Davita Merrimac Trail Dialysis

“IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient’s equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to ensure facility staff: wear gloves when touching patient’s equipment at the dialysis station for one (1) of five (5) Staff Members (SM), SM # 3; perform hand hygiene after glove removal for one (1) of five (5) SM, SM # 3; and perform hand hygiene after touching the face mask for two (2) of five (5) SM, SM # 5 and # 6. The findings include: On July 9, 2024 between 10:00 AM and 12:00 PM, the following observations were made during the initiation and termination of dialysis treatment: At 10:12 AM, SM # 3 was observed at Station # 11 adjusting the dialysis machine while only wearing one glove. SM # 3 failed to perform hand hygiene after removing the one glove and then began typing on the “clean” rolling computer. At 10:16 AM, SM # 6 was observed at the medication preparation area wearing a face mask below the chin. SM # 6 pulled the mask up above the nose by touching the front of the face mask and failed to perform hand hygiene. SM # 6 then pulled the mask back down below the chin by touching the front of the face mask and failed to perform hand hygiene. At 10:23 AM, SM # 3 was observed at Station # 11 adjusted the dialysis machine. SM # 3 failed to perform hand hygiene after removing gloves and before continuing patient care. At 10:30 AM, SM # 5 was observed at Station # 13 wearing the face mask below the chin. SM # 5 pulled the mask up above the nose by touching the front of the face mask and failed to perform hand hygiene before continuing patient care. At 10:41 AM, SM # 3 was observed at Station # 11. SM # 3 failed to perform hand hygiene after removing gloves and before continuing patient care. Center for Disease Control (CDC) guidelines include: “Hands should be washed before applying mask and after removing the mask”. On July 10, 2024 at 2:30 PM, a review of the facility’s policy titled “Infection Control” reads in part “Hand Hygiene: All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene prior to gloving and immediately after removal of gloves”. Facility guidance for face masks included “How to put on your mask: secure ties or elastic bands around ears or at middle of head and neck depending on style, fit flexible band to bridge of nose, and fit mask snug to face and around chin. How to remove PPE (personal protective equipment): the front of your mask is considered dirty. If hands become contaminated during the removal, perform hand hygiene. Remove your surgical mask by the ear loops.” On July 10, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 11 and # 12 during the exit interview.”

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to ensure facility staff wear face masks correctly for two (2) of five (5) Staff Members (SM), SM # 5 and # 6. The findings include: On July 9, 2024 between 10:00 AM and 12:00 PM, the following observations were made during the initiation and termination of dialysis treatment: At 10:16 AM, SM # 6 was observed at the medication preparation area wearing a face mask below the chin. SM # 6 pulled the face mask up above the nose and then SM # 6 pulled the mask back down below the chin. At 10:30 AM, SM # 5 was observed at Station # 13 wearing the face mask below the chin. SM # 5 pulled the mask up above the nose. On July 10, 2024 at 2:30 PM, a review of the Facility guidance for face masks included “How to put on your mask: secure ties or elastic bands around ears or at middle of head and neck depending on style, fit flexible band to bridge of nose, and fit mask snug to face and around chin. How to remove PPE (personal protective equipment): Remove your surgical mask by the ear loops.” On July 10, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 11 and # 12 during the exit interview.”

“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: 34452 Based on observations, document reviews and interviews, it was determined that the facility failed to ensure items (stethoscopes) taken to the dialysis stations were cleaned and disinfected before taken to a common clean area for one (1) of five (5) Staff Members (SM), SM # 4. The findings include: On July 9, 2024 between 10:00 AM and 12:00 PM the following was observed during initiation and termination of treatments: At 10:15 AM, SM # 4 was observed at Station # 13. SM # 4 used the stethoscope to assess the Patient’s access site. SM # 4 failed to clean and disinfect the stethoscope after use and before placing it on the clean counter. On July 10, 2024 at 2:30 PM, a review of the facility’s policy titled “Infection Control” reads in part “Non-disposable items are to be disinfected after each patient use. Stethoscopes will be disinfected with alcohol prep pad and/or 1:100 (one to one hundred).” On July 10, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 11 and # 12 during the exit interview.”

