Davita Bull Run Dialysis

“PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This Standard is not met as evidenced by: 49355 Based on medical record review, interview and document review, it was determined the facility failed to ensure dialysis patients are appropriately screened for tuberculosis (TB) while performing a comprehensive health assessment, per facility policy. The findings: The facility document entitled, “Tuberculosis Infection Control Policy,” policy number 12-07-03, revision date April 2025, reads in part: ... “Policy: 1. Patients with chronic kidney disease (CKD) are considered high risk for progression from latent TB infection (LTBI) to active TB disease and will be screened for TB prior to first treatment, as well as participate in ongoing surveillance following admission, per requirements of this policy, regardless of BCG history. 2. TB Surveillance will be performed on admission, annually and as indicated.” A review of the medical record for patient (MR)2 on September 3, 2025, at 1:53 P.M. revealed a Tuberculosis Risk Appraisal Questionnaire (TB-RAQ) was performed on August 13, 2025. No further documentation of TB screening was observed or available. MR2’s first dialysis treatment was on July 25, 2025. During an interview on September 3, 2025, at 3:00 P.M., facility staff (EMP)1 confirmed no further documentation was available indicating TB screening for MR2 prior to the first treatment. EMP1 indicated that TB screening should be performed prior to the first dialysis treatment.”

“Establishment of the EP Program Dialysis CFR(s): §494.62 Condition for Coverage: The dialysis facility must comply with all applicable Federal, State, and local emergency preparedness requirements. These emergencies include, but are not limited to, fire, equipment or power failures, care related emergencies, water supply interruption, and natural disasters likely to occur in the facility’s geographic area. The dialysis facility must establish and maintain an emergency preparedness program that meets the requirements of this section. The emergency preparedness program must include, but not be limited to, the following elements: This Condition is not met as evidenced by: 40084 Based on the scope and severity of deficiencies related to the facility’s Emergency Preparedness Program (EP), the facility failed to substantially comply with this condition. See Tags: E-0020 E-0033 E-0036 E-0039 E-0040”

“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, interview, and document review, it was determined the facility failed to secure patients protected health information (PHI) and medications 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 April 2025, reads in part: ... “Emergency Evacuation Kit ... 8. Evacuation kit will be sealed with a breakaway lock....” The evacuation kit in the home modality area of the facility failed to have a breakaway lock, per policy, when inspected by the surveyor on July 21, 2025, as 3:24 P.M. Employee (EMP) 4 was present at the inspection and confirmed that the container did not have a lock but should have.”

“Methods for Sharing Information CFR(s): §403.748(c)(4)-(6), §416.54(c)(4)-(6), §418.113(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §441.184(c)(4)-(6), §460.84(c)(4)-(6), §482.15(c)(4)-(6), §483.73(c)(4)-(6), §483.475(c)(4)-(6), §484.102(c)(4)-(5), §485.68(c)(4), §485.542(c)(4)-(6), §485.625(c)(4)-(6), §485.727(c)(4), §485.920(c)(4)-(6), §491.12(c)(4), §494.62(c)(4)-(6). [(c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years [annually for LTC facilities]. The communication plan must include all of the following: (4) A method for sharing information and medical documentation for patients under the [facility’s] care, as necessary, with other health providers to maintain the continuity of care. (5) A means, in the event of an evacuation, to release patient information as permitted under 45 CFR 164.510(b)(1)(ii). [This provision is not required for HHAs under §484.102(c), CORFs under §485.68(c)] (6) [(4) or (5)]A means of providing information about the general condition and location of patients under the [facility’s] care as permitted under 45 CFR 164.510(b)(4). *[For RNHCIs at §403.748(c):] (4) A method for sharing information and care documentation for patients under the RNHCI’s care, as necessary, with care providers to maintain the continuity of care, based on the written election statement made by the patient or his or her legal representative. *[For RHCs/FQHCs at §491.12(c):] (4) A means of providing information about the general condition and location of patients under the facility’s care as permitted under 45 CFR 164.510(b)(4). This Standard is not met as evidenced by: 49355 Based on observation, interview and document review, it was determined the facility failed to include treatment orders for all home peritoneal dialysis (HPD) patients and failed to maintain current updated copies of patients’ treatment orders in the evacuation kit of the home modality area of the facility, as per policy. The findings: The facility’s document, “Facility Emergency Management Plan (ICHD, Home),” policy 4-07-01, last revision date April 2025, reads 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 very patient information is updated and replaced at least monthly.” The home modality evacuation kit was inspected at 3:24 P.M. on July 21, 2025. There were fifteen (15) HPD patient treatment orders in the kit, all dated February 17, 2025. Employee (EMP) 4 indicated there were nineteen (19) HPD patients on the current census. EMP4 agreed that treatment orders for all HPD patients should be included in the evacuation kit and that all orders should be updated and printed monthly, at a minimum.”

