Davita Lansdowne Dialysis

“Policies for Evac. and Primary/Alt. Comm. CFR(s): §403.748(b)(3), §416.54(b)(2), §418.113(b)(6)(ii), §441.184(b)(3), §460.84(b)(3), §482.15(b)(3), §483.73(b)(3), §483.475(b)(3), §485.68(b)(1), §485.542(b)(3), §485.625(b)(3), §485.727(b)(1), §485.920(b)(2), §491.12(b)(1), §494.62(b)(2) [(b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(3) or (1), (2), (6)] Safe evacuation from the [facility], which includes consideration of care and treatment needs of evacuees; staff responsibilities; transportation; identification of evacuation location(s); and primary and alternate means of communication with external sources of assistance. *[For RNHCIs at §403.748(b)(3) and ASCs at §416.54(b)(2) and REHs at §485.542(b)(3):] Safe evacuation from the [RNHCI or ASC or REHs] which includes the following: (i) Consideration of care needs of evacuees. (ii) Staff responsibilities. (iii) Transportation. (iv) Identification of evacuation location(s). (v) Primary and alternate means of communication with external sources of assistance. * [For CORFs at §485.68(b)(1), Clinics, Rehabilitation Agencies, OPT/Speech at §485.727(b)(1), and ESRD Facilities at §494.62(b)(2):] Safe evacuation from the [CORF; Clinics, Rehabilitation Agencies, and Public Health Agencies as Providers of Outpatient Physical Therapy and Speech-Language Pathology Services; and ESRD Facilities], which includes staff responsibilities, and needs of the patients. * [For RHCs/FQHCs at §491.12(b)(1):] Safe evacuation from the RHC/FQHC, which includes appropriate placement of exit signs; staff responsibilities and needs of the patients. This Standard is not met as evidenced by: 49355 Based on observation, facility staff (EMP) interviews, and document review, it was determined the facility failed to secure patients’ protected health information (PHI) in the home modality evacuation kit with a breakaway lock, as per the facility’s policy. The findings: A review of the facility’s policy titled “Facility Emergency Management Plan (ICHD, Home)” policy 4-07-01, last revision date October 2024 reads in part: ... “Emergency Evacuation Kit ... 6. Each evacuation kit(s) should contain: a. Copy of each patient’s treatment orders.... ... 8. Evacuation kit will be sealed with a breakaway lock....” Inspection of the facility’s home modality area evacuation cart on September 30, 2025, at 9:43 A.M. revealed a clear plastic container with a lid on top of the locked evacuation cart. Current copies of patients’ treatment orders were inside. The clear plastic container did not have a breakaway lock. EMP8 and EMP12 were present during the inspection and confirmed PHI was in the container without a breakaway lock. EMP8 agreed the treatment orders should be kept in the evacuation cart, which does have a breakaway lock.”

“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: 49355 Based on facility document review and interviews, it was determined the facility failed to provide documentation of training and testing for employees (EMP) for fire safety preparedness. Specifically, the facility failed to hold quarterly fire drills, as per policy. The findings: A review of the facility’s policy titled, “Facility Emergency Management Plan (ICHD, Home),” policy 4-07-01, revision date October 2024, reads in part: ... “Fire Safety Preparedness 1. FA, or designee, is responsible to: a. Maintain a fire safety preparedness program to prevent or minimize the likelihood of a fire that may result in death, injury, or property damage in accordance with CMS .... b. Conduct and review quarterly fire safety and evacuation training and drills for compliance, identify additional training and education needs. ...Training and Education Emergency Management Plan 1. The FA, or designee, is responsible to provide training of EMP: a. Teammates: ... ii. Quarterly 1. Fire Safety Preparedness v. Document training in teammate file 1. Training/In-service Documentation Form 3. Fire Safety Drills ... b. Required on a QUARTERLY basis. c. One drill to be conducted for each shift of patients” During review of the facility’s Emergency Preparedness binder on September 29, 2025, at 5:01 P.M., there was documentation of fire drills on January 14, 2024, July 5, 2024, September 6, 2024 and December 11, 2024. Fire drills were documented on January 19, 2025, July 16, 2025 and July 17, 2025. No documentation was available for any fire drills held during the second quarter of 2024 or 2025. During an interview on July 29, 2025 at 5:45 P.M., EMP2 and EMP15 indicated that after looking through other records, they could not find any documentation of fire drills being held during the second quarter of 2024 or 2025.”