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to ensure facility staff clean contaminated surfaces for one (1) of one (1) Staff Member (SM), SM # 4. The findings include: On July 9, 2024 between 10:00 PM and 12:00 PM the following was observed during initiation and termination of treatments: At 10:15 AM, SM # 4 was observed at Station # 13. SM # 4 placed a dirty stethoscope on the counter after use, and failed to clean and decontaminate the counter. At 10:30 AM, Patient (P) # 8 at Station # 13 was observed exiting the facility post treatment. P # 8 placed dirty belongings on the clean counter near the scale. No staff member cleaned and decontaminated the counter. On July 10, 2024 at 2:30 PM, a review of the facility’s policy titled “Infection Control” reads in part “Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible.” On July 10, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 11 and # 12 during the exit interview.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 41450 Based on staff interview and facility documentation review, the facility staff failed to provide Hepatitis B vaccines for two (2) of nine (9) staff members (SM), SM #5 and SM #9. The findings include: On 7/10/24 at approximately 11:00 AM, staff record reviews were conducted and revealed the following 2 staff had no documentation of Hepatitis B immunization, to include current Hepatitis B vaccination or antibody status: SM #5, hired on 2/19/24, SM #9, hired on 10/10/23. In an interview at approximately 1:30 PM, SM #1 confirmed the findings and stated, “It is my expectation for all personnel to be screened for HBV [Hepatitis B Virus] at the time of hire as part of our onboarding process.” Review of the facility’s policy titled, “Teammate Hepatitis B Monitoring and Follow-Up Guidance”, revision date April 2024, subtitle, “Policy”, item 1, read, “New teammates ...will be screened for hepatitis B surface antigen (HBsAg) and hepatitis B surface antibody (anti-HBs) within 10 days and offered the vaccination as indicated by their results”.”

“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: 34452 Based on observation, document review and interview, it was determined that the facility failed to ensure facility staff use aseptic technique for preparing intravenous medications from vials for one (1) of one (1) Staff Member (SM), SM # 6. The findings include: On July 9, 2024 between 10:00 AM and 12:00 PM, the following observations were made during the initiation and termination of dialysis treatment: At 10:25 AM, SM # 6 was observed preparing medications in the medication preparation area. SM # 6 failed to clean the top of the vial with alcohol before piercing with the needle. On July 10, 2024 at 2:30 PM, a review of the facility’s policy titled “Medication” reads in part “All teammates administering medications must utilize aseptic technique.” Guidance for best practice by ANA (American Nurses Association) includes “wipe the access diaphragm (septum) with 70% alcohol before piercing the vial.” On July 10, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 11 and # 12 during the exit interview.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 34452 Based on document reviews and interviews, it was determined that the facility staff failed to evaluate and ensure the dialysis prescription was administered as ordered by the Physician for two (2) of seven (7) Patients (P), P # 5 and P # 6. The findings include: On July 10, 2024 between 9:00 AM and 12:00 PM, clinical record reviews revealed the following: P # 5- The flowsheet dated June 20, 2024 revealed the Physician ordered blood flow rate (BFR) was 400. Documentation from 12:01 PM through 1:10 PM revealed the BFR was 315. There was no documentation of the reason for the decreased BFR or that the Registered Nurse (RN) or Physician was notified. The flowsheet dated July 2, 2024 revealed the Physician ordered blood BFR was 400. Documentation from 11:31 AM through 1:46 PM revealed the BFR was between 300 and 350; 1:48 PM through 3:32 PM the BFR was 300. There was no documentation of the reason for the decreased BFR or that the RN or Physician was notified. P # 6- The flowsheet dated July 4, 2024 revealed the Physician ordered BFR was 450. Documentation from 6:24 AM through 9:54 AM revealed the BFR was 375. There was no documentation of the reason for the decreased BFR or that the RN or Physician was notified. On July 10, 2024 at 2:30 PM, a review of the facility’s policy titled “Pre-Intra-Post treatment” reads in part “blood flow rate is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one hour of treatment initiation. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” On July 10, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 11 and # 12 during the exit interview.”