“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 interview, 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 April 2025, 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 wtih 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” ... Emergency Drills ... Fire safety drills: ... b. Required on a QUARTERLY basis.” During review of the facility’s Emergency Preparedness binder on July 22, 2025, there was documentation of fire drills on March 12, 2025, for employees on Monday, Wednesday, Friday shifts and on March 13, 2025, for the Tuesday, Thursday, Saturday employees. No documentation was available for any other drills. During an interview on July 22, 2025 at 3:05 P.M., EMP7 indicated that after reviewing the binder, they could not find any documentation of any other fire drills being held.”

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 49355 Based on interview and document review, it was determined the facility failed to provide documentation of annual exercises to test the emergency preparedness plan. The findings: The facility’s document entitled, “Facility Emergency Management Plan (ICHD, Home),” policy 4-07-01, revision date April 2025, reads in part: ...Authority and Responsibility ...5. The FA, or designee, is responsible for a. Implementation, adherence, and training of facility specific EMP [Emergency Management Plan] and applicable policy and procedures ... c. Collaboration with the Medical Director to lead the development and implementation of the EMP, including review and revision of existing policies and processes, participation and evaluation of emergency preparedness drills.... ... Emergency Drills 1. The FA, or designee, will maintain the emergency preparedness training and testing based on the facility EMP. 2. EMP training exercises: ...e. Frequency: i. The facility will conduct and/or participate in one (1) exercise to test the facility EMP at least ANNUALLY, conducted on OPPOSITE years (one-year full-scale exercise next year facility-based/exercise of choice)....” The facility’s Emergency Preparedness binder was reviewed on July 22, 2025. A tabletop exercise was documented as occurring on October 30, 2024, but no information pertaining to the drill was located. There were no drills documented for 2025, 2024, 2023, or 2022. During an interview on July 22, 2025, employee (EMP) 7 confirmed there was no further documentation available on any testing exercise performed at the facility from 2022 to 2025. EMP7 also indicated that there were no other EMP binders found.”

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 49355 Based on interview, medical record reviews and document review, it was determined the facility failed to document that emergency preparedness (EP) orientation and training was performed, per policy, for two (2) out eight (8) patients (MR), MR8 and MR11. Specifically, MR8 and MR11 did not receive EP orientation and training on or before the date of the first treatment. The findings: A review of the facility’s policy titled, “Facility Emergency Management Plan (ICHD, Home),” policy 4-07-01, revision date April 2025, reads in part: ... Training and Education 1. The FA, or designee, is responsible to provide training of EMP: ... b. Patients: ... iii. Upon admission to the facility.” A review of the medical record on July 22, 2025, revealed MR8 was admitted to the facility and received the first treatment on May 15, 2025. Documentation provided indicates MR11 received the EP orientation and training on June 12, 2025. A review of the medical record on July 22, 2025, revealed MR11 was admitted to the facility and received the first treatment on February 12, 2025. Documentation provided indicates MR11 received the EP orientation and training on March 19, 2025. During an interview on July 22, 2025, EMP7 indicated patients should receive EP orientation and training prior to or on the date of the first dialysis treatment.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [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-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 49355 Based on infection control observations and document review, it was determined the facility failed to ensure dialysis stations and chairs were completely disinfected prior to bringing clean supplies to the station. The facility also failed to immediately clean up and disinfect three (3) blood drips in front of an occupied dialysis chair. The facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy 1-05-01, revised date April 2023, reads, in part: ... “Disinfection 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials.... a. Prior to routine disinfection, remove all visible blood i. For visible blood or gross blood spills, a 1:10 (one to ten) bleach solution must be utilized ii. After all visible blood is cleaned with the 1:10 (one to ten) bleach solution, teammates are to use a new disposable towel soaked with 1:10 (one to ten) bleach solution and clean area a second time. iii. Cleaning of visible blood should be performed when first observed. ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g. control panel; top, front and sides of dialysis machine; touchscreens; countertops).” On July 21, 2025, at 11:29 A.M., this surveyor observed three (3) blood drips, each approximately 1 inch in diameter, in front of an occupied dialysis chair at station #11. It is unknown whether the blood was that of the seated patient or the prior patient. The blood appeared to be in the pathway between the dialysis chair at station #11 and the large biohazardous waste container where staff (EMP) dispose of used bloodlines and dialyzers. On July 22, 2025, at 10:52 A.M., EMP17 was observed cleaning the dialysis machine at station #7. Once cleaned, EMP17 brought supplies to the station, preparing the machine for the next patient. After the set-up of the machine was complete, EMP17 disinfected the chair. During an interview on July 22, 2025, EMP1 indicated the complete dialysis station should be disinfected prior to bringing clean supplies for the next patient and any blood spills should be cleaned up and the area disinfected immediately.”

