Davita Princess Anne 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: 42929 Based on observations, interviews, and document review, it was determined the facility staff failed to ensure the evacuation kit supplies were secured with a breakaway lock and update the patient’s orders and medication list monthly in the evacuation kit, as per the facility’s policy. Findings: On 11/27/2023 at 11:39 a.m., the surveyor observed the evacuation kit with a piece of paper taped across the lid and front of the container with a note stating not to open the container. Once the surveyor removed the paper, there were no breakaway locks on the container to secure the medication and patient protected health information included in the kit, as per the facility’s policy. The patient’s orders contained in the evacuation kit that were dated 9/18/2023, were not updated monthly as per the facility’s policy. A review of the facility’s policy “Emergency Management Plan” states in part: ...Emergency Evacuation Kit... 6. Each evacuation kit(s) should contain: a. Copy of each patient’s treatment orders and medication list. FA or designee will verify patient information is updated and replaced at least monthly.... The date and initials of the teammate checking the contents should be placed on a label outside the kit(s). 8. Evacuation kit will be sealed with a breakaway lock and is only to be opened in the event of an emergency situation, monthly review, and/or the replacement of an outdated item... The above concerns were discussed with Staff Member (SM) 1, SM4, and SM10 at the exit conference on 11/29/2023 at 11:30 a.m.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 42042 Based on observations, interviews, and document review, it was determined the facility staff failed to ensure aseptic technique for medications by: the storage of expired medications available for patient use; and not including all of the necessary components of medication labeling for one (1) out of one (1) intravenous (IV) medication syringes. Findings: On 11/27/23 at 11:35 a.m., the surveyors conducted a “flash tour” of facility to include observations of the treatment floor. During tour, the surveyor identified a refrigerator labeled, “Medication Refrigerator #2” adjacent to the medication preparation area. On 11/27/23 at 11:44 a.m., the surveyor inspected the contents of the refrigerator and identified the following expired medications: 1. Hepatitis B vaccine (“Energix-B”), 20 mcg/mL, 1 mL, single-dose vial; Lot # “F73DG”, Expiration Date: 07/03/23; Quantity: 5 2. Pneumococcal 13 Valent (“Prevnar 13”), 0.5 mL mL, single-dose vial; Lot # “EY2562”, Expiration Date: 10/01/23; Quantity: 3 On 11/27/23 at 11:58 a.m., the surveyor observed a pre-drawn medication syringe filled with approximately 0.25 mL of clear liquid with a label indicating it was for Patient (P) 1 and contained the ordered medication, Epogen 2,400 Units. Following closer inspection, the surveyor confirmed there was no information on the label indicating the date and time prepared, nor the staff responsible. Following treatment floor observations on 11/27/23 at approximately 3:45 p.m., the surveyor met with both Staff Member (SM) 1 and SM4 for interview and disseminated the aforementioned treatment floor observations. The surveyor reviewed the facility policy titled, “Medications Requiring Refrigeration” policy (with last revision date of December 2022), which provides facility protocol and procedures for both the storage and management of medications requiring refrigeration. The policy delineates the procedure for checking the contents of the medication refrigerator, and states that daily checks are performed to ensure that no expired medications are present. The surveyor was also supplied the facility policy titled, “Medication Policy” (with last revision date of October 2023). On page three (3), the policy states, “All open or unopened medication packages (i.e. vials, ampules, etc.) are stored according to the manufacturer’s directions. Do not use any medication that has been stored improperly or has expired” [sic]. On page five (5), the same document continued to state, “All medications are checked monthly for expiration dates ...Medications are ordered and replaced prior to expiration.” The same policy continued to state, “Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations”. Additionally, in reference to the required components of medication labeling, the same “Medication Policy” stated the following: If medications are prepared and administered immediately, by the same licensed nurse teammate, the medications do not need to be labeled. If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient’s name, name of medication, date, time prepared, dose and initials of teammate preparing the medication. The surveyor disseminated the findings to SM1, SM, and SM10 during exit conference on 11/29/23 at 11:15 am. Staff demonstrated understanding of the findings. Opportunity for clarification and questions given without further response.”

“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 observations, interviews, and document review, it was determined the facility staff failed to maintain aseptic technique when providing care to a central venous catheter (CVC) exit site for one (1) of two (2) observations Findings: On 11/27/2023 at 3:21 p.m., surveyors observed Staff Member (SM) 8 providing care to the CVC exit site on Patient (P) 10 at dialysis station 4. P10 was wearing a sweater with a high crew neck, covering the majority of the CVC site. SM8 did not secure the neck of the sweater away from the CVC site and began cleansing the site with a swab. SM8 placed the end of the antiseptic swab under the neckline of the sweater to cleanse areas of the site that were not visible. SM8 finished cleansing the site and the neckline of the sweater remained against the cleansed exit site and catheter for multiple minutes until the site was covered with a dressing. A review of facility procedure titled “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure” states, in part: ...Procedure ...3. ...Verify patient’s clothing is secured away from the exit site/work area. The above concern was discussed with SM 1 and 4 on 11/27/2023 and at the exit conference on 11/30/2023 at 11:30 a.m. with SM1, SM4, and SM10.”

