Davita Mill Street Home Training (Pd)

“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: 47413 Based on record review, observation, and interview the facility staff failed to perform glove changes and hand hygiene when moving from “dirty” to “clean” tasks while providing care for 2 of 3 patients (Patient (Pt) # 5, 8) and the facility staff failed to perform hand hygiene and glove changes when moving between patient stations for 1 of 5 patients (Pt #5) in a total of 5 observations of patient care. Findings Include: A review of the facility’s policy #1-12-17 titled, “DSD Infection Control for Dialysis Facilities” last revised April 2024 revealed, “... HAND HYGIENE: 1. All teammates... will perform hand hygiene... a. upon entering and exiting the patient treatment den/bedside area... c. after contamination with blood or other infectious material... f. between patients even if the contact is casual... Gloves should be changed when: ... 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...” During an observation on 08/06/2024 at 8:13 AM, PCT (Patient Care Technician) H touched Pt #5’s garbage can and sharps container wearing clean gloves and then touched Pt #5’s “clean field” to access Pt #5’s CVC (central venous catheter). No glove change or hand hygiene performed. During an observation on 08/06/2024 at 11:22 AM, PCT H touched Pt #7’s dialysis machine and then went to Pt #5’s dialysis station to assist Pt #5 with his/her clothing. PCT H did not change gloves and perform hand hygiene in between Patient #7’s dialysis station and Patient #5’s dialysis station. During an interview on 08/06/2024 at 1:58 PM, the observation findings were discussed with Manager of Clinical Services L who stated, “Gloves should be removed and hand hygiene should be performed.” 29972 On 08/06/2024 beginning at 7:55 AM, observed PCT H initiating Pt #8’s dialysis treatment using an Arteriovenus Fistula/Graft (AVF/G). PCT H donned gloves and cleansed the skin over the AVF/G site with an antiseptic; PCT H then proceeded to touch his/her hair and touch the Reverse Osmosis machine at the station immediately prior to cannulating Pt #8’s AVF/G. PCT H did not remove “dirty” gloves, perform hand hygiene, and don “clean” gloves prior to cannulating to prevent potential cross contamination. During interview with Manager of Clinical Services (MCS) L, while discussing observations on 08/06/2024 beginning at 2:00 PM, MCS L stated that staff should have removed gloves and donned a clean pair of gloves prior to performing cannulation.”

“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: 47413 Based on record review, observation and interview, facility staff failed to ensure that non-disposable items taken into the patient stations are disinfected between patients in 3 of 3 observations of patient care (Patients (Pt) #5, #7, #8), in a total sample of 5 observations of care. Findings Include: A review of the facility’s policy #1-12-17 titled, “Infection Control for Dialysis Facilities” last revised April 2024 revealed, “... Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area... Disposable gloves... may be stored on the computer cart shelves but not on counters where terminals are mounted...” During an observation on 08/06/2024 at 7:30 AM at the dialysis unit in the Skilled Nursing Facility (SNF), an opened, non-disposable glove box was at Pt station 2 during Pt #7’s dialysis treatment. The opened glove box was not disinfected prior to or after use. During an observation on 08/06/2024 at 7:45 AM at the dialysis unit in the SNF, an opened, non-disposable glove box was at Pt station 3 during Pt #8’s dialysis treatment. The opened glove box was not disinfected prior to or after use. During an observation on 08/06/2024 at 8:26 AM at the dialysis unit in the SNF, an opened, non-disposable glove box was at Pt station 4 during Pt #5’s dialysis treatment. The opened glove box was not disinfected prior to or after use. During an interview on 08/06/2024 at 8:50 AM with RN (Registered Nurse) O at the dialysis unit in the SNF (Skilled Nursing Facility), when asked how the glove boxes are decontaminated between patients, RN O stated, “We don’t wipe them down.” During an interview with Manager of Clinical Services (MCS) L, while discussing observations on 08/06/2024 beginning at 2:00 PM, MCS L stated, “The gloves should be on the rounding cart, so that they are a little bit further away from the patient station.””