“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: 49355 Based on interview, personnel record reviews and facility document review, it was determined the facility failed to document facility staff (EMP) were screened for hepatitis B, per facility policy, for two (2) of fourteen (14) personnel files. The findings: The facility’s policy entitled “Teammate Hepatitis B Monitoring and Follow-Up Guidance,” policy 4-06-03, revised April 2024, reads, in part: “Policy: 1. New teammates who are not able to provide documentation of hepatitis B surface antibodies of 10 mlU/ml or greater from any time in the past, regardless of documentation indicating completion of the hepatitis B vaccine series, will be screened for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) within [ten] 10 days and offered the vaccination as indicated by their results.” A review of the personnel file worksheet for the facility on July 22, 2205, at 8:45 A.M. indicated two (2) new EMPs, EMP10 and EMP18, did not have dates documented for Hepatitis screening. Both teammates were hired the beginning of May, 2025. The surveyor requested EMP7 confirm the lack of documentation. EMP7 accessed an online database, but failed to find any information pertaining to Hepatitis B screening for these two EMPs. EMP7 indicated that all employees should be screened for Hepatits B and that information should be documented in the employee’s personnel file.”

“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, interviews and document review, it was determined the facility failed to follow appropriate infection control measures, per policy, when providing care to a central venous catheter (CVC) in three (3) out of three (3) observations. The findings: A review of facility’s 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 ... Upon completion of Dialysis ... 34. ...Scrub the sides, threads and end of the hub thoroughly with friction for 15 seconds.” While disconnecting patient (MR) 1 at station #3 from treatment on July 21, 2025, at 10:23 A.M., employee (EMP) 8 wiped each CVC hub in a circular motion with an alcohol prep pad for approximately five (5) seconds. During an observation at 10:51 A.M. on July 21, 2025, while disconnecting MR2 from treatment, EMP8 wiped each CVC hub for approximately four (4) seconds. During an observation at 4:23 P.M. on July 21,2025, EMP10 wiped each CVC hub for approximately five (5) seconds when disconnecting MR13 at station #10 from treatment. During an interview on June 21, 2025, at 8:17 A.M., EMP7 indicated that the CVC hubs should be scrubbed for fifteen (15) seconds, as per facility’s policy. During an interview on July 22, 2025, EMP1 agreed that CVC hubs should be scrubbed for 15 (fifteen) seconds, per policy, when discontinuing treatment.”

