1) hour). The RN pre treatment assessment was documented at 1:12 PM (greater than one (1) hour). P # 9- The flowsheet dated July 16, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “118/67”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 16, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “104/63”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 16, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “112/71”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The treatment was initiated at 6:07 AM and ended at 9:50 AM. The RN prescription verification was documented at 7:10 AM (greater than one (1) hour). The RN pre treatment assessment was documented at 7:11 AM (greater than one (1) hour). The flowsheet dated July 18, 2024 revealed the treatment was initiated at 6:07 AM and ended at 9:50 AM. The RN prescription verification was documented at 8:00 AM, (greater than one (1) hour) The RN pre treatment assessment was documented at 1:12 PM, (greater than one (1) hour) The flowsheet dated July 20, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “101/68”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. There was no treatment data to include BP between 7:02 AM and 8:02 AM (greater than 30 minutes). P # 10- The flowsheet dated July 10, 2024 revealed the treatment was initiated at 10:31 AM and ended at 2:12 PM. The RN prescription verification was documented at 12:02 PM (greater than one (1) hour). The RN pre treatment assessment was documented at 12:03 PM (greater than one (1) hour). The flowsheet dated July 17, 2024 revealed the treatment was initiated at 10:37 AM and ended at 2:01 PM. The RN prescription verification was documented at 11:45 AM (greater than one (1) hour). The RN pre treatment assessment was documented at 11:45 PM (greater than one (1) hour). The flowsheet dated July 22, 2024 revealed the treatment was initiated at 10:45 AM and ended at 2:33 PM. The RN prescription verification was documented at 12:04 PM (greater than one (1) hour). The RN pre treatment assessment was documented at 12:06 PM (greater than one (1) hour). On July 24, 2024 at 2:30 PM, a review of the facility’s policy titled “Pre-Intra-Post treatment” reads in part “Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse: Measurement of BP sitting and standing (if patient unable to stand, document reason), Patient weight. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment. Non nocturnal treatments are completed a least every thirty (30) minutes. At a minimum, obtain and document: BP, vascular access visible.” On July 24, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 16 and # 17 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 reviews and interviews, it was determined that the facility staff failed to ensure Patients participated in the Plan of Care meeting for eight (8) of ten (10) Patients (P), P # 1, # 2, # 3, # 4, # 6, # 8, # 9 and # 10. The findings include: On July 24, 2024 between 1:00 PM and 3:00 PM, clinical record reviews revealed the following: P # 1- The plan of care meeting dated June 20, 2024 failed to be signed by the Patient or reviewed with the Patient. Documentation revealed “Not reviewed with Patient. Patient not present at meeting.” P # 1 is an ICHD (InCenter Hemodialysis) Patient. P # 2- The plan of care meeting dated May 13, 2024 failed to be signed by the Patient or reviewed with the Patient. Documentation revealed “Not reviewed with Patient. Patient not present at meeting.” P # 2 is an HHD (Home Hemodialysis) Patient. P # 3- The plan of care meeting dated May 28, 2024 failed to be signed by the Patient or reviewed with the Patient. Documentation revealed “Not reviewed with Patient. Patient not present at meeting.” P # 3 is an ICHD (InCenter Hemodialysis) Patient. P # 4- The plan of care meeting dated July 17, 2023 failed to be signed by the Patient or reviewed with the Patient. Documentation revealed “Not reviewed with Patient. Patient not present at meeting.” P # 4 is an ICHD (InCenter Hemodialysis) Patient. P # 6- The plan of care meeting dated July 11, 2024 failed to be signed by the Patient or reviewed with the Patient. Documentation revealed “Not reviewed with Patient. Patient not present at meeting.” P # 6 is an ICHD (InCenter Hemodialysis) Patient. P # 8- The plan of care meeting dated July 19, 2024 failed to be signed by the Patient or reviewed with the Patient. Documentation revealed “Not reviewed with Patient. Patient not present at meeting.” P # 8 is an ICHD (InCenter Hemodialysis) Patient. P # 9- The plan of care meeting dated June 21, 2024 failed to be signed by the Patient or reviewed with the Patient. Documentation revealed “Not reviewed with Patient. Patient not present at meeting.” P # 9 is an ICHD (InCenter Hemodialysis) Patient. P # 10- The plan of care meeting dated June 20, 2024 failed to be signed by the Patient or reviewed with the Patient. Documentation revealed “Not reviewed with Patient. Patient not present at meeting.” P # 10 is an ICHD (InCenter Hemodialysis) Patient. On July 24, 2024 at 2:30 PM, 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 completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative.” On July 24, 2024 at 3:00 PM, the findings were discussed with Staff Members # 1, # 16 and # 17 during the exit interview.”

“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 interview and facility documentation review, the facility staff failed to implement the facility’s health and safety policy for tuberculosis monitoring for one (1) of seven (7) staff members (SM), SM #7. The findings include: On 7/24/24 at approximately 11:00 AM, staff record reviews were conducted and revealed that Staff Member (SM) #7, hired on 4/8/24, had no documentation of Tuberculosis (TB) screening, to include a current TB risk assessment and/or symptom evaluation. At approximately 1:30 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”.”

“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 reviews and interviews, it was determined that the facility failed to access and review the ESRD (End Stage Renal Disease) Quality Improvement Report provide by the ESRD network for the months between January 2024 and June 2024. The findings include: On July 24, 2024 at 2:00 PM, a review of the facility’s January 2024 through June 2024 Quality meetings revealed there was no documentation of the ESRD Quality Improvement Report discussions. On July 24, 2024 at 2:30 PM, an interview with Staff Member (SM) # 1 revealed the facility has not been accessing the ESRD Quality Improvement Report nor have they been discussing the information during the Quality meetings. On July 24, 2024 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”. On July 24, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 16 and # 17 during the exit interview.”