“IC-HBV-ISOLATION (EXISTING FACILITY) CFR(s): 494.30(a)(1)(i) Isolation of HBV+ Patients To isolate HBsAg positive patients, designate a separate room for their treatment. For existing units in which a separate room is not possible, HBsAg positive patients should be separated from HBsAg susceptible patients in an area removed from the mainstream of activity. This Standard is not met as evidenced by: 29972 Based on record review and interview the facility failed to have a transfer agreement/contract to accommodate potential Hepatitis B positive patients in 1 of 2 home hemodialysis modalities reviewed (in skilled nursing facility), in 3 modalities reviewed. Findings Include: Review of policy and procedure #1-05-02 titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance” last revised April 2024 revealed: - “Confirmed positive patients are dialyzed in an isolation room or area designated for use by only surface antigen positive patients.” - “Per the Conditions for Coverage: beginning 2/9/2009 all new facilities must have a separate isolation room unless the facility has obtained a waiver from CMS (Centers of Medicare and Medicaid)...” Per interview with Facility Administrator (FA) A on 08/01/2024 at 10:10 AM, FA A stated that dialysis facility staff provide hemodialysis treatments in a room located in a skilled nursing facility (SNF). Per FA A the room accommodates 6 patient stations. During interview with Manager of Clinical Services (MCS) L on 08/01/2024 at 1:25 PM, MCS L stated that the dialysis unit was opened in October 2023 and does not have an isolation room, designated isolation area, or a waiver. MCS L stated that the dialysis unit does not accept hepatitis B positive patients and if a current patient were to test positive for Hepatitis B they would transfer the patient to another facility. Per MCS L, the facility does not have an agreement/contract with a local facility to accept transfer of hepatitis B positive patients.”

“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: 47413 Based on record review, observation and interview, the facility staff failed to perform central venous catheter (CVC) exit site care using aseptic technique for 1 of 1 patients observed (Patient (Pt) #5) in a total sample of 1 observation of care of patients with a CVC. Findings Include: A review of the facility’s policy #1-04-02B titled, “Central Venous Catheter with ClearGuard HD Antimicrobial End Caps Procedure” last revised October 2023 revealed, “... Verify patient’s clothing is secured away from exit site/work area... Securing the patient’s clothing away from the work area minimizes the risk of cross-contamination...” On 08/06/2024 at 8:15 AM, observed PCT (Patient Care Technician) H cleaning the skin surrounding Pt #5’s CVC exit site; after cleaning, Pt #5’s clothing touched the clean skin surrounding CVC site, potentially recontaminating the CVC exit site. During an interview with Manager of Clinical Services (MCS) L, while discussing CVC observations on 08/06/2024 at 2:00 PM, MCS L stated, “Correct, you are supposed to protect the area that has been cleaned. We have told nursing home staff that they should bring patient’s over to the dialysis unit wearing button-up shirts.””

“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: 29972 Based on record review and interview the facility failed to ensure that all members of the interdisciplinary team (IDT) interact and discuss the findings of the IDT patient assessments to facilitate in the development of a comprehensive patient plan of care in 1 of 5 patient records reviewed (Patient (Pt) #5), in a total of 5 patient medical records reviewed. Findings Include: Review of policy and procedure #1-12-08 titled, “Hemodialysis Patient Assessment and Plan of Care” last revised April 2024 revealed: - “The facility’s IDT consists of, at a minimum, the patient or the patient’s personal representative, a registered nurse (RN), a physician or non-physician practitioner...a social worker (SW), and a dietician (RD).” - “For patients residing in the SNF (Skilled Nursing Facility), the IDT will also include a representative of the SNF to verify that an adequate coordination of care is accomplished. The complete disciplinary team will meet at the SNF to establish a plan of care for the resident.” - The patient’s plan of care will be completed by facility’s (IDT) including patient...and signed by team members including the patient...” Review of Pt #5’s Patient Plan of Care (SNF patient) revealed that the IDT meeting date was on 06/28/2024. Per review of Pt #5’s Plan of Care IDT signature page, the RN G signed on 06/03/24 (before the plan of care meeting occurred), SW N signed on 07/19/24, RD M did not document the date signed, the SNF RN (SNF staff) and Pt #5 both signed on 06/24/2024 (before care plan meeting occurred). There is no documented evidence that all members of the IDT participated in Pt #5’s plan of care meeting on 06/28/2024. Documentation on the Pt #5’s Patient Plan of Care form revealed, a “Signature acknowledges review and approval of Patient Plan of Care at Interdisciplinary Team Meeting.” Per interview with Social Worker (SW) N on 08/2/2024 beginning at 9:20 AM, SW N stated that the IDT should be meeting as a team to discuss each patient’s plan of care (SNF patients) but this does not usually happen. SW N stated, “We need a process for care plan meetings...” Per interview with RN O on 08/06/2024 beginning at 8:40 AM, when asked if the IDT meet together in person, virtually, or via telephone to discuss a patient’s plan of care (SNF patients), RN O stated that the members of the IDT are not always available to discuss the patient’s plan of care together so this does not always happen. RN O stated it’s a “case by case” basis. During interview with Manager of Clinical Services (MCS) L, while discussing medical record findings on 08/01/2024 beginning at 4:00 PM, MCS L stated that the IDT should be meeting as a team to discuss patient’s care plan. MCS L stated that the date staff sign the care plan indicates the date the care plan was signed and not the date the care plan was completed; this is inconsistent with the Patient Plan of Care form stating that the “Signature acknowledges review and approval of Patient Plan of Care at Interdisciplinary Team Meeting.””