“Multiple Occupancies CFR(s): NFPA 101 Multiple Occupancies - Sections of Ambulatory Health Care Facilities Multiple occupancies shall be in accordance with 6.1.14. Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following: * The occupancy is not intended to serve ambulatory health care occupants for treatment or customary access. * They are separated from the ambulatory health care occupancy by a 1 hour fire resistance rating. Ambulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following: * Walls have not less than 1 hour fire resistance rating and extend from floor slab to roof slab. * Doors are constructed of not less than 1-3/4 inches thick, solid-bonded wood core or equivalent and is equipped with positive latches. * Doors are self-closing and are kept in the closed position, except when in use. * Windows in the barriers are of fixed fire window assemblies per 8.3. Per regulation, ASCs are classified as Ambulatory Health Care Occupancies, regardless of the number of patients served. 20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44 This Standard is not met as evidenced by: 40084 Based on observation and interview, it was determined the facility failed to maintain the 1 hour fire resistance separation from other tenants or occupants due to: penetrations to, or an incomplete fire wall, and; a self-closing rear exit fire door that failed to function appropriately and close completely. The findings include: During the life safety code survey conducted on September 30, 2025 the surveyor observed fire wall penetrations above all exists of the facility. The penetrations were from wire/conduits, HVAC duct work, and drywall that failed to extend from the floor slab to the roof slab. The surveyor also found a self-closing exit fire door on the first floor that failed to function appropriately and close completely. The findings were relayed to and confirmed by Staff Member #8.”

“Exit Signage CFR(s): NFPA 101 Exit Signage Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 20.2.10, 21.2.10, 7.10 This Standard is not met as evidenced by: 40084 Based on observation and interview, it was determined the facility failed to conduct monthly inspections of facility exit signage. The findings include: During the life safety survey of the facility on September 30, 2025, an interview with Staff Member #8 revealed the facility does not conduct monthly inspections of facility exits signs. Staff Member #8 indicated inspections may be conducted quarterly as part of the facility safety rounds.”

“Protection - Other CFR(s): NFPA 101 Protection - Other List in the REMARKS section any LSC Section 20.3 and 21.3 Protection requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 40084 Based on observation and interview, it was determined a self-closing door with a 45 minute fire rating for a storage room on the first floor was propped open by a large trash can. The findings include: During the life safety code survey of the facility on September 30, 2025, the surveyor found a self-closing door with a 45 minute fire rating for a storage room on the first floor of the facility propped open by a large trash can. The observation was confirmed by Staff Member #8.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 21.7.1.4 through 21.7.1.7 This Standard is not met as evidenced by: 40084 Based on observation and interview, it was determined the facility failed to conduct fire drills at least quarterly. The findings include: During the life safety code survey of the facility on September 30, 2025, a review of fire drill paperwork found the facility failed to conduct fire drills in the second quarter of 2024 and 2025. Staff Member #2 confirmed a fire drill was conducted in the first and third quarter but not in the second.”

“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: 49355 Based on observation, staff (EMP) interview and facility document review, it was determined the facility failed to ensure Personal Protective Equipment (PPE) was worn, per policy, by all visitors on the patient treatment floor. The findings: Review of facility document, “Infection Control For Dialysis Facilities,” policy 1-05-01, revision date April 2023, reads in part: ... “PPE (i.e., gown, gloves, eye protection, face shield) ... 6. Appropriate fluid resistant/fluid impervious gowns will be worn by all ... visitors when in the treatment area.” At 10:43 A.M. on September 29, 2025, when this surveyor entered the treatment floor for the first time, a visitor was sitting with the patient at station #11 and was not wearing a gown. Approximately five (5) minutes later, EMP6 handed the visitor a gown and asked that it be worn. This surveyor overheard the visitor reply, “what is this all about?” At 3:36 P.M., a visitor walked onto the treatment floor and approached the patient at station #3. The visitor was not wearing a gown. Within a few minutes, EMP7 handed the visitor a gown and asked that it be worn. During an interview on September 30, 2025, at approximately 2:00 PM, EMP1 indicated that all visitors should don an impervious gown when entering the treatment floor.”