“CARBON ADSORP-MONITOR, TEST FREQUENCY CFR(s): 494.40(a) 6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly. This Standard is not met as evidenced by: 40084 Based on interviews, personnel record reviews, and facility document review, it was determined the facility failed to document facility staff (EMP) were screened for color blindness, per facility policy, for four (4) of fourteen (14) personnel files. The findings: The facility’s policy entitled “Color Vision Evaluation,” policy 8-02-03, revision date October 2017, reads, in part: ...”Policy: 1. Teammates/patients/helpers who will be utilizing test kits or strips that rely on color differentiation for test results will be evaluated for ability to see color. Color blindness testing is performed at time of hire. 2. Only DaVita approved color blind testing material will be utilized if screening is performed at the facility. A teammate/patient/helper may provide documentation of color blind testing by an outside physician or optometrist. 3. The Facility Administrator/Program Manager/designee is responsible for assuring that the appropriate teammates are evaluated for ability to see color. 4. Documentation of the color vision evaluation will be documented in the teammate’s file and/or patient’s medical record. 5. Only teammates/patients/helpers who can discern the colors displayed by a particular test strip or kit will perform testing” A review of the personnel file worksheet for the facility on July 22, 2205, at 8:45 A.M. indicated four (4) EMPs, EMP8, EMP10, EMP11 and EMP18, did not have documented dates for color blindness screening. The surveyor requested additional information but EMP7 indicated no additional information could be located. On July 22, 2025, EMP7 indicated that all appropriate personnel, based on the job description, should be tested for color blindness and that information documented in their personnel file.”

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 49355 Based on observations, interviews and document review, it was determined the facility failed to insure that patient treatment chairs are maintained to allow for effective cleaning and disinfection. Specifically, three (3) dialysis chairs currently in use on the treatment floor were observed to have torn/cracked upholstery. The findings: The facility’s policy entitled, “Infection Control for Dialysis Facilities,” policy 1-05-01, revision April 2023, reads, in part: ... “Disinfection ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair...)....” During morning observations on the treatment floor on July 22, 2025, a minimum of three (3) dialysis chairs were noted to have upholstery tears/cracks. The treatment chairs at station #11, station #12 and station #15 had a tear/crack in the seats upholstery. The remainder of the chairs were occupied and therefore this surveyor was unable to inspect them. At an interview at approximately 3:15 P.M. on July 22, 2025, employee (EMP) 7 and EMP16 indicated that treatment chairs with torn upholstery could not be sufficiently disinfected and should be pulled from the treatment floor until repaired or replaced.”

“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, interview and documentation review, it was determined the facility failed to document a quarterly note by the social worker to evaluate a home peritoneal dialysis (HPD) patient’s psychosocial health status, per policy, in one (1) out of eight (8) medical records reviewed, Patient (MR) 12. The findings: The review of the facility’s Peritoneal Dialysis Policies and Procedures document entitled, “Provision of Social Services,” policy 5-15-03, revision date October 2020, reads, in part ... “3. The services provided will include: ... Documenting the patient’s progress quarterly or more frequently as needed in the medical record.” A review of the medical record for MR12 on July 22, 2025, at 9:47 A.M., with the assistance of employee (EMP) 4, revealed the last documented social work note contained in the electronic medical record was dated March 5, 2025. EMP4 agreed the last documented social work note was as noted above and per policy, documentation of a note from the social worker should be present at least once quarterly.”

“PA-F/U REASSESSMENT-WITHIN 3 MO OF INITIAL CFR(s): 494.80(b)(2) A follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient’s plan of care specified in §494.90. This Standard is not met as evidenced by: 49355 Based on medical record reviews, interview and documentation review, it was determined the facility failed to document a three (3) month, ninety (90) day, comprehensive patient reassessment in one (1) out of eight (8) medical records reviewed, patient (MR) 11. The findings: A review of the facility’s policy entitled, “Incenter Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” policy 1-14-01, revision date October 2024, reads, in part: ... Policy: Assessment: ... 5. A follow up 90 day re-assessment will be completed to evaluate the patient’s status and provide information to adjust the patient’s plan of care.” The electronic medical record of MR11 was reviewed on July 22, 2025, with the assistance of EMP7. MR11 received their first treatment at the facility on February 12, 2025. There was no documentation of a 90-day, three month plan of care reassessment performed. EMP7 agreed that the reassessment was not present in the medical record.”

