Davita Chantilly Dialysis

“IC-IF TO STATION=DISP/DEDICATE OR DISINFECT CFR(s): 494.30(a)(1)(i) Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient’s station should be used only for that patient and should not be returned to a common clean area or used on other patients. This Standard is not met as evidenced by: 42929 Based on two (2) infection control observations, interview, and facility document review, it was determined the facility failed to disinfect items used for patient care before returning the items to a common clean area. Findings: The facility’s policy titled “Infection Control for Dialysis Facilities” revised April 2023 states in part: ... 7. a. Gloves should be changed when: iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system.... 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. If item cannot be cleaned and disinfected it will be dedicated for use on a single patient.... On July 8, 2024, at 11:06 a.m. the surveyor observed Staff Member #14 use a marker to write on the syringe attached to the occupied patient station #4 and then without changing gloves or disinfecting the marker, the staff member moved to station #3 to write on the syringe attached to the occupied patient station, then proceeded to place the marker on the computer table without disinfecting. On July 8, 2024, at 11:40 a.m. Staff Member #9 used a thermometer to take a patient’s temporal temperature and then placed the thermometer back on the computer table without cleaning the thermometer. On July 9, 2024, at 1:30 p.m., Staff Member #1 and Staff Member #12 agreed that non-disposable items should be disinfected between patients and before being returned to clean common areas.”

“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: 42929 Based on three (3) infection control observations, interviews, and facility document review, it was determined the facility staff failed to clean and disinfect contaminated surfaces to prevent the risk of transmission of infectious diseases. Findings: The facility’s policy titled “Infection Control for Dialysis Facilities” revised April 2023, states in part: ... 7. a. Gloves should be changed when: ii. When going from a “dirty” area or task to a “clean” area or task ... iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient’s dialysis delivery system.... b. Dialysis station must be completely vacated by the previous patent before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station and set up for the next patient.... 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). 14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. If item cannot be cleaned and disinfected it will be dedicated for use on a single patient.... The facility’s procedure titled “Station/Training Room Disinfection” stated version 3, June 2021, states in part: ... Adequate number of towels should be brought to the area to be disinfected immediately before initiation of disinfection process i.e., not in advance ... On July 8, 2024, at 11:22 a.m. Staff Member #8 placed the “dirty” blood pressure cuff on the “dirty” dialysis chair and wiped one side of the cuff with the bleach wipe, then flipped the blood pressure cuff over and placed the side that was disinfected on the “dirty” chair so the staff member could wipe the other side of the cuff. Staff Member #8 failed to disinfect the emergency evacuation kit hanging on the back of the station’s television monitor and the sharps container when cleaning the station. On July 8, 2024, at 11:26 a.m. Staff Member #8 removed the prime waste container from the “dirty” dialysis machine, dumped the contents into the dirty sink, dunked the prime waste container into the bleach mixture that contained clamps and hemostats, then swirled the bleach in the prime waste bucket, emptied the bucket, and then returned it to the machine. On July 8, 2024, at 2:47 p.m. Staff Member #9 placed bleach wipes on the bottom of the dialysis machine of a patient who was awaiting removal of a needle while the patient was still in the dialysis chair at the end of treatment.”

“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: 42929 Based on interviews, personnel record reviews, and facility document review, it was determined the facility failed to ensure staff were screened for hepatitis B for three (3) of four (4) personnel files reviewed. Findings: The facility’s policy titled “Teammate Hepatitis B Monitoring and Follow-Up Guidance” revised April 2024, states in part: 1. New teammates who are not able to provide documentation of hepatitis B surface antibodies of 10mlU/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. The personnel record for Staff Member #3 revealed that Staff Member #3’s hire date was January 3, 2022, and the staff member signed a hepatitis vaccine declination form on May 17, 2023, but there was no evidence that the staff member was screened for hepatitis B within ten (10) days of hire. The personnel record for Staff Member #4 revealed that Staff Member #4’s hire date was March 18, 2024, and the staff member was screened for hepatitis on June 5, 2024. The personnel record for Staff Member #4 revealed that Staff Member #16’s hire date was June 3, 2024, and there was no documentation that the staff member has been screened for hepatitis as of July 9, 2024. During an interview on July 9, 2024 at 1:30 p.m., Staff Member #12 indicated that Staff Member #12 thought the policy meant that the new teammates should be screened for hepatitis within ten (10) days of “being on the treatment floor.” The surveyor reviewed the facility’s policy “Teammate Hepatitis B Monitoring and Follow-Up Guidance” regarding screening new teammates with Staff Member #12 and Staff Member #1.”