“IC-HANDLING INFECTIOUS WASTE CFR(s): 494.30(a)(4)(i) [The facility must demonstrate that it follows standard infection control precautions by implementing-] (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the- (i) Handling, storage and disposal of potentially infectious waste; This Standard is not met as evidenced by: 49355 Based on observations, employee (EMP) interview, and document review, it was determined that the facility staff failed to appropriately dispose of contaminated fistula/graft needles during one (1) of two (2) decannulation observations, patient (MR)8. The findings: Review of the facility document, “Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles,” procedure 1-04-01B, revision date April 2023, reads in part: ... “Procedure ... 8. With the safety device engaged, dispose of safety fistula needle in the sharps container.” On September 29, 2025 at 3:00 P.M. EMP6 was observed at station #10 decannulating MR8’s access site. EMP6 removed the contaminated fistula needle and placed it on the chair side table, bandaged the site, and then carried the contaminated needle to a sharps container at an adjacent station for disposal. During an interview on September 30, 2025 at approximately 1:00 PM, EMP1 indicated that contaminated fistula needles should be disposed of in a sharps container immediately after removal.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 49355 Based on observations, facility staff (EMP) interview and document review, the facility failed to: 1) ensure expired medications and supplies are not available for patient use in the in-center and home modality treatment areas of the facility; 2) and/or ensure that open multidose vials of medication are appropriately labeled, per policy. The findings: The facility’s policy entitled, “Medication Policy,” policy 1-06-01, revision date October 2023, reads in part: ... “Policy: ... 29. ... Each vial is labeled with the initials of the person opening the vial and the expiration date. ... 30. All medications in the facility are checked monthly. Insulin and other medications with preservatives are dated and initialed once opened. All medications are checked monthly for expiration dates. ... 32. Disposal of expired medications ... are removed from the treatment and inventory areas and disposed of per state/local regulations.” Review of facility policy entitled, “Facility Emergency Management Plan (ICHD, HOME)” policy 4-07-01, revision date October 2024 reads in part: “ ... Emergency Evacuation Kit ... 7. FA or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly ....” During observations on the in-center hemodialysis treatment floor on September 29-30, 2025,the following medications and supplies were found to be expired: * Influenza Vaccine Fluzone Hig-Dose NDC # 49281-0124-65 2024-2025 formula, expired June 2025, #4 single-dose prefilled syringes, 0.5 ml each * Influenza Vaccine Flucelvax NDC # 70461-0654-03, 2024-2025 formula, expired June 30, 2025, #7 single-dose prefilled syringes, 0.5 ml each * pH Test Strips, #1 opened container, expiration date June 30, 2025 * Multidose vial Heparin 30,000 units/30 ml. No initials or date by staff member that opened it * Multidose vial Heparin 30,000 units/30 ml. No initials of staff member that opened it During observations in the home modality area of the facility on September 30, 2025, at 9:43 A.M. the following medication and supplies were found to be expired: * #9 2x2 sterile gauze pads, expiration date February 13, 2025 * #5 BD Vacutainer Safety-Lok Blood Collection Set, expiration date May 31, 2025 * #4 BD Blood Collection Assembly with Male Luer Lock, expiration date April 25, 2025 * Multidose vial Heparin 30,000 units/30 ml, expiration date September 1, 2025 During an interview on September 30, 2025, at 9:52 A.M., EMP8 indicated that expired medications and supplies should be discarded from the home modality evacuation cart, as per the facility’s policy. During an interview on September 30, 2025, at approximately 2:00 P.M., EMP1 indicated that all expired medications and supplies are to be immediately removed from both the in-center and home modality treatment areas. EMP1 also indicated that opened multidose vials of medication should be initialed and dated by the staff member that opens them.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 49355 Based on observation, facility staff (EMP) interviews and document review, it was determined the facility failed to follow appropriate infection control measures, per policy, when initiating or discontinuing dialysis treatment via central venous catheter (CVC) in five (5) out of five (5) observations. The findings: Review of facility policy entitled, “Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure,” procedure 1-04-02B, revision date April 2025, reads in part: ... “Notes: ... Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason. ... Procedure ... 16. ... Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue, for example blood. ... Upon completion of Dialysis ... 34. ... Scrub the sides, threads and end of the hub thoroughly with friction for 15 seconds.” During an observation at 10:43 A.M. on September 29, 2025, while initiating treatment on patient (MR)9, EMP6 wiped each CVC hub for approximately seven (7) seconds. During an observation at 11:38 A.M. on September 29, 2025, while initiating treatment on MR10, EMP5 wiped each CVC hub for approximately five (5) seconds. During an observation at 11:57 A.M. on September 29, 2025, while initiating treatment on MR2, EMP4 did not wipe either CVC hub. During an observation at 3:19 P.M. on September 29, 2025, while discontinuing treatment on MR10, EMP5 wiped each CVC hub for approximately three (3) seconds. During an observation at 3:34 P.M. on September 29, 2025, while discontinuing treatment on MR2, EMP4 wiped one CVC hub for approximately three (3) seconds and the second hub for approximately twelve (12) seconds. During an interview on September 29, 2025, at 3:53 P.M., EMP6 indicated that each CVC hub should be scrubbed for fifteen (15) seconds, as per facility’s policy, prior to initiation and after discontinuing of treatment. During an interview on September 30, 2025, at approximately 2:00 P.M., EMP1 indicated CVC hubs should be scrubbed for 15 (fifteen) seconds, per policy, when initiating and discontinuing treatment.”