“DIALYS PROPORT-MONITOR PH/CONDUCTIVITY CFR(s): 494.40(a) 5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer’s instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient. This Standard is not met as evidenced by: 49355 Based on observations and facility document review, it was determined that facility staff failed to perform dialysate conductivity testing according to the facility’s policy for two (2) of two (2) observations. Findings: On 11/27/2023 at 1:14 p.m., the surveyor observed Staff Member (SM) 8 perform a conductivity test using the Myron L Conductivity Meter D-1. SM8 obtained a dialysate sample from the machine in a disposable paper cup. SM8 took the dialysate sample to the Myron L meter and poured the sample into the meter’s cell cup. SM8 placed the plunger into the cell cup, raised the plunger up three (3) times, pressed the black button and obtained a reading. On 11/27/22023 at 2:24 p.m., the surveyor observed SM9 perform a conductivity test using the Myron L Conductivity Meter D-1. SM9 obtained a dialysate sample from the machine in a disposable paper cup. SM9 took the dialysate sample to the Myron L meter and poured the sample into the meter’s cell cup. SM9 placed the plunger into the cell cup, raised the plunger up three (3) times, pressed the black button and obtained a reading. A review of the facility’s procedure titled “Operation of Portable Myron L Conductivity Meter (D-1) states, in part: ...Procedure ...3. Rinse the cell cup and plunger 3 times with sample to be tested. ...7. Repeat Steps #3 and #4 until the reading is constant (3 or 4 times). These findings were discussed at the exit conference on 11/30/2023 at 11:30 a.m. with SM1, SM4, and SM10.”

“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: 42929 Based on interviews and document review, it was determined that the facility staff failed to: document notification to the registered nurse of abnormal blood pressure for four (4) of five (5) patients’ flow sheets sampled; and document notification to the registered nurse or physician for post treatment weight above or below one (1) kg from target weight for one (1) of five (5) patients’ flow sheets sampled. Findings: On 11/28/2023, the surveyor conducted a medical record flow sheet review of five (5) in-center hemodialysis patients (P) sampled. A review of the flow sheets determined that the staff failed to include documentation of notification to the registered nurse or physician for abnormal findings related to pre-, intra-, and post- dialysis blood pressures (BP)as per the facility’s policy for: P1 on: 11/13/2023 with a pre-treatment standing BP of 154/106. 11/15/2023 with a pre-treatment sitting BP of 177/107 and intradialytic pressures from 123/73 at 1:32 p.m. to 134/105 at 1:44 p.m. 11/17/2023 with a pre-treatment standing BP of 160/106 and intradialytic pressures from 92/56 at 12:33 p.m. to 135/88 at 1:02 p.m. then to 164/101 at 1:32 p.m. with no recheck until 1:47 p.m. 11/21/2023 with a pre-treatment standing BP of 158/115 and intradialytic pressures from 130/77 at 6:34 a.m. to 141/109 at 7:04 a.m. 11/24/2023 with a pre-treatment standing BP of 200/126 and sitting BP of 194/117, and intradialytic pressures from 178/125 at the start of treatment at 5:55 a.m. to 175/118 at 6:04 a.m. to 126/89 at 6:34 a.m. P2 on: 11/10/2023 with a post-treatment standing BP of 173/102 and sitting BP of 163/100. 11/13/2023 with a pre-treatment standing BP of 163/105 and post-treatment sitting BP of 163/104. 11/17/2023 with a pre-treatment standing BP of 169/106 and post-treatment standing BP of 147/102. 11/21/2023 with a pre-treatment standing BP of 162/121 and sitting BP of 150/113, and a post-treatment standing BP of 172/104 and sitting BP of 166/103. 11/24/2023 with a pre-treatment standing BP of 160/131 and a post-treatment standing BP of 160/110. P3 on: 10/17/2023 with starting treatment BP of 112/52 at 6:35 a.m. and the next BP documented as 82/62 at 9:17 a.m. P5 on: 11/10/2023 with a pre-treatment standing BP of 191/106 and a post-treatment standing BP of 179/100 and sitting BP of 195/100. 11/13/2023 with a pre-treatment sitting BP of 192/100 and a post-treatment sitting BP of 185/100. 11/15/2023 with pre-treatment standing and sitting BPs of 174/101. 11/17/2023 with a pre-treatment standing BP of 178/107 and sitting BP of 188/100 and a post-treatment standing BP of 202/91. 11/21/2023 with a pre-treatment sitting BP of 199/106 and post-treatment standing BP of 184/103. 11/24/2023 with a pre-treatment standing BP of 192/107 and sitting BP of 188/101. A review of the flow sheets determined that staff failed to include documentation of notification to the registered nurse or physician for post treatment weight above or below one (1) kg from target weight for: P3 on: 10/14/2023 with a target weight of 90.5 kg and a post-treatment weight of 101.3 kg. 10/17/2023 with a target weight of 90.5 kg and a post-treatment weight of 98.9 kg. 11/2/2023 with a target weight of 96.0 kg and a post-treatment weight of 93.8 kg. 11/4/2023 with a target weight of 96.0 kg and a post-treatment weight of 94.7 kg. A review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” states in part: ...Policy 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: i. Measurement of Blood Pressure (BP) 1. Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet) 2. Intradialytic BP in the sitting/reclined or supine position ...Intradialytic Data Collection/Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring ...b. At a minimum, obtain and document the following: i. Blood pressure ...11. Abnormal findings or findings outside of any patient specific physician ordered parameter will be reported to the licensed nurse immediately (refer to Abnormal Findings section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician or (NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record ...Post Treatment Data Collection/Assessment 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 17. Licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility. Abnormal Findings ...Abnormal Findings Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. Within each category, definitions may be adjusted by a patient specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is a concern for the patient’s condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. Members of the patient care team should report ANY changes inpatient conditions or concerns of patient well-being immediately to the licensed nurse at any time. Fluid Status: ... Post-Treatment: If patient is above or below [one] 1 kg [kilogram] form the target weight. Blood pressure: Pre dialysis: Systolic greater than 180 mm/Hg or less that 90 mm/Hg Diastolic greater than or equal to 100 mm/Hg Blood Pressure-Intradialytic: Difference of 20 mm/Hg increase or decrease from patient’s last Intradialytic treatment BP reading... Blood Pressure Post Treatment: If the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg If patient is not able to stand, document reason and sitting BP. Sitting BP for patient’s that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg... The above concerns were discussed with Staff Member (SM) 1, SM4, and SM10 at the exit conference on 11/29/2023 at 11:30 a.m.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 42929 Based on interviews and document review, it was determined that the facility staff failed to document the reason and notification to the registered nurse of the change in blood flow rate (BFR) for four (4) of five (5) patients sampled. Findings: On 10/18/2023 the surveyor conducted a medical record flow sheet review of five (5) in-center hemodialysis patients sampled. A review of the flow sheets determined that the facility staff failed to administer the prescribed order and to include documentation of the reason and notification to the registered nurse of the change in blood flow rate (BFR) for: P2 for: 11/10/2023 for a BFR prescribed at 400 mL/min and run at 350 mL/min. 11/17/2023 for a BFR prescribed at 400 mL/min and run at 360 mL/min. 11/24/2023 for a BFR prescribed at 400 mL/min and run at 350 mL/min, 300 mL/min, and 0 mL/min. P3 for: 9/12/2023 for a BFR prescribed at 400 mL/min and run at 350 mL/min. 10/14/2023 for a BFR prescribed at 400 mL/min and run at 350 mL/min and 325 mL/min. 10/17/2023 for a BFR prescribed at 400 mL/min and run at 285 mL/min. 11/4/2023 for a BFR prescribed at 400 mL/min and run at 300 mL/min. P4 for: 11/10/2023 for a BFR prescribed at 400 mL/min and run at 375 mL/min. P5 for: 11/21/2023 for a BFR prescribed at 350 mL/min and run at 300 mL/min. A review of the facility’s policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” states in part: ...Policy: ...3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which 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 (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: ...f. Blood flow rate ...Pre-Treatment Data Collection/Assessment 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to “Abnormal Findings” section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 5. The assessment is a nursing responsibility. The nurse will assess the patient pre-treatment as warranted by the patient’s condition. 6. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner (NPP) if applicable) will be notified of any concerns that may preclude the incitation of dialysis. 7. If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated. Intradialytic Data Collection/Assessment. 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: ...b. At a minimum, obtain and document the following: ...iii Blood and dialysate flows, arterial and venous pressures ...10. 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. 11. Abnormal findings or findings outside of any patient specific physician ordered parameter will be reported to the licensed nurse immediately (refer to Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician or (NPP if applicable) as needed of changes in patient status. 13. All findings, interventions and patient response will be documented in the patient’s medical record... Post Treatment Data Collection/Assessment 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge... The above concerns were discussed with Staff Member (SM) 1, SM4, and SM10 at the exit conference on 11/29/2023 at 11:30 a.m.