“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: 42929 Based on observations, interviews, and document review, it was determined the facility failed to ensure aseptic technique when preparing and administering medications. Specifically, the facility failed to include all of the necessary components of medication labeling. Findings: The facility’s policy titled “Medication Policy” revised October 2023, states in part: ... 20. ... If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of teammate preparing the medication... On July 8, 2024, at 10:28 a.m. the surveyor observed five (5) heparin filled syringes on the counter across from station #8 with no time or initials noted on the label. On July 9, 2024, at 1:30 p.m., Staff Member #12 agreed that the medication filled syringes should be labeled with the time and teammates initials.”

“PR-RECEIVE UNDERSTANDABLE INFORMATION CFR(s): 494.70(a)(2) The patient has the right to- (2) Receive all information in a way that he or she can understand; This Standard is not met as evidenced by: 36946 Based on staff interview and medical record review, it was determined the facility failed to ensure each patient received information in a language the patient could understand in one (1) of one (1) medical record reviewed of a non-English speaking patient (Medical record #5). Findings: The medical record for Patient #5 contained documentation that the patient spoke Farsi as a primary language and had no secondary language documented. All documents that were signed by the patient in the patient record to include patient consent forms, emergency preparedness procedures, and care plan updates were written in English and signed by the patient. No documentation in the medical record indicated information regarding the patient’s care was presented to the patient in Farsi. No documentation in the medical record indicated that a translator was used when discussing clinical information with the patient. An interview was conducted with staff member #1 on 07/09/24 who stated that the facility had some forms that were available in Spanish and frequently encountered languages, but the facility had no forms that were translated into Farsi. Staff Member #1 stated that the language line could be used to communicate with the patient in Farsi. Staff Member #1 confirmed that no documentation in the medical record indicated a language line was used with the patient. Staff Member #1 stated the facility has a tech who speaks Farsi and can interpret for the patient. Staff Member #1 confirmed the tech was not a qualified interpreter. The facility’s policy, Communication with persons with limited English proficiency was reviewed and reads in part: Language assistance services will be provided either through: (i) use of a teammate who is a Qualified Interpreter or (ii) use of a formal contractual arrangement with an approved external vendor providing Interpretation of Translation services....D. DaVita will conduct a regular review of the language access needs of our patient population, and update the services offered as necessary...F. Providing Written Translation 1. Vital Documents will be made available to patients in their primary language either frequently encountered by the facility or specifically requested by the patient. When Translation of Vital Documents is needed and is not readily available to the facility, the facility will reach out to a Davita approved vendor to request the Translation of the needed document. Documents submitted for translation must be in final, approved form with updated and accurate legal and medical information. 2. Facilities will provide translation of other written facility materials if needed, as well as written notice of the availability of that translation, free of charge, for LEP (limited English proficiency) individuals...A document will be considered vital if it contains information that is critical for obtaining federal services and/or benefits, meaningful access or participation a service/program, or is required by law.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the facility failed to ensure each patient’s comprehensive assessment included an accurate evaluation of current health status and medical condition in one (1) of five (5) medical records reviewed in the survey sample (Medical record #5). Findings: An interview was conducted with Staff Member #8 during the flash tour on 07/08/2024. Staff Member #8 reported that Patient #5 pulls at their lines and had just pulled them out again last week. Staff Member #8 reported the social worker stated that the patient does not qualify for an attendant to sit with the patient during dialysis. Staff Member #8 was unsure what if any interventions had been put in place to keep patient from pulling at their lines. The comprehensive assessment and care plan for the patient that was last updated May 07, 2024 failed to include any interventions related to keeping the patient from pulling at their lines; failed to include any information related to this new behavior; failed to include any documentation that the risks of pulling out dialysis lines were discussed with patient or his/her representative. Outside hospital records from 2019 contained documentation that Patient #5 had a diagnosis of dementia. The dialysis physician documented in a progress note on 04/29/24 that Patient #5 was “pleasantly demented.” The patient’s comprehensive assessment last updated May 07, 2024 contained no documentation of the patient’s comorbid dementia diagnosis. A heading in the assessment labeled “Comorbidities” contained the following: “No documentation provided.” The assessment also states that the patient has no barriers to a home modality despite the fact that no documented discussion regarding modality education was present in the medical record. The assessment contained no documentation regarding the patient’s mental status other than documentation indicating the patient had a poor understanding of their illness. It was unclear from the assessment whether or not the patient’s understanding was poor due to information not be presented to the patient in a language they could understand (Patient only speaks Farsi) or due to cognitive deficits. Despite having a dementia diagnosis the assessment did not indicate if the patient had capacity to make decisions nor did it address who could make decisions on behalf of the patient. Staff Member #1 was interviewed on 07/09/24 and confirmed the patient’s comprehensive assessment was incomplete and did not contain accurate documentation of the patient’s medical status and comorbid conditions. The facility’s policy Interdisciplinary team (IDT) Patient Assessment and Plan of Care was reviewed and reads in part: Assessment criteria will include , but not be limited to, evaluation of: Current health status and medical condition, including co-morbid conditions...psychosocial needs by a social worker.”