“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: 47413 Based on record review and interview, the facility staff failed to ensure intradialytic data collection/assessment was completed per facility policy in 1 of 2 hemodialysis medical records reviewed (Patient (Pt) #5); failed to perform a nursing assessment of abnormal findings during dialysis treatments in 1 of 2 hemodialysis medical records reviewed (Pt #5); and failed to ensure that nursing assessment documentation addressed patients above or below 1 kilogram (kg) of their target weight after dialysis treatment in 1 of 2 hemodialysis medical records reviewed (Pt #5), in a total sample of 5 medical records reviewed. Findings Include: A review of the facility’s policy #1-03-08 titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment” last revised April 2024 revealed, “... Intradialytic Data Collection/Assessment: Non-nocturnal treatments are completed at least every thirty (30) minutes ... Vital signs and treatment monitoring:... At a minimum obtain and document the following: Blood and dialysate flows, arterial and venous pressures... Vascular access visible and line connections intact... If an abnormal finding(s) or concern is identified post treatment... The licensed nurse will assess the patient prior to discharge... Abnormal Findings: ... Members of the patient care team should report ANY changes in patient conditions... immediately to the licensed nurse at any time: ... Post Treatment: If patient is above or below 1 kg from the target weight...” Examples of missing intradialytic data collection/assessment: A review of Pt #5’s medical record revealed on the treatment sheet dated 07/24/2024, Patient #5’s dialysis treatment started at 8:15 AM and ended at 10:15 AM. Review of the treatment sheet revealed intradialytic data collection/assessment of BFR (blood flow rate), DFR (dialysis flow rate), AP (arterial pressure), VP (venous pressure) and visualized access was not documented during checks at 9:15 AM, 9:45 AM, and 10:15 AM. A review of Pt #5’s medical record revealed on the treatment sheet dated 07/26/2024, Pt #5’s dialysis treatment started at 7:25 AM and ended at 11:01 AM. Review of the treatment sheet revealed intradialytic data collection/assessment of BFR, DFR, AP, VP and visualized access was not documented during checks at 7:30 AM, 8:30 AM, 9:00 AM, 9:30 AM, 10:30 AM and 11:01 AM. A review of Pt #5’s medical record revealed on the treatment sheet dated 07/31/2024, Pt #5’s dialysis treatment started at 7:09 AM and ended at 10:46 AM. Review of the treatment sheet revealed intradialytic data collection/assessment of BFR, DFR, AP, VP and visualized access was not documented during checks 7:39 AM, 8:39 AM, 9:39 AM, and 10:39 AM. During an interview with Manager of Clinical Services (MCS) L on 08/01/2024 at 4:14 PM, while discussing medical record findings, MCS L confirmed the findings and stated, “Staff should follow the policy.” Examples of missing nursing assessments for abnormal findings: A review of Pt #5’s medical record revealed on the treatment sheet dated 07/29/2024, Pt #5’s pre-treatment assessment revealed: “Edema; Yes; Left Leg: Pitting +1; Right Leg: Pitting +1.” Pt #5’s post-treatment assessment revealed: “Edema; Yes; N/A.” A review of Pt #5’s medical record revealed on the treatment sheet dated 07/31/2024, Pt #5’s pre-treatment assessment revealed: “Edema; Yes; Left Ankle: Pitting +2; Left Leg: Pitting +2; Right Ankle: Pitting +2; Right Leg: Pitting +2.” Pt #5’s post-treatment assessment revealed: “Edema; Yes; N/A.” During an interview with Manager of Clinical Services (MCS) L on 08/01/2024 at 4:14 PM, while discussing the medical record findings, MCS L confirmed the findings and stated, “There should be a post-treatment assessment documented in regards to a patient’s fluid or swelling status.” Examples of Not Meeting Estimated Dry Weight: A review of Pt #5’s current in-center hemodialysis orders revealed an Estimated Dry Weight (EDW) of 71 kilograms (kgs). The treatment sheet dated 07/29/2024 revealed Pt #5’s post dialysis weight was documented as 79 kgs, 8 kgs over the EDW. There was no documented evidence of nursing interventions and contact with the physician to report the patient leaving above the target weight. A review of Pt #5’s current in-center hemodialysis orders revealed an Estimated Dry Weight (EDW) of 71 kilograms (kgs). The treatment sheet dated 07/31/2024 revealed Pt #5’s post dialysis weight was documented as 76.7 kgs, 5.7 kgs over the EDW. There was no documented evidence of nursing interventions and contact with the physician to report the patient leaving above the target weight. During an interview with Manager of Clinical Services (MCS) L on 08/01/2024 at 4:14 PM, while discussing the medical record findings, MCS L confirmed the findings and stated, “There should be an assessment addressing the patient leaving over the target weight. Staff should work with the Nephrologist on the target weight not being met.””