“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, document review and interviews, it was determined the facility failed to document abnormal findings and notification to the charge nurse of: 1) unmet target weights (TW) compared to post treatment weights (PTW) in two (2) out of eight (8) medical records reviewed; 2) blood pressure (BP) measurements outside of facility guidelines in one (1) out of eight (8) medical records reviewed; 4) heart rate/pulse (HPR) measurements outside of facility guidelines in two (2) out of eight (8) medical records reviewed; 3) and documentation of completed pre-treatment nursing assessments by the policy-specified time in two (2) out of eight (8) 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. ... 8. The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation.... ... 11. Abnormal finding or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to “Abnormal Findings” section in this policy). The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. ... 13. All findings, interventions and patient response will be documented in the patient’s medical record. ... 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. ... Fluid Status: ... Post-treatment: If patient is above or below 1 kg from the target weight ... Blood Pressure-Intradialytic: * Systolic greater than 180 mm/Hg or less than 90 mm/Hg * Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg ... Heart or Pulse Rate Pre/Intra/Post: * Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat.” A review of the following medical records revealed: Patient (MR) 1: Flowsheet dated July 7, 2025: heart/pulse rate (HPR) 42 beats per minute (bpm) at 11:02 A.M.; 56 bpm at 11:03 A.M.; 40 at 11:05 A.M.; and 51 bpm at 12:32 P.M. Updated notes were added one (1) hour later at 12:10 P.M. for 11:02 A.M. and 11:05 A.M. readings. No documentation at time of events. Flowsheet dated July 16, 2025: treatment start time was 10:02 A.M., documented nursing pre-assessment note completion was 2:53 P.M. Flowsheet dated July 18, 2025: HPR 38 bpm at 10:32 A.M.; 57 bpm at 10:47 A.M.; 53 bpm at 11:02 A.M.; 44 at 11:31 bpm; 38 bpm at 12:31 and 44 bpm at 1:01 P.M. No documentation was noted on the flowsheet. MR9: Flowsheet dated July 19, 2025: PTW was documented as 37.3 kg, TW was 36 kg, a deviation of 1.3 kg. No documentation was noted on the flowsheet. MR10: Flowsheet dated July 11, 2025: diastolic BP: 49 mm/Hg at 12:33 P.M.; 41 mm/Hg at 1:02 P.M.; 45 mm/Hg at 1:32 P.M.; 49 mm/Hg at 2:02 P.M.; 42 mm/Hg at 2:32 P.M.; and 48 mm/Hg at 3:03 P.M. No documentation was noted on the flowsheet. Flowsheet dated July 16, 2025: diastolic BP: 46 mm/Hg at 11:26 A.M.; 47 mm/Hg at 12:02 P.M.; 44 mm/Hg at 12:32 P.M.; 43 mm/Hg at 1:32 P.M.; 43 mm/Hg at 2:02; 40 mm/Hg at 2:40 P.M.; 40 mm/Hg at 3:04 P.M.; and 48 mm/Hg at 3:08 P.M. No documentation was noted on the flowsheet. Flowsheet dated July 18, 2025: diastolic BP: 42 mm/Hg at 1:02 P.M.; 44 mm/Hg at 1:32 P.M.; and 45 at 2:47 P.M. No documentation was noted on the flowsheet. MR11: Flowsheet dated June 30, 2025: HPR 104 bpm at 5:03 P.M.; and 102 bpm at 6:03 P.M. No documentation was noted on the flowsheet. Treatment start time was 2:52 P.M., documented nursing pre-assessment note completion was 5:36 P.M. Flowsheet dated July 4, 2025: PTW was documented as 71.1 kg, TW was 70 kg, a deviation of 1.1 kg. No documentation was noted on the flowsheet. HPR 102 bpm at 5:31 P.M.; and 107 bpm at 5:57 P.M. No documentation was noted on the flowsheet. Flowsheet dated July 8, 2025: HPR 106 bpm at 11:48 A.M.; 102 bpm at 2:02 P.M.; 105 bpm at 3:02 P.M.; and 101 bpm at 3:22 P.M. No documentation was noted on the flowsheet. Flowsheet dated July 12, 2025: treatment start time was 3:03 P.M., documented nursing pre-assessment note completion was 4:26 P.M. Flowsheet dated July 14, 2025: HPR 102 bpm at 5:03 P.M.; 106 bpm at 5:33 P.M.; 110 bpm at 6:03 P.M.; and 119 bpm at 6:33 P.M. No documentation was noted on the flowsheet. Flowsheet dated July 18, 2025: PTW was documented as 71.3 kg, TW was 70 kg, a deviation of 1.3 kg. No documentation was noted on the flowsheet. HPR 105 bpm at 6:02 P.M.; and 110 bpm at 6:35 P.M. No documentation was noted on the flowsheet. Treatment start time was 3:03 P.M., documented nursing pre-assessment note completion was 4:31 P.M. During an interview on July 21, 2025, EMP12 indicated that pre-assessment nursing notes should be completed within one (1) hour from the start of treatment and any unmet target weights or abnormal BP readings or HPR should be documented in the flowsheet and the charge nurse notified. During a joint interview on July 22, 2025, at 10:05 A.M., EMP1 and EMP2 indicated the expectation is that any abnormal measurement should be documented in the flowsheet and the charge nurse notified immediately. Both also verbalized pre-assessment nursing notes should be completed within one (1) hour of the start of treatment.”