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the facility failed to ensure each unstable patient’s care plan was revised at least monthly for unstable patients in one (1) of one (1) unstable patient record reviewed in the survey sample (Medical record #5). Findings: The interdisciplinary team identified Patient #5 as being unstable due to unanticipated weight loss on 05/07/24. The medical record failed to contain any documentation of subsequent updates to the plan of care. An interview was conducted on 07/09/24 with Staff Member #1 who confirmed Patient #5 should have had comprehensive reassessment and updated plan of care in June and July and these updates had not been completed. The facility’s policy, Interdisciplinary Team (IDT) Patient Assessment and Plan of Care was reviewed and reads in part: 21. Implementation of assessments and plans of care are detailed in the table below: Monthly (unstable patients) Assessment: Monthly until patient is determined by interdisciplinary team to be stable...Plan of Care: Complete patient plan of care meeting within 15 days of the completion of the re-assessment and plan of care.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the facility failed to ensure each patient received services as ordered in their plan of care in one (1) of five (5) medical records reviewed in the survey sample ( Medical Record #1). Findings: The medical record for Patient #1 contained documentation that the patient was ordered heparin with each dialysis treatment after the patient’s line clotted on 07/01/24. The record contained documentation that the patient refused all or part of the heparin dose on 07/01/24, 07/03/24, 07/05/24, and 07/08/24. Documentation from the technician indicated the patient refused the heparin for “personal reasons.” There was no documentation in the record that the nurse or the physician was ever notified the patient refused the heparin. The physician documented on 07/1/24 that the patient was receiving 1000 units (loading dose) of heparin and 800 units per hour of heparin. There was no documentation from the physician that indicated he/she was aware the patient had not received the medication as ordered. An interview was conducted with Staff Member #1 during record review on 07/09/24 who confirmed the lack of documentation the record that the nurse or physician was made aware the heparin was not given as ordered.”

