Davita Stevens Point Dialysis

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility 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. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 43037 Based on observation, record review and interview, the facility staff failed to ensure that emergency cart (code cart) supplies were not expired per facility policy in 1 of 1 observation in a total sample of 1 code cart observed. Findings include: A review of facility policy 1-05-01, “Infection Control for Dialysis Facilities” last revised April 2023 revealed, “...Supplies: 8. Supplies will be maintained in a manner that maintains their integrity...b. Expiration date and package will be verified...” During an observation of the code cart on 10/15/2024 at 9:50 AM with Registered Nurse L present, revealed 5 packages of sterile surgical gloves all with expiration dates of 8/24/2024. Registered Nurse L stated, “Those should have been replaced.” During an interview on 10/15/2024 at 12:25 PM, the observation findings were discussed with Facility Administrator A who stated that expired supplies should have been removed from the code cart and replaced during the monthly code cart check.”

“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: 43037 Based on record review and interview the facility failed to perform annual exercises testing the facility’s Emergency Preparedness (EP) Plan in 1 of 1 EP Plan reviewed. A review of the facility’s Emergency Preparedness Plan revealed no documented full-scale community-based exercises, facility-based functional exercises or table-top workshop exercises for calendar year 2023. Required exercises were complete for calendar year 2024. During an interview on 10/15/2024 at 12:25 PM findings were discussed with Facility Administrator A who when asked about annual testing stated, “I was not the FA at that time. I don’t know where the documentation would be.””

“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: 43037 Based on observation, record review and interview the facility staff failed to ensure patients completed hand hygiene after glove removal and holding access sites until bleeding stopped for 3 of 3 patients (Patient #s 8, 9 & 11) observed holding access sites in a total sample of 11 observations of patient care. Findings include: A review of facility policy 1-05-01, “Infection Control for Dialysis Facilities” last revised April 2023 revealed, “...2. Patients and caregivers will be encouraged to...b. Perform hand hygiene after treatment before leaving treatment area...7. Disposable gloves will be worn when caring for the patient or touching the patient’s equipment at the dialysis station, this will include patients and visitors assisting with procedures such as self-canulation or holding access sites...” During an observation on 10/14/2024 at 10:12 AM, Patient #8 held access sites with his/her gloved hand, removed the glove and walked to the scale. Patient #8’s access sites began bleeding again at the scale and Patient #8 then held the gauze covered access sites with an ungloved hand, returned to their chair, put a glove on and again held access sites until bleeding stopped. A new dressing was applied to Patient #8’s access sites and Patient #8 then removed the glove and left the treatment area without completing hand hygiene. During an observation on 10/14/2024 at 10:15 AM, Patient #9 held access sites with his/her gloved hand, removed the glove and left the treatment area without completing hand hygiene. During an observation on 10/14/2024 at 10:25 AM, Patient #11 held access sites with his/her gloved hand, removed the glove and left the treatment area without completing hand hygiene. During an interview on 10/15/2024 at 12:25 PM, the observation findings were discussed with Facility Administrator A who stated that patients should complete hand hygiene after holding access sites and before they leave the treatment area.”

“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: 43037 Based on observation, record review and interview, the facility staff failed to ensure aseptic technique was maintained when working with central venous catheters (CVC), per facility policy for 2 of 2 patients (Patient #s 7 & 10) with a CVC observed in a total sample of 2 observations of care of patients with a CVC. Findings include: A review of facility policy 1-04-02B, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure” last revised October, 2024 revealed, “...1...Put on PPE (Personal Protective Equipment) and provide a mask to the patient...3...Verify patient’s clothing is secured away from the exit site/work area...” During an observation on 10/14/2024 at 10:15 AM, Patient Care Technician (PCT) G began exit site care/dressing change of Patient #10’s CVC without providing Patient #10 with a mask to wear during the procedure. PCT G provided a mask for Patient #10 to wear before blood line attachment occurred. During an observation on 10/14/2024 at 11:24 AM, Patient Care Technician E was performing exit site care/dressing change of Patient #7’s CVC. Patient #7’s clothing was pulled back by PCT E’s hand to expose the CVC exit site and accommodate cleaning of the site, but not secured to keep clothing away from the site when cleaning was completed and prior to dressing application. Patient #7’s clothing rubbed against exit site and CVC line until a clean dressing was applied over the exit site. During an interview on 10/15/2024 at 12:25 PM, the observation findings were discussed with Facility Administrator A who stated that Patient #10 should have been given a mask to wear before exit site care was started and PCT E should have secured Patient #7’s clothing away from his/her CVC exit site with tape.”