“PA-ASSESS B/P, FLUID MANAGEMENT NEEDS CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs. This Standard is not met as evidenced by: 34452 Based on observation, document reviews and interviews, it was determined that the facility failed to ensure: patient weights were obtained by staff pre and post treatment for two (2) of two (2) Patients, P # 6 and # 8; standing blood pressure were obtained pre and post treatment for four (4) of seven (7) Patients, P # 1, # 3, # 4 and # 5; treatment data to include blood pressures were documented every 30 minutes during the treatment for one (1) of one (1) Patients, P # 4; treatment data to include access visualization was documented every 30 minutes during the treatment for three (3) of seven (7) Patients, P # 4, # 6 and # 7; the Registered Nurse (RN) assessed and documented the patient assessment within 1 hour of the initiation of the treatment for four (4) of seven (7) Patients, P # 2 # 3, # 4 and # 5; and the RN verified the treatment prescription within 1 hour of the initiation of the treatment for four (4) of seven (7) Patients, P # 2, # 3, # 4 and # 5. The findings include: On July 9, 2024 between 10:00 PM and 12:00 PM the following was observed during initiation and termination of treatments: At 10:30 AM, P # 8 was observed weighing self before exit from the treatment area with no Staff Member (SM) present. At 10:40 AM, P # 6 was observed being weighed by transport staff before exit from the treatment area with no SM present. On July 10, 2024 between 9:00 AM and 12:00 PM, clinical record reviews revealed the following: P # 1- The flowsheet dated June 24, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “150/89”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated June 26, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “130/80”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 1, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “N/A”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 5, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “126/89”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. P # 2- The flowsheet dated July 6, 2024 revealed the treatment start time was documented at 6:22 AM. The RN prescription verification was documented at 8:07 AM (greater than one (1) hour). The RN pre treatment assessment was documented at 8:08 AM (greater than one (1) hour). P # 3- The flowsheet dated June 25, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “179/52”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated June 27, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “155/61”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated June 29, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “132/54”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 2, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “N/A”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The treatment start time was documented at 10:27 AM, The RN prescription verification was documented at 12:52 PM (greater than one (1) hour). The RN pre treatment assessment was documented at 12:55 PM (greater than one (1) hour). The flowsheet dated July 4, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “N/A”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 6, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “132/70”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The treatment start time was documented at 10:20 AM. The RN prescription verification was documented at 11:23 AM (greater than one (1) hour). The RN pre treatment assessment was documented at 11:26 AM (greater than one (1) hour). P # 4- The flowsheet dated June 26, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “110/60”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. There was no documented access visualization between 8:03 AM and 9:24 AM (greater than thirty (30) minutes). The flowsheet dated July 3, 2024 revealed there was no documented access visualization between 6:32 AM and 7:32 AM between 5:28 AM (greater than thirty (30) minutes). The flowsheet dated July 5, 2024 revealed the treatment start time was documented at 5:54 AM The RN prescription verification documented at 7:43 AM (greater than one (1) hour). The RN treatment assessment was documented at 7:45 AM (greater than one (1) hour). There was no treatment data to include blood pressure (BP) between 5:56 AM and 7:02 AM (greater than thirty (30) minutes). P # 5- The flowsheet dated July 2, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “1121/71”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated June 27, 2024 revealed the pre treatment standing blood pressure documented as “N/A”. The post treatment standing blood pressure was documented as “140/69”. There was no documentation of why the standing blood pressure could not be obtained. The nursing evaluation documented ambulation status as “Ambulatory - no assistance needed”. The flowsheet dated July 6, 2024 revealed the treatment start time was documented at 10:08 AM. The RN prescription verification documented at 11:21 AM (greater than one (1) hour). The RN treatment assessment was documented at 11:22 AM. (greater than one (1) hour). P # 6- The flowsheet dated July 2, 2024 revealed there was no documented access visualization between 6:32 AM and 9:02 AM (greater than thirty (30) minutes). The flowsheet dated July 6, 2024 revealed there was no documented access visualization between 7:32 AM and 9:02 AM (greater than thirty (30) minutes). P # 7- The flowsheet dated June 24, 2024 revealed there was no documented access visualization between 2:07 PM and 3:03 PM (greater than thirty (30) minutes). The flowsheet dated June 26, 2024 revealed there was no documented access visualization between 3:02 PM and 4:02 PM (greater than thirty (30) minutes). On July 10, 2024 at 2:30 PM, a review of the facility’s policy titled “Pre-Intra-Post treatment” reads in part “Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse: Measurement of BP sitting and standing (if patient unable to stand, document reason), Patient weight. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment. Non nocturnal treatments are completed a least every thirty (30) minutes. At a minimum, obtain and document: BP, vascular access visible.” On July 10, 2024 at 3:00 PM, the findings were discussed with Staff Members # 1, # 11 and # 12 during the exit interview.”