“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: 49355 Based on medical record reviews, interviews and document review, it was determined the facility failed to follow physician’s orders and failed to document the reason for the deviation for: 1) prescribed blood flow rate (BFR) and/or dialysate flow rate (DFR) for two (2) out of eight (8) records reviewed 2) and/or decreased length of treatment times shorter than the prescribed duration without documentation and/or a completed Against Medical Advice form in two (2) out of eight (8) 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: ... “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.... Prescription components include but are not necessarily limited to: ... b. Treatment time ... f. Blood flow rate g. Dialysate flow rate ... 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. ... 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. ... 17. Licensed nurse will use their clinical judgement 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.” The facility’s policy entitled, “Prescribed Treatment Time Not Met, policy 1-01-09, revision date April 2024, reads, in part: ... “A. Completion of the Early Termination of Treatment Against Medical Advice Form 1. The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. ... 3. The RN will obtain the patient’s signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient’s signature prior to rinse-back, the RN will obtain the patient’s signature on the form prior to the patient’s departure from the facility. 4. A RN must countersign all Early Termination of Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 5. If a patient refuses to sign the Early Termination of Treatment Against Medical Advice form, the RN will document the patient’s refusal with the words “patient refused” in the patient signature box along with the date. Under such circumstances, the RN will sign the form and will also obtain a witness’ signature on the form. 6. This applies only to shortened treatments. ... B. Prescribed Treatment Time Not Met 1. If the shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs. NOTE: Shortened/Early Termination of dialysis treatment includes all reasons the prescribed dialysis time is not met by 30 or more minutes. ... 3. If a patient’s treatment is shortened/early terminated, the RN will document the event in the patient’s electronic health record. Documentation will include, as appropriate: * The amount of time by which the treatment was shortened * A description of why the treatment was shortened * Whether the patient’s nephrologist was notified * A description of the follow-up medical orders provided by the patient’s attending nephrologist (if any) * A description of all other interventions planned to address the shortened treatment, including recommendation to the patient. ... 5. Additionally, if the patient’s dialysis treatment is terminated 30 or more minutes prior to the ordered treatment length, the reason must be documented in the patient electronic health record at the time the treatment was terminated while reconciling the treatment times. ... 6. The Meetings (FHM), as appropriate.” A review of the following medical records revealed: Patient (MR) 8: Flowsheet dated July 8, 2025: prescribed treatment duration 210 minutes, actual treatment duration 193 minutes, a deviation of 17 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent from the medical record. Flowsheet dated July 10, 2025: prescribed treatment duration 210 minutes, actual treatment duration 150 minutes, a deviation of 60 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent from the medical record. MR9: Flowsheet dated July 10, 2025: prescribed DFR 700 ml/min, actual DFR was 0 ml/min for the first 139 minutes of the 210 minute treatment and then increased to prescribed rate. No documentation noted in the flowsheet. Flowsheet dated July 12, 2025: prescribed DFR 700 ml/min, actual DFR was 0 ml/min for the first 172 minutes of the 210 minute treatment an then increased to prescribed rate. No documentation noted in the flowsheet. Flowsheet dated July 14, 2025: prescribed DFR 700 ml/min, actual DFR was 0 ml/min for the first 106 minutes of the 210 minute treatment and then increased to prescribed rate. No documentation noted in the flowsheet. Flowsheet dated July 17, 2025: prescribed DFR 700 ml/min, actual DFR was 0 ml/min for the first 123 minutes of the 210 minute treatment and then increased to prescribed rate. No documentation noted in the flowsheet. MR11: Flowsheet dated June 30, 2025: prescribed BFR 350 ml/min, actual BFR was 400 ml/min for the final 167 minutes of the 210 minute treatment. No documentation noted in the flowsheet. Flowsheet dated July 4, 2025: prescribed treatment duration 210 minutes, actual treatment duration 178 minutes, a deviation of 32 minutes. No documentation was noted in the flowsheet and a completed AMA form was absent from the medical record. Flowsheet dated July 11 2025: prescribed BFR 350 ml/min, actual BFR was 300 ml/min for 90 minutes of the 210 minute treatment and then increased to prescribed rate. No documentation noted in the flowsheet. During an interview on July 21, 2025, EMP12 indicated any deviation from the prescribed values should be documented and the charge nurse notified. During a joint interview on July 22, 2025, at 10:05 A.M., EMP1 and EMP2 indicated any deviation from the prescribed values for BFR, DFR and/or shortened length of treatment should be documented in the flowsheet and the charge nurse notified.”