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 42042 Based on observations, interviews, and document review, it was determined the facility failed to: administer Heparin as ordered per policy guidelines for two (2) of two (2) observed medication preparation observations; and ensure the registered nurse recorded patient progress notes at least monthly for five (5) of six (6) patients sampled, as per the facility’s policy. Findings: On 11/27/23 at 1:22 p.m. and 1:27 p.m., the surveyor observed Staff Member (SM) 8 prepare intravenous (IV) Heparin in the clean medication preparation area for Patient (P) 8 and P9, respectively. During the medication preparation process, SM8 informed the surveyor that despite both patients having ordered loading dose of Heparin, 2,000 Units, an extra 0.4 mL (milliliters) should be added to the syringe and administered into the priming lines of the machine in order to remove any air or other substances. SM8 stated that the additional amount equates to around 2,500 Units in total for both P8 and P9. The surveyor questioned the staff member regarding the rationale, to which SM8 added that the extra amount ensures that the in-center hemodialysis machines, Model “Fresenius 2008K2”, administers the full medication dose. SM8 added that the extra dose is used to ensure sufficient priming of the tubing lines with Heparin, which the staff member stated contains 0.4 mL in volume capacity. The surveyor inquired whether or not the line could be primed with saline instead. SM8 stated that they were instructed to utilize extra Heparin in the dialysis line but stated that the practice was facility-specific, and they were aware of the practice not being incorporated at another local facility. SM8 did not elaborate on further details. In the afternoon of 11/28/23, flow sheet documentation for both P8 and P9 related to the treatments received on 11/27/23 were reviewed. Upon review, surveyor observed that both patients had active orders for a loading dose of Heparin, 2,000 Units during each dialysis treatment. Under “Medications Administered” section corresponding to treatment on 11/27/23, P8 was documented as receiving Heparin 2,000 Units on 11/27/23 at 2:43 p.m. by SM8. Additionally, the same treatment documentation for P9 indicated that the patient received the same ordered Heparin dose on 11/27/23 at 5:03 p.m.. On 11/28/23 at 12:26 p.m., the surveyor conducted a telephone interview with SM6 who had ordered the Heparin dosages for both patients. SM6 confirmed during interview that they were not aware of the facility practice of drawing up additional Heparin to what is ordered. At approximately 3:50 p.m. on 11/28/23, the surveyor met with SM4 for interview in the conference room to discuss the aforementioned Heparin practice. SM4 confirmed the practice of adding 0.4 mL of Heparin to all ordered loading doses is consistent with facility administration guidelines, and that the practice helps to mitigate the amount of not administered Heparin due to machine priming. In the afternoon of 11/28/23, the surveyors reviewed the dialysis machine’s operating manual titled, “2008K2 Hemodialysis Machine Operating Manual” (Policy # 490136”). On pages eighty-four (84) through eighty-eight (88), the document delineates the process for the automatic delivery of Heparin. On page eighty-seven (87), the manual specifically states, “Warning! Make sure that there is sufficient heparin for the bolus and subsequent heparin infusion. Do not load the syringe beyond the prescribed amount”. In the evening of 11/28/23, the surveyors were supplied by SM4 the policies governing both machine usage and the administration of Heparin medication. Under “Use of Heparin” section, the policy titled, “Anticoagulation” (with last revision date of 10/2023), states that the heparin volume drawn up into the syringe should “equal the dosage prescribed by the physician or non-physician practitioner (NPP)” [sic]. The surveyor was provided the policy titled, “Treatment Initiation Utilizing Fresenius 2008 Series Dialysis Delivery Systems with All Single Use Dialyzer Types and Streamline or Combiset or Nipro Blood Lines” (with last revision date of 10/2023) by SM4. The policy delineates the procedure for appropriately priming the dialysis machine lines in order to remove air from the tubing lines. The surveyor observed that the policy does not indicate to increase the dosage of Heparin by 0.4 mL. On page three (3), the policy states to “verify heparin line has been back-primed with saline.” The surveyor disseminated the findings to SM1, SM4, and SM10 during exit conference on 11/29/23 at 11:15 am. Staff demonstrated understanding of the findings. Opportunity for clarification and questions given without further response. On 11/28/2023 the surveyors reviewed interdisciplinary team progress notes for six (6) in-center dialysis patients with SM1. A review of the medical records contained evidence that there were no monthly nursing progress notes for P2, P3, P4, P5, and P6. SM1 confirmed that there was no documentation of monthly nurse progress notes for those five (5) patients. SM4 confirmed that the nurses are supposed to complete a monthly nursing progress note for each patient, as per the facility’s policy. A review of the facility’s policy titled “Medical Record Quality Assurance” states in part: ... 17. Nurses are required to record patient progress notes at least monthly for patients or as necessary to assess and document changes in patient’s medical status and needs. All progress notes and Plan of Care follow-up notes are to be dated and signed at the time they are written or entered electronically.... The above concerns were discussed with SM1, SM4, and SM10 at the exit conference on 11/29/2023 at 11:30 a.m. 42929”