“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: 43037 Based on record review and interview, the facility staff failed to ensure the administration of the pre-treatment heparin (anticoagulant medication) bolus was at least 3 to 5 minutes prior to the initiation of dialysis, per facility policy, in 3 of 4 in-center hemodialysis patients (Patient #s 1, 3 & 4) with current active orders for heparin boluses in a total sample of 5 medical records reviewed. Findings include: A review of facility policy 1-06-02, “Anticoagulation” last revised September 2024 revealed, “...14. To anticoagulate the patient, the initial loading dose of heparin is administered through the venous fistula needle or venous port of the central venous catheter (CVC) at least three (3) to five (5) minutes prior to the initiation of the hemodialysis treatment...” A review of Patient #1’s current in-center hemodialysis order revealed an order for 2000 units of heparin bolus. A review of treatment sheet dated 10/8/2024 revealed Patient #1’s dialysis was started at 12:46 PM and heparin bolus was documented as given at 12:47 PM (1 minute after the initiation of dialysis.) A review of Patient #3’s current in-center hemodialysis order revealed an order for 3000 units of heparin bolus. A review of treatment sheet dated 10/8/2024 revealed Patient #3’s dialysis was started at 10:56 AM and heparin bolus was documented as given at 10:58 AM (2 minutes after the initiation of dialysis.) A review of Patient #4’s current in-center hemodialysis order revealed an order for 1500 units of heparin bolus. A review of treatment sheet dated 10/12/2024 revealed Patient #4’s dialysis was started at 8:56 AM and heparin bolus was documented as given at 8:58 AM (2 minutes after the initiation of dialysis.) During an interview on 10/15/2024 at 12:25 PM, the medical record review findings were discussed with and confirmed by Facility Administrator A who stated that heparin boluses should be given 3 to 5 minutes prior to the initiation of dialysis.”

“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: 43037 Based on record review and interview, the facility staff failed to ensure that nursing assessment documentation addressed patients leaving above or below 1 kilogram (kg) of their target weight in 1 of 5 (Patient #3) in-center medical records reviewed in a total sample of 5 medical records reviewed. Findings include: A review of facility policy 1-03-08, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised April 2024 revealed, “...Abnormal Findings: Unless other abnormal parameters are established by the Governing Body and documented in the Governing Body minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record...If patient is above or below 1 kg from the target weight...” A review of Patient #3’s current in-center hemodialysis orders revealed an Estimated Dry Weight (EDW) of 91 kg. The treatment sheet dated 10/1/2024 revealed Patient #3’s post dialysis weight was documented as 92.4 kg, 1.4 kg over the EDW. There was no documentation regarding the reason for Patient #3 leaving above EDW. During an interview on 10/15/2024 at 12:25 PM, the medical record findings were discussed with and confirmed by Facility Administrator A who stated, “There should have been a note written.””

“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: 43037 Based on record review and interview, the facility staff failed to complete documentation of why physician orders were not followed for prescribed dialysate flow rates for 1 of 5 in-center medical records reviewed (Patient #1) in a total sample of 5 medical records reviewed. Findings include: A review of facility policy 1-03-08, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised April 2024 revealed, “...Intradialytic Data Collection Assessment...b. At a minimum, obtain and document the following:...iii. Blood and dialysate flows...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...” A review of Patient #1’s medical record revealed a physician order for the dialysate flow rate (DFR) of 600 mL/min (milliliters per minute). The treatment sheet dated 10/5/2024 revealed the DFR was set at 500 mL/min for the entire treatment. There was no documentation in the medical record for the reason the DFR was lower than the ordered rate. During an interview on 10/15/2024 at 12:25 PM, the medical record review findings were discussed with and confirmed by Facility Administrator A who stated there should have been documentation regarding the DFR not being set at the prescribed rate.”

“CFC-GOVERNANCE CFR(s): 494.180 This Condition is not met as evidenced by: 29972 Based on record review and interview staff failed to follow the process and procedure for involuntary discharge as per policy to ensure there was an appropriate discharge/transfer and continuity of care in 1 of 1 involuntary discharges reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed. Findings Include: Facility staff failed to follow the process and procedure for involuntary discharge as per policy to ensure there was an appropriate discharge/transfer and continuity of care. See Tag V-0766.”