“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: 29972 Based on record review, observation, and interview staff failed to evaluate the Arteriovenous Fistula/Graft (AVF/G) access site before cannulation as per policy in 1 of 2 observations of staff initiating treatment using an AVF/G (Patient (Pt) #8); and failed to perform skin antisepsis prior to cannulation as per policy in 1 of 2 observations of staff initiating treatment using an AVF/G (Pt #7), in a total sample of 3 observations of patient care. Findings Include: Review of policy and procedure #1-04-01D titled, “AV Fistula or Graft Cannulation...” last revised October 2022 revealed the following: - Skin Antiseptic--Povidone Iodine--Air Drying Time is 2 minutes. - “Perform inspection, auscultation (listening with a stethoscope) and palpation on entire length of access. Determine presence of bruit and thrill (indicates flow through the access). On 08/06/2024 at 7:30 AM, observed Patient Care Technician (PCT) H initiating Pt #7’s dialysis treatment using an Arteriovenus Fistula/Graft (AVF/G). PCT H cleansed the skin with Povidone Iodine antiseptic, waited 1 minute for the antiseptic to dry, and proceeded to cannulate Pt #7’s AVF/G. PCT H did not wait 2 minutes for the antiseptic to dry as per policy. On 08/06/2024 at 8:00 AM, observed PCT H initiating Pt #8’s dialysis treatment using an Arteriovenus Fistula/Graft (AVF/G). PCT H did not use a stethoscope to listen to Pt #8’s vascular access site prior to cannulation as per policy. During interview with Manager of Clinical Services (MCS) L, while discussing observations on 08/06/2024 beginning at 2:00 PM, MCS L stated that staff should evaluate the AVF/G using a stethoscope prior to cannulating the vascular access site. MCS L stated that staff should follow the policy to ensure the appropriate dry time for the antiseptic used.”