“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, interviews 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, facility staff (EMP) touched the cannulation sites of arteriovenous (AV) fistulas/grafts after the insertion sites were prepped with antiseptic. The findings: The facility’s procedure entitled, “AV Fistula or Graft Cannulation with Nipro or Medisystms 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 contamination.” On July 21, 2025, at 11:16 A.M., EMP9 palpated patient (MR) 25’s AV fistula site at station #7 after cleansing the area with antiseptic and did not recleanse the area before accessing the site. During a joint interview on July 22, 2025, at 10:05 A.M., EMP1 and EMP2 indicated the site should be recleansed after palpating and before cannulating and not touched again.”

“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 facility document review and interview, 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 eight (8) medical records reviewed, patient (MR) 7 and MR8. The findings: A review of the facility’s policies entitled, “Incenter Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” and “Peritoneal Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” each revised October 2024 state, in part: ... “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.... ... Modality Change - within 30 days of change in modality (or within 13 treatments)” The electronic medical record of MR7, a home peritoneal dialysis patient (HPD), was reviewed on July 22, 2025, with the assistance of facility staff (EMP) 4. MR7 had transitioned from in-center hemodialysis to HPD, receiving their first treatment on June 13, 2025. A POC located in the record was dated April 2, 2025, but covered the time when MR7 was receiving in-center hemodialysis treatment. There was no documentation of a new 30-day POC, due to the change in modality, in the electronic medical record. EMP11 agreed the new POC was not present in the medical record and should have been completed within thirty (30) days of MR7 starting HPD treatments. The electronic medical record of MR8, an in-center hemodialysis (ICHD) patient, was reviewed on July 22, 2025, with the assistance of EMP7. MR8 received their first treatment on May 15, 2025. There was no documentation of an initial 30-day POC in the electronic medical record. EMP7 confirmed there was no documentation of an initial POC for MR8 and the POC for MR11 was over 30-days past the start of treatment date.”