“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: 36946 Based on interviews and document review, it was determined that the facility staff failed to ensure the Registered Nurse (RN) was notified when patient’s post treatment weight was above or below 1 kg from target weight for three (3) of four (4) in-center hemodialysis patient records reviewed in the survey sample (Medical record #’s 1, 2, and 4). Additionally, the facility failed to ensure the RN was notified of an abnormal blood pressure in one (1) of four (4) in-center hemodialysis records reviewed in the survey sample (Medical record #4). Findings: The medical record for Patient #1 contained a target weight of 88 kg. In six (6) of six (6) treatments completed between 06/24/24 and 07/05/24, the patient’s weight was documented at least one (1) kg over the target weight of 88 kg after treatment. The record contained no documentation that the RN was notified of the weight in any of the above noted six (6) treatments. The medical record for Patient #2 contained a documented target weight of 70.5 kg. The record contained documentation that the patient was more than 1 kg above the target weight after treatment in six (6) of six (6) treatments from 06/24/24-07/03/24. The record failed to contain evidence that the nurse was notified of the increased post treatment weight. The medical record for Patient #4 contained documented target weight of 91 kg. Six (6) treatment records were reviewed from the time period of 06/25/24 to 07/06/24. Documentation indicated the patient was over 1 kg above the target weight of 91 kg on 07/02/24 and 07/04/24. The medical record did not contain documentation that the nurse was notified of the increased weight. On 06/29/24 the patient’s blood pressure was documented 204/97 at 10:31 AM and on 07/02/24 at 10:32 AM the patient’s blood pressure was documented by the tech as 80/24. Neither blood pressure was documented as reported to the RN. An interview with Staff Member #1 on 07/09/24 revealed that post treatment weights greater than 1 kg above the target weight and abnormal blood pressures should be reported to the RN. 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. ...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.. 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... Post-treatment If patient is above or below 1 kg form 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...”

“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: 36946 Based on medical record review, facility policy review, and staff interview, it was determined the facility staff failed to document the reason for, and notification to the registered nurse, of the change in blood flow rate (BFR) for two (2) of four (4) medical records of in-center hemodialysis patients records reviewed in the survey sample (Patient #’s 2 and 5). Findings: Six (6) treatment records for the time period 06/24/24-07/05/24 were reviewed for Patient #2. The medical record for patient #2 contained documentation of a provider’s order for a BFR of 350. On 06/29/24, the patient’s dialysis ran at a BFR of 315 from 10:01 AM - 12:33 PM. The medical record contained no documentation of why the BFR was not at the ordered rate or that the nurse was notified the BFR was not as ordered by the provider. Six (6) treatment records for Patient #5 were reviewed from the time period of 06/24/24 to 07/05/24. The patient had a provider ordered BFR of 450. The BFR was not running as ordered from 12:05 PM - 1:40 PM on 06/26/24. The medical record contained no documentation of why the BFR was not as ordered or that the RN was notified. 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 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. 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...”

“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: 42929 Based on observation, interviews, and document review, it was determined facility staff failed to maintain asepsis prior to accessing an arteriovenous (AV) fistula in one (1) of three (3) observations involving the care of an AV fistula or graft Findings: A review of the facility procedure, “AV FISTULA OR GRAFT CANNULATION WITH NIPRO OR MEDISYSTEMS SAFETY FISTULA NEEDLES (SFN) AND ADMINISTRATION OF HEPARIN LOADING DOSE,” revised October 2022, states in part: ... 11. While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry.... 13. Do not palpate insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation. ... On July 8, 2024, at 11:02 a.m. the staff member at station #5, a dialysis technician, accessed a patient’s AV fistula. The surveyor observed the dialysis technician wiping both access sites with alcohol. Then the technician touched both access sites immediately prior to inserting the needles without recleaning the access sites. On July 9, 2024, at 1:30 p.m. Staff Member #12 confirmed that the fistula access site should be recleaned after the technician palpates the skin.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 36946 Based on staff interview and document review, it was determined the facility failed to ensure each member of the interdisciplinary team signed the patient’s plan of care in one (1) of five (5) medical records reviewed in the survey sample (Medical record #4). Findings: The medical record for Patient #4 contained an initial plan of care dated 07/08/24. The plan of care failed to contain the signatures of the Registered Nurse, the patient, or the physician. The facility’s policy, Interdisciplinary team (IDT) patient assessment and plan of care was reviewed and reads in part: The patient’s plan of care will be completed by the facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative. An interview was conducted with Staff Member #1 on 07/09/24 who confirmed the lack of signatures on the patient’s care plan.”

“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: 36946 Based on staff interview and document review, it was determined the facility failed to ensure it implemented the initial plan of care within 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 in two (2) of five (5) medical records reviewed in the survey sample (Medical record #’s 1 and 4). Findings: The medical record for Patient #1 contained documentation that the patient was admitted on 04/29/24. The initial plan of care should have been completed by 05/29/29. The initial care plan was not completed and implemented until 06/12/24. During record review, Staff Member #1 confirmed that the care plan was completed late. The medical record for Patient #4 contained documentation that the patient received the first treatment 05/16/24. The initial care plan should have been implemented by 06/16/24, but was not completed until 07/08/24. An interview was conducted with Staff Member #1 on 07/09/24 during record review who confirmed the care plan should have been completed before 07/08/24 and the patient had not missed any treatments.”