“POC-IMPLEMENT UPDATE-15 DAYS P PT ASSESS CFR(s): 494.90(b)(2) Implementation of monthly or annual updates of the plan of care must be performed within 15 days of the completion of the additional patient assessments specified in §494.80(d). This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to complete the comprehensive patient plan of care (POC) within 15 days of the comprehensive patient assessment in 1 of 5 patient medical records reviewed (Patient (Pt) #5), in a total sample of 5 medical records reviewed. Findings Include: Review of policy and procedure #1-12-08 titled, “Hemodialysis Patient Assessment and Plan of Care” last revised April 2024 revealed: -The Plan of Care... must be completed within 15 days of completing the re-assessment. Review of Pt #5’s medical record revealed the most recent POC meeting was on 06/28/2024. Review of Pt #5’s Comprehensive Assessment Report revealed the Registered Nurse (RN) completed Pt #5’s comprehensive assessment on 05/27/2024 (32 days before POC meeting), Dietician (RD) on 05/31/2024 (28 days before POC meeting), Social Worker (SW) on 06/08/2024 (20 days before POC meeting), and the Physician on 06/05/2024 (23 days before POC meeting); Pt #5’s POC meeting was not completed within 15 days of the interdisciplinary team (IDT) patient assessments as per policy. During interview with Manager of Clinical Services (MCS) L, while discussing medical record findings on 08/01/2024 beginning at 4:00 PM, MCS L stated that staff should be following the policy in regards to the POC and patient assessments.”

“H-COORDINATION OF CARE BY MEMBER OF IDT CFR(s): 494.100(c)(1)(ii) Services include, but are not limited to, the following: (ii) Coordination of the home patient’s care by a member of the dialysis facility’s interdisciplinary team. This Standard is not met as evidenced by: 29972 Based on interview and record review the facility staff failed to effectively coordinate transportation for patients receiving treatment in the dialysis unit at the Skilled Nursing Facility (SNF) in 1 of 1 dialysis units reviewed in a SNF (Staff assisted Hemodialysis), in a total sample of 1 reviewed. Findings Include: Review of the “Home Hemodialysis Coordination Agreement” (agreement with dialysis facility and SNF) signed on 04/27/2022 revealed: - G. “Operator (SNF) shall have the sole responsibility for transporting HHD (home hemodialysis) patients to and from the Treatment Den (dialysis unit) within the NF (nursing facility) to receive dialysis treatment at the scheduled time.” During an interview with Patient (PT) #5 on 08/06/2024 at 7:59 AM at the dialysis unit in the SNF, when asked about drop-off and pick-up times for dialysis treatment, Pt #5 stated that sometimes s/he has to wait a “long” time to get picked up and does not feel there is enough staff available. Per interview with Patient Care Technician (PCT) H and Registered Nurse (RN) O on 08/06/2024 beginning at 8:40 AM, PCT H stated that the SNF is responsible for transporting patients to and from dialysis treatment. PCT H stated that patients have been arriving for treatment late and sometimes it takes “30 minutes to 2 hours” for SNF staff to pick up patients after dialysis treatment. PCT H stated that the SNF Director of Nursing and the Regional Operation Director (ROD) K are notified every time this happens, but “nothing has changed.” RN O stated that the SNF is given a schedule of the dialysis treatment times and is called when the patient’s treatments are completed; per RN O the SNF staff do not always answer the phone when dialysis staff call for pick up. Review of Operational Data of Patient On Time Arrival/Pick up revealed in 06/24/2024 3 patients arrived late to dialysis treatment and 4 patient pick-ups were escalated to Administration; on 06/26/2024 2 patients arrived late to dialysis treatment, and 2 pick ups were escalated to Administration; on 06/28/2024 1 patient arrived late to treatment, 1 patient pick up escalated to Administration. There was no data for July 2024. During interview with ROM K on 08/06/2024 beginning at 12:20 PM, ROM K stated that SNF patient drop off and pick up times have been delayed and were brought forward to the nursing home administration. ROM K stated that there was no documented evidence of staff developing an action plan with the SNF to address late pick up and drop of times, and monitoring the plan to ensure this issue is addressed.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 29972 Based on record review and interview facility staff failed to set goals, track, trend, and address issues with Blood Pressure (BP) Management and failed to use community developed performance measures to track fluid management concerns for 1 of 3 Quality Assessment and Performance Improvement (QAPI) programs reviewed (Hemodialysis in the Skilled Nursing Facility), in a total of 3 QAPI programs reviewed. Findings include: Review of policy and procedure #1-14-06 titled, “Continuous Quality Improvement Program” last revised April 2021 revealed: - “The facility will measure, analyze, and track quality indicators or other aspects of performance.” - “The facility CQI (Continuous Quality Improvement) program is organized, documented, and reflects current knowledge and professional standards.” Review of the Centers for Medicare and Medicaid (CMS) MAT (Measures Assessment Tool) guidelines revealed BP and Fluid Management performance measures includes tracking the Ultra Filtration Rate (UFR) of 13 ml (milliters)/kg (kilogram)/ hr (hour) and tracking pre treatment BP >140/90 and post treatment BP >130/80. Per review of the quality data in the Facility Health Record (FHR) for April 2024, May 2024, and June 2024 of the Hemodialysis unit in the Skilled Nursing Facility (treatment 3x/week), there was no documentation of the facility setting goals, tracking, trending, and addressing concerns related to BP management as per CMS MAT guidelines. Review of quality Fluid indicators in FHR for April 2024, May 2024, and June 2024 for the Hemodialysis in the Skilled Nursing Facility (3x/week), revealed there was no documentation of staff tracking and trending concerns with UFR > 13 ml/kg/hr as per CMS MAT guidelines. During interview with Manager of Clinical Services (MCS) L and Regional Operations Manager (ROM) K, while discussing QAPI for the dialysis unit in the SNF on 08/06/2024 beginning at 2:00 PM, MCS L stated that the staff do not monitor BP and Fluid management indicators in monthly FHR. MCS L stated that staff address individual patients with a UFR >13 ml/kg/hr, but this is not tracked and trended in QAPI.”