“PR-RECEIVE WRITTEN NOTICE 30 DAYS PRE IVD CFR(s): 494.70(b)(2) The patient has the right to- (2) Receive written notice 30 days in advance of an involuntary discharge, after the facility follows the involuntary discharge procedures described in §494.180(f)(4). In the case of immediate threats to the health and safety of others, an abbreviated discharge procedure may be allowed. This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to give a 30 day notice prior to involuntarily discharging a patient in 1 of 3 patient transfers reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure #03-01-07A titled, “Patient’s Rights” last revised October 2021 revealed the following: - Patient rights include: #23 “To be transferred or discharged only for medical reasons, for my own welfare or that of other patients, or for nonpayment of fees. If I am discharged for these reasons, I will be given advance written notice of 30 days unless the reason involves issues of immediate safety to other patients or teammates. Review of Pt #1’s medical record revealed that Pt #1 was admitted to the dialysis facility on 05/16/2024; Pt #1 had only two dialysis treatments at the facility on 05/16/2024 and 05/18/2024 before being hospitalized on 05/23/2024 to 05/24/2024 and 05/30/2024 to 06/12/2024. Review of Pt #1’s Hospital Discharge Summary dated 06/12/2024 at 4:02 PM, revealed the hospital was unable to coordinate outpatient dialysis due to the facility’s refusal to accept Pt #1 back to the facility. Per review of Pt #1’s Patient Notes (Dialysis facility) dated 05/30/2024 at 10:28 AM, Facility Administrator A documented, “Discussed with Medical Director (C)...(Pt #1) will not be accepted back to facility unless he has appropriate housing, transportation to dialysis, and basic needs are met.” There was no documented evidence found of a physician order to discharge Patient #1 or that a 30 day notice of discharge was provided. Per interview with Facility Administrator (FA) A on 07/10/2024 at 10:50 AM, FA A stated that MD C told FA A that Pt #1 would not be accepted back until the hospital ensured Pt #1 had a place to stay, transportation to dialysis, and basic needs were met. FA A stated that she/he informed the hospital staff of MD C’s decision. FA A stated that Pt #1 was not given a 30 day notice for involuntary discharge.”