“PA-DIALYSIS ACCESS TYPE & MAINTENANCE CFR(s): 494.80(a)(8) The patient’s comprehensive assessment must include, but is not limited to, the following: (8) Evaluation of dialysis access type and maintenance (for example, arteriovenous fistulas, arteriovenous grafts and peritoneal catheters). This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility failed to assess and evaluate the access site and obtain an order for the use of clamps for one (1) of one (1) Patients (P), P # 6. The findings include: On July 9, 2024 at 10:05 AM, Patient # 6 (P #6) was observed during the termination of treatment at Station # 9. Staff Member (SM) # 3 applied a clamp the access site. SM # 3 failed to assess the thrill and bruit of the access above and below the clamp. On July 9, 2024 at 1:30 PM, an interview with SM # 1 revealed there was no order for clamp use on P # 6 after the order for clamps was requested by the surveyor. On July 10, 2024 at 2:30 PM, a review of the facility’s policy titled “Utilizing Vascular Access Clamps” reads in part “A physician’s order is always required for utilization of vascular access clamps. During use, the thrill and bruit of the access will be checked above and below the clamp.” On July 10, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 11 and # 12 during the exit interview.”

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) 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- (1) At least annually for stable patients; This Standard is not met as evidenced by: 34452 Based on document reviews and interviews, it was determined that the facility staff failed to ensure there was a current assessment by the Registered Nurse (RN) for one (1) of seven (7) Patients (P), P # 5. The findings include: On July 9, 2024 between 1:00 PM and 3:00 PM, clinical record reviews revealed the following: P # 5- The plan of care meeting dated January 23, 2024 failed to have a current nursing assessment by the RN. A review of the care plan revealed the RN Comprehensive assessment had not been completed. On July 10, 2024 at 2:30 PM, a review of the facility’s policy titled “Interdisciplinary team (IDT) Patient Assessment and plan of care” reads in part “The facility’s interdisciplinary team consists of at a minimum the patient or the patient’s personal representative, a registered nurse, a physician or non physician practitioner, ... a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment.” On July 10, 2024 at 3:00 PM, the findings were discussed with Staff Members # 1, # 11 and # 12 during the exit interview.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 34452 Based on document reviews and interviews, it was determined that the facility staff failed to ensure the Registered Nurse (RN) participated in the Plan of Care meeting for one (1) of seven (7) Patients (P), P # 5. The findings include: On July 9, 2024 between 1:00 PM and 3:00 PM, clinical record reviews revealed the following: P # 5- The plan of care meeting dated January 23, 2024 failed to have a signature by the RN. There was no signature to indicate participation in the plan of care meeting. On July 10, 2024 at 2:30 PM, a review of the facility’s policy titled “Interdisciplinary team (IDT) Patient Assessment and plan of care” reads in part “The patient’s plan of care will completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative.” On July 10, 2024 at 3:00 PM, the findings were discussed with Staff Members # 1, # 11 and # 12 during the exit interview.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers; This Standard is not met as evidenced by: 41450 Based on staff interview and facility documentation review, the facility staff failed to implement the facility’s health and safety policy for Tuberculosis monitoring for two (2) of nine (9) staff members (SM), SM #4, and #8. The findings include: On 7/10/24 at approximately 11:00 AM, staff record reviews were conducted and revealed the following staff members had no documentation of Tuberculosis (TB) screening, to include a current TB risk assessment and/or symptom evaluation: SM #4, hired on 11/29/21, and SM #8, hired on 8/30/20. In an interview at approximately 1:30 PM, SM #1 confirmed the findings and stated, “It is my expectation for all personnel to be screened for TB at the time of hire as well as annually, that is our facility’s policy.” Review of the facility’s policy titled, “Tuberculosis Monitoring and Follow-Up”, revision date April 2020, page 1, read, “Baseline new hire requirements ...teammates will complete the following: 1. TB-Risk Assessment and Symptom Evaluation Questionnaire ...” and page 3, read “Annual teammate requirements ...All teammates will complete the TB Individual Risk Assessment and Symptom Evaluation”.