“QAPI-INDICATOR-ANEMIA MANAGEMENT CFR(s): 494.110(a)(2)(iv) The program must include, but not be limited to, the following: (iv) Anemia management. This Standard is not met as evidenced by: 29972 Based on record review and interview, the facility failed to ensure the interdisciplinary team (IDT) address Anemia management quality indicators, including tracking blood transfusions, Transferrin Saturations (Tsat %), and Ferritin for 1 of 3 Quality Assessment and Performance Improvement (QAPI) programs reviewed (Hemodialysis in the Skilled Nursing Facility), in a total of 3 QAPI programs reviewed. Findings Include: Review of policy and procedure #1-14-06 titled, “Continuous Quality Improvement Program” last revised April 2021 revealed: - “The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not limited to, the following:...Anemia Management...” - “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...” Per review of the quality data in the Facility Health Record (FHR) for April 2024, May 2024, and June 2024 of the Hemodialysis unit in the Skilled Nursing Facility, there was no documentation of the facility tracking, trending, and addressing concerns related to blood transfusions, Tsat %, and Ferritin. During interview with Manager of Clinical Services (MCS) L and Regional Operations Manager (ROM) K, while discussing QAPI for the dialysis unit in the SNF on 08/06/2024 beginning at 2:00 PM, ROM K stated that there was no documented evidence of staff addressing the above Anemia management indicators in FHR. Per ROM K, these indicators should be addressed monthly.”

“QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT CFR(s): 494.110(a)(2)(ix) The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents. This Standard is not met as evidenced by: 29972 Based on record review and interview facility staff failed to discuss trends and develop action plans to address Hepatitis B susceptible patients in 1 of 3 Quality Assessment and Performance Improvement (QAPI) programs reviewed (Hemodialysis in the Skilled Nursing Facility), in a total of 3 QAPI programs reviewed. Findings include: Review of policy and procedure #1-14-06 titled, “Continuous Quality Improvement Program” last revised April 2021 revealed: - “The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not limited to, the following:...Infection Control, including...Vaccination rates for Hepatitis B...” - “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...” Review of the Vaccination and Surveillance Report revealed in June 2024 there were 5 patients (Pt #5, 8, 9, 10, 11) receiving dialysis at the Skilled Nursing Facility (SNF) that were Hepatitis B susceptible. Review of the Facility Health Record (FHR) Quality dashboard for the dialysis unit in the SNF for April 2024, May 2024, and June 2024, revealed there was no documentation of a plan addressing Hepatitis B susceptible patients. During interview with Manager of Clinical Services (MCS) L and Regional Operations Manager (ROM) K, while discussing QAPI for the dialysis unit in the SNF on 08/06/2024 beginning at 2:00 PM, ROM K stated that there was no documented evidence in FHR of staff recognizing and addressing Hepatitis B susceptible patients.”