“GOV-GB&MED DIR RESP STAFF FLW DC/TRANSFER P&P CFR(s): 494.180(f)(1)-(3) The governing body must ensure that all staff follow the facility’s patient discharge and transfer policies and procedures. The medical director ensures that no patient is discharged or transferred from the facility unless - (1) The patient or payer no longer reimburses the facility for the ordered services; (2) The facility ceases to operate; (3) The transfer is necessary for the patient’s welfare because the facility can no longer meet the patient ’ s documented medical needs; This Standard is not met as evidenced by: 29972 Based on record review and interview staff failed to follow the process and procedure for involuntary discharge as per policy to ensure there was an appropriate discharge/transfer and continuity of care in 1 of 1 involuntary discharges reviewed (Patient (Pt) #1), in a total sample of 10 medical records reviewed. Findings Include: Review of policy and procedure #03-01-07A titled, “Patient’s Rights” last revised October 2021 revealed the following: - Patient rights include: #23. “To be transferred or discharged only for medical reasons, for my own welfare or that of other patients, or for nonpayment of fees...” Review of policy and procedure #8-03-02 titled, “Patient Behavior Agreements, 30 Day Discharge, Involuntary Discharge or Involuntary Transfer,” revealed the following: - “The facility and Risk Manager will consult with the ESRD Network regarding 30 day discharge or involuntary discharge or transfer to another facility.” - “The patient’s physician and facility Medical Director must be notified of the pending involuntary transfer or discharge and provide a signed order. This notification and order will be documented in the patient’s electronic health record.” - “...State agency and ESRD (End Stage Renal Disease) Network must be notified of the involuntary discharge...” - “Social Worker/designee will provide the patient with a list of area dialysis facilities that may be able to accept the patient, and the patient will be allowed to provide input as to facility preference...” - “Good faith efforts should be made to place the patient at the patient’s preferred facility and/or find the closest facility to the patient’s residence that will accept the patient transfer...” - “The goal of contacting another dialysis facility is for continuity of care...” Review of Pt #1’s medical record revealed that Pt #1’s first treatment at the dialysis facility was on 05/16/2024; Pt #1 had only two dialysis treatments at the facility on 05/16/2024 and 05/18/2024 before being hospitalized on 05/23/2024 to 05/24/2024 and 05/30/2024 to 06/12/2024. Pt #1 was admitted to a different dialysis facility on 06/21/2024. Review of Pt #1’s Hospital Discharge Summary (hospitalization #2) revealed Pt #1 was admitted to the hospital on 05/30/2024 at 10:12 AM and left against medical advice (AMA) on 06/12/2024 (no time); Pt #1’s Primary Discharge Diagnosis revealed, “Missed hemodialysis, Recurrent C. Diff (Clostridium Difficile--bacteria that causes diarrhea), B-Cell lymphoma (cancer of immune system b-cells), Behavioral disturbance/agitation.” Per Hospital Course documentation, “...Care coordination was also involved and efforts were made to try to identify a different outpatient hemodialysis chair as (Pt #1’s) prior hemodialysis facility would not accept (Pt #1) back. Pt left AMA pending at the time of his discharge (Pt #1) did not have an outpatient hemodialysis chair.” Per review of Pt #1’s Patient Notes (Dialysis facility) dated 05/30/2024 at 10:28 AM, Facility Administrator A documented, “Discussed with Medical Director (C)...(Pt #1) will not be accepted back to facility unless (Pt #1) has appropriate housing, transportation to dialysis, and basic needs are met.” Per interview with Facility Administrator (FA) A on 07/10/2024 at 10:50 AM, FA A stated that Pt #1 was homeless and had checked out of the shelter and was living in his/her car. Per FA A, Pt #1 only had 2 treatments at the dialysis facility before being hospitalized twice. FA A stated that the hospital staff called and informed FA A that the hospital was preparing to discharge Pt #1 and was calling to coordinate Pt #1’s outpatient dialysis treatment. FA A informed MD C of the hospitals plan to discharge Pt #1 and MD C told FA A that Pt #1 would not be accepted back until the hospital ensured Pt #1 had a place to stay, transportation to dialysis, and basic needs were met. FA A stated that she/he informed the hospital staff of MD C’s decision. FA A stated there was no MD order to involuntarily discharge Pt #1. FA A stated that Patient Services Director E (ESRD Network 11) called FA A about Pt #1 not being accepted back to the facility and Director E informed FA A that not accepting Pt #1 back due to those reasons would be considered an involuntary discharge. FA A informed MD C of this and MD C insisted that the hospital must meet the specified criteria before MD C would accept the patient back. FA A stated that she/he was not aware that the ESRD Network, State Agency, and CMS (Centers for Medicare and Medicaid) should be notified for involuntary discharges. Per interview with Social Worker (SW) D on 07/10/2024 at 11:50 AM, when asked if the facility has ever had an involuntary discharge, SW D stated she/he has “never had one” and had “not experienced one yet.” SW D stated that she never met Pt #1 and had not worked with Pt #1 on any issues. SW D stated that Pt #1 left the hospital AMA and never came back to the dialysis facility. SW D stated that she/he did not follow up with the hospital to coordinate care or find out what happened with Pt #1. SW D stated the Pt #1 was admitted to a different dialysis facility, but SW D was not aware of why. When asked if patients who are being involuntarily discharged are given assistance to find a different dialysis facility, SW D stated “I don’t know the answer to that.” SW D stated that it’s a team approach, resources are offered to the patient, but it’s ultimately the patient’s decision. Per interview with MD C on 07/10/2024 at 12:30 PM, MD C stated that Pt #1 had a lot of social issues and prior to hospitalization Pt #1 was homeless living in his/her car in the parking lot of Walmart. Per MD C, Pt #1 had issues with transportation, homelessness, and was non-compliant with treatment and the hospital needed a better discharge plan for Pt #1. MD C stated that he/she told FA A to inform hospital staff that MD C would not accept Pt #1 until the hospital had a “better discharge plan”; MD C stated that she/he wanted Pt #1 to be kept in the hospital until these issues were resolved. MD C stated that Pt #1 needed a “place to live” and “transportation to get to dialysis 3 times a week.” MD C stated she/he did not approve or write an order for Pt #1 to be involuntarily discharged, however MD C would not accept Pt #1 back. MD C stated that he/she does not believe a patient is involuntarily discharged if a patient is not accepted back due to an improper hospital discharge plan. MD C stated that he/she did not speak with hospital staff to inquire about the discharge plan. MD C’s rationale for discharge did not match the accepted reasons for IVD as per policy. Per interview with Patient Services Director E (ESRD Network 11) on 07/10/2024 at 3:42 PM, Director E stated she/he was called by hospital staff (hospitalization #2) on 06/06/2024 and informed that Pt #1’s dialysis facility was refusing to accept Pt #1 back. Director E stated that she/he called and spoke with FA A on 06/06/2024; FA A stated that the MD C was on vacation and would not take Pt #1 back until transportation and housing needs were met. Director E stated that she/he educated FA A on involuntary discharge requirements and told FA A that the facility needs to accept Pt #1 back. Director E stated that FA A agreed and then about 1 week later FA A informed Director E, that MD C would not accept Pt #1 back until after MD C arrived back from vacation. Director E stated that the dialysis facility did not follow protocol.”