“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: 36946 Based on interviews and document review, it was determined the dialysis facility failed to ensure that all dialysis patients were seen by a physician, nurse practitioner, clinical nurse specialist or physician 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 in two (2) of five (5) patients reviewed in the survey sample (Medical record #’s 1 and 2). Findings: The medical record for patient #1 contained provider notes dated 05/06/24; 06/03/24; and 07/01/24. Each note contained the following fields: Fluid/BP; Adequacy; Anemia; Nutrition, Bone Mineral disorder; Transplant Status. Under each field the provider had documented the following: Clinical assessment at goal unless otherwise documented. There was no documentation related to “patient’s problems/needs, intervention, and response to intervention” as required by the facility’s policy. The medical record for patient #2 contained provider notes dated 05/06/24; 06/03/24; and 07/01/24. Each note contained the following fields: Fluid/BP; Adequacy; Anemia; Nutrition, Bone Mineral disorder; Transplant Status. Under each field the provider had documented the following: Clinical assessment at goal unless otherwise documented. There was no documentation related to “patient’s problems/needs, intervention, and response to intervention” as required by the facility’s policy. A review of the facility’s policy titled “Progress Note Policy” states in part: Purpose: To verify progress notes are documented by the Physician, Nurse, Dietitian, and Social Worker. Documentation needs to include treatment given or planned, patient encounters and the condition of the patient. Policy: 1. Progress notes are completed to verify documentation of patient’s problems/needs, intervention, and response to intervention and are expressed in a narrative format. Progress notes may be in an electronic or hand written format. 2. Progress notes are used to communicate information among various disciplines or to expand upon information or problems noted in other parts of the medical records, or obtained from other sources (consults, treatment records, etc.) 3. Progress notes will capture communications related to patient’s care that occur outside of the medical record (e.g. telephone, Secure Messaging, etc). 4. Progress notes should be readily accessible to every authorized member of the healthcare team. 5. All progress notes are to be dated and signed at the time they are written or entered electronically.... 7. Progress notes should demonstrate implementation of the plan of care, complete and pertinent information about condition of patient, and clearly portray the patient, the care and outcomes of that care. Physician: The attending Nephrologist is required to record progress notes at least monthly and for any clinical event, which must be recorded in a timeframe that provides other interdisciplinary team members with an up-to-date picture of the status of the patient at all times.... An interview was conducted with Staff Member #1 on 07/09/24 who confirmed the lack of meaningful content in the provider progress notes for the above noted patients.”

“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: 36946 Based on staff interview and document review, it was determined the facility failed to take action that resulted in performance improvement. Specifically, the facility failed to take actions to adequately address patients’ intradialytic weight gain from May 2023 - May 2024. Findings: The facility’s quality assessment performance improvement program data was reviewed for the previous 12 months. Documentation indicated the facility had not met its goal for excessive intradialytic weight gain since May of 2023. Data from May 2024 indicated that only 47 percent of patients had an acceptable amount of weight gain between treatments. The action plan for increased intradialytic weight gain was reviewed and found to be the same plan documented each month for the last 12 months without change and included the following interventions: “Focused counseling on sodium and fluid restriction using motivational interviewing as indicated. IDT (Interdisciplinary team) to review target weights routinely. Educate/encourage sodium/fluid restriction of less than 32 ounces a day for patients with target weight below 60 kg. Encouraged diabetic management and follow up with MD. Extra treatments, as needed. The plan failed to contain evidence that interventions and/or process improvement plans were ever changed after failing to meet facility goals for the last 12 months. An interview was conducted with Staff Member #1 on 07/09/24 who indicated that additional interventions have been put in place but have not been documented in the plan. The facility’s policy, Continuous Quality Improvement Program was reviewed and reads in part: 8. Continuous monitoring of the above indicators will be reflected in the meeting minutes. Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement, and will track this change in performance over time to verify improvements are sustained.”