“PA-MSW-PSYCHOSOCIAL NEEDS CFR(s): 494.80(a)(7) The patient’s comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker. This Standard is not met as evidenced by: 49355 Based on medical record reviews, facility staff (EMP) interview and documentation review, it was determined the facility failed to document a quarterly note by the social worker to evaluate a dialysis patient’s psychosocial health status, per policy, in one (1) out of seven (7) medical records reviewed, Patient (MR)4. The findings: Review of facility policy entitled, “Social Work Intervention and Documentation Requirements,” procedure: 1-14-03A, revision date October 2023, reads in part: ... “Documentation in Each Patient’s Medical Record Social Work Progress Note ... Timing ... Quarterly or more frequently as needed ... Comments ... Documentation is individualized and reflects the specific social work needs of the patient....” A review of the medical record for MR4 on September 30, 2025, with facility staff (EMP)1, revealed the last documented social work note contained in the electronic medical record was dated March 30, 2025. During an interview on September 29, 2025, EMP11 indicated a social worker is responsible for documenting in the patient’s medical record quarterly, at the minimum. EMP1 confirmed the last documented social work note was as described above and per policy, documentation from the social worker should be present at least once quarterly.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 49355 Based on medical record reviews, facility staff (EMP) interviews and document review, it was determined the facility failed to document pre-treatment nursing assessments on in-center hemodialysis (ICHD) patients, per facility policy, in two (2) out of five (5) medical records reviewed. The findings: The facility’s policy entitled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy 1-03-08, revision date April 2024, reads in part: ... “Pre-Treatment Data Collection/Assessment ... 5. The assessment is a nursing responsibility. ... Intradialytic Data Collection/Assessment ... 8. The licensed nurse will ... complete the nursing assessment within one (1) hour of dialysis treatment initiation....” A review of the following medical records revealed: Patient (MR)1: Flowsheet dated September 19, 2025: treatment start time was 11:16 A.M., documented nursing pre-assessment note completion was 12:23 P.M. MR4: Flowsheet dated September 22, 2025: treatment start time was 6:18 A.M., documented nursing pre-assessment note completion was 10:49 A.M. During an interview at 3:53 P.M. on September 29, 2025, EMP6 indicated a nursing pre-treatment assessment note should be completed within one (1) hour of initiation of treatment. During an interview at approximately 2:00 P.M. on September 30, 2025, EMP1 indicated the pre-treatment nursing note should be completed within one (1) hour of the start of dialysis.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49355 Based on observations, facility staff (EMP) interview and document review, it was determined the facility failed to properly care for arteriovenous (AV) grafts/fistulas according to the facility’s policy. Specifically, in one (1) out of two (2) observations, EMPs touched the cannulation sites of arteriovenous (AV) fistulas/grafts after the insertion sites were prepped with antiseptic. The findings: Review of facility document entitled, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” procedure 1-04-01E, revision date April 2025, reads in part: ... “Procedure: ... 13. Do not palpate insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.” During observation on September 29, 2025, at 3:15 P.M., EMP4 palpated patient (MR)12’s AV fistula access sites at station #1 after cleansing the areas with antiseptic. MR12 did not recleanse the areas before accessing the sites. During an interview at 3:53 P.M. on September 29, 2025, EMP6 indicated the sites should be recleansed after palpating and before cannulating and not touched again.”