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 34452 Based on observation, document review and interview, it was determined that the facility staff failed to maintain an accurate clinical record by documenting correct ambulatory status for one (1) of seven (7) Patients (P), P # 2; and failed to document medication administration accurately for one (1) of one (1) Patients, P # 6. The findings include: On July 9, 2024 between 1:00 PM and 3:00 PM, the following was observed in the treatment area during initiation and termination of treatments: At 10:05 AM, P # 6 was observed during termination of the dialysis treatment at Station # 9. P # 6 had a white liquid infusion on the intravenous (IV) pump infusing. Approximately 1/4 of the bag was still hanging after the treatment had ended. At 11:00 AM, P # 2 was observed entering the facility for dialysis treatment. P # 2 was ambulatory with a rolling walker. On July 10, 2024 between 9:30 AM and 12:30 PM, clinical record reviews revealed the following: P # 2- The Patient Summary report printed on July 9, 2024 documents ambulatory status: “Ambulatory - No assistance needed”. The flowsheet dated July 9, 2024 revealed the pre treatment assessment included “mobility: wheelchair; ambulatory: ambulatory - no assistance needed”. P # 6- The flowsheet dated July 9, 2024 revealed an order for IDPN (intradialytic PN, a form of partial parenteral nutrition administered during regularly scheduled dialysis sessions as a supplement) three times per week. The flowsheet documentation reads in part “ordered dose administered: yes, Given 834 milliliters, signed by RN”. On July 10, 2024 at 2:45 PM, an interview with Staff Member # 1 revealed staff are expected to document accurately. “The IDPN comes pre made with a volume of 834 ml. The entire bag would be required to infuse to give 834 ml. Staff are expected to document the amount that was infused based on the what the IV pump shows.” On July 10, 2024 at 2:50 PM, a review of the facility’s policy titled “Medical records documentation guidance” reads in part “All entries must be accurate. Document accurately and concisely but completely.””

“GOV-RESPONDS TO NW REQUEST/WORKS TOWARD GOALS CFR(s): 494.180(i) The governing body receives and acts upon recommendations from the ESRD network. The dialysis facility must cooperate with the ESRD network designated for its geographic area, in fulfilling the terms of the Network’s current statement of work. Each facility must participate in ESRD network activities and pursue network goals. This Standard is not met as evidenced by: 34452 Based on document reviews and interviews, it was determined that the facility failed to access and review the ESRD (End Stage Renal Disease) Quality Improvement Report provide by the ESRD network for six (6) months, January 2024 through June 2024.. The findings include: On July 10, 2024 at 2:00 PM, a review of the facility’s Quality meetings documentation revealed there was no documented evidence of the ESRD Quality Improvement Report discussions between January 2024 and June 2024. On July 10, 2024 at 2:30 PM, an interview with Staff Member (SM) # 1 revealed the facility has not been accessing the ESRD Quality Improvement Report nor have they been discussing the information during the Quality meetings. On July 10, 2024 at 2:45 PM, a review of the facility’s policy titled “General Statement on Clinical Policies” reads in part “Facility and facility teammates will operate and furnish services in compliance with applicable Federal, State, local laws and regulations pertaining to licensure and any other relevant health and safety requirements including individual ESRD network requirements”. On July 10, 2024 at 3:00 PM, the findings were discussed with SM # 1, # 11 and # 12 during the exit interview.”