“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, 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 eight (8) medical records reviewed, patient (MR) 8. The findings: The facility’s 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.” A review of the medical record for MR8 on July 22, 2025, with the assistance of facility staff (EMP) 7, did not reveal any physician notes. MR8 started dialysis treatments on May 15, 2025. EMP7 confirmed the lack of physician notes in the record and indicated that a physician note should be documented for each patient once monthly, at the minimum.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 40084 Based on interview and record review, it was determined the facility’s Quality Assurance and Performance Improvement (QAPI) program failed to take action to ensure sustained improvement over time. Specifically, the QAPI program failed to correct known issues related to emergency preparedness, cleaning the dialysis station, central venous catheter (CVC) care, abnormal findings, dialysis prescription adherence, initial plan of care (POC), and monthly practitioner documentation. The findings include: Emergency Preparedness Current Recertification Survey Based on observation, interview, and document review, it was determined the facility failed to secure patients protected health information (PHI) and medications in the home modality evacuation kit with a breakaway lock, as per the facility’s policy. Based on observation, interview and document review, it was determined the facility failed to include treatment orders for all home peritoneal dialysis (HPD) patients and failed to maintain current updated copies of patients’ treatment orders in the evacuation kit of the home modality area of the facility, as per policy. Recertification Survey Ending August 3, 2022 Based on observation, interviews, and document review, it was determined the facility failed to secure and protect the confidentiality of patient information in the evacuation kits as per the facility’s policy. Based on observation, interviews, and document review, it was determined the facility failed to maintain an updated copy of the patient’s treatment orders in the evacuation kit as per facility policy. Tag V-0122 Current Recertification Survey Based on infection control observations and document review, it was determined the facility failed to ensure dialysis stations and chairs were completely disinfected prior to bringing clean supplies to the station. The facility also failed to immediately clean up and disinfect three (3) blood drips in front of an occupied dialysis chair. Recertification Survey Ending August 3, 2022 Based on four (4) infection control observations and document review, it was determined that the facility staff failed to ensure dialysis stations and chairs were appropriately disinfected between patients to reduce the risk of spreading infectious agents. Tag V-0147 Current Recertification Survey Based on observation, interviews and document review, it was determined the facility failed to follow appropriate infection control measures, per policy, when providing care to a central venous catheter (CVC) in three (3) out of three (3) observations. Recertification Survey Ending August 3, 2022 Based on observation and document review, it was determined the facility staff failed to maintain aseptic technique when accessing the central venous catheter (CVC) for one (1) of two (2) patients observed. Tag V-0543 Current Recertification Survey Based on medical record reviews, document review and interviews, it was determined the facility failed to document abnormal findings and notification to the charge nurse of: 1) unmet target weights (TW) compared to post treatment weights (PTW) in two (2) out of eight (8) medical records reviewed; 2) blood pressure (BP) measurements outside of facility guidelines in one (1) out of eight (8) medical records reviewed; 4) heart rate/pulse (HPR) measurements outside of facility guidelines in two (2) out of eight (8) medical records reviewed; 3) and documentation of completed pre-treatment nursing assessments by the policy-specified time in two (2) out of eight (8) medical records reviewed. Recertification Survey Ending August 3, 2022 Based on medical record and policy review, it was determined that the facility staff failed to: document notification to the registered nurse of abnormal blood pressure for four (4) of six (6) patients sampled; and document notification to the registered nurse or physician of target weight not being met for five (5) of six (6) patients sampled. Tag V-0544 Current Recertification Survey Based on medical record reviews, interviews and document review, it was determined the facility failed to follow physician’s orders and failed to document the reason for the deviation for: 1) prescribed blood flow rate (BFR) and/or dialysate flow rate (DFR) for two (2) out of eight (8) records reviewed 2) and/or decreased length of treatment times shorter than the prescribed duration without documentation and/or a completed Against Medical Advice form in two (2) out of eight (8) medical records reviewed. Recertification Survey Ending August 3, 2022 Based on medical record and policy 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 two (2) of six (6) patients sampled; and administer the prescribed order for the dialysate flow rate (DFR) for one (1) of six (6) patients sampled. Tag V-0557 Current Recertification Survey Based on facility document review and interview, 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 eight (8) medical records reviewed, patient (MR) 7 and MR8. Recertification Survey Ending August 3, 2022 Based on interviews and document review, it was determined the facility staff failed to ensure the initial plan of care (POC) was completed within thirty (30) days after admission to the dialysis facility or thirteen (13) outpatient hemodialysis sessions beginning with the first outpatient dialysis session for two (2) of six (6) patients sampled. Tag V-0560 Current Recertification Survey Based on medical record review, 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 eight (8) medical records reviewed, patient (MR) 8. Recertification Survey Ending August 3, 2022 Based on interviews and document review, it was determined the facility staff failed to ensure that dialysis patients were seen by a physician, nurse practitioner, clinical nurse specialist or physician’s assistant providing ESRD care at least monthly for three (3) out of six (6) patients sampled.”