“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: 49355 Based on medical record review, facility staff (EMP) interview and document review, it was determined the facility failed to ensure each member of the interdisciplinary team and the patient (MR) signed the patient’s plan of care in one (1) of seven (7) medical records reviewed, MR6. The findings: Review of facility document entitled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” policy 1-14-01, revision date October 2024, reads in part: ... “Plan of Care: ... 14. The patient’s plan of care will be 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 September 30, 2025, a review of the medical record for MR6, with the assistance of EMP12, failed to contained an initial plan of care signed by the IDT. During an interview on September 30, 2025, EMP12 confirmed the medical record did not contain a signed copy of the initial plan of care for MR6, but indicated the record should have contained the signed document.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 49355 Based on medical record review, facility staff (EMP) interview and facility document review, it was determined the facility failed to complete the initial plan of care (POC) within thirty (30) calendar days after admission to the dialysis facility, per policy, for two (2) of seven (7) medical records reviewed, patient (MR)5 and MR7. The findings: A review of the facility document entitled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” policy 1-14-01, revision date October 2024, reads in part: ... “Plan of Care: ... 10. An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days.... ... New Patient: Assessment within 30 days of admission to facility....” A review of the medical records for peritoneal dialysis (PD) patient MR5 and home hemodialysis (HHD) patient MR7 was performed on September 30, 2025, with the assistance of EMP12. The review revealed MR5 started PD on July 18, 2025. MR5’s record did not contain an initial POC. The review revealed MR7 started HHD on April 2, 2025. MR7’s initial POC was dated May 16, 2025. During an interview on September 30, 2025, EMP12 acknowledged MR5’s record did not contain an initial POC. EMP12 indicated there was additional information required to complete the POC. A Peritoneal Equilibration Test (PET) and an adequacy study had not be done as of this date and needed to be included in the initial POC. EMP12 acknowledged the initial POC for MR7 was later than thirty (30) days as per facility policy.”

“POC-PTS SEEN BY MED STAFF 1X/MO CFR(s): 494.90(b)(4) The dialysis facility must ensure that all dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly, as evidenced by a monthly progress note placed in the medical record, and periodically while the hemodialysis patient is receiving in-facility dialysis. This Standard is not met as evidenced by: 49355 Based on medical record review, facility staff (EMP) interview and document review, it was determined the facility failed to document a monthly physician note to evaluate a patient’s current health status and medical condition, per policy, in one (1) out of seven (7) medical records reviewed, patient (MR)3. The findings: Review of facility document entitled, “Progress Note Policy,” policy 3-02-17, revision date October 2024, reads in part: ... “Physician: The attending Nephrologist is required to record patient progress notes at least monthly and for any clinical event, which must be recorded in a time frame that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times.” Review of facility’s document entitled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” policy 1-14-01, revision date October 2024, reads in part: ... “18. The dialysis facility will verify that all in-center hemodialysis patients are seen by an attending End Stage Kidney Disease (ESKD) physician at the dialysis facility while the dialysis treatment is being provided at least monthly ... and that the visit is documented in the progress not of the patient’s medical record.” The medical record for MR3 was reviewed on September 30, 2025, with the assistance of EMP1. The review revealed the last documented physician note was dated July 29, 0225. EMP1 confirmed the date of the last physician note and indicated that a physician note should be documented in the record once monthly, at a minimum.”