Davita Prescott Dialysis

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 52534 Based on document review and interview, it was determined that the facility failed to ensure consent was obtained prior to administration of medication/vaccine for (1) of (1) patients (Patient #1). The facility ’ s failure to obtain informed consent poses the potential risk of violating the patient’s right to participate in their plan of care which may result in adverse health outcomes. Findings include: The document titled “Patient’s Rights” revealed “As a DaVita patient I understand I am entitled to the following: ...To be informed about and participate, if desired, in all aspects of my individualized plan of care and be informed of the right to refuse treatment and to be fully informed of the medical consequences of refusing treatment/appointment ....” The policy titled “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance” revealed “...Hepatitis B Vaccination ...An order will be obtained for hepatitis B vaccination. The patient is provided the Vaccination Information Sheet (VIS) and a consent form (included in Patient Registration Packet found in Reggie). The patient will consent to the vaccination or will decline. The completed form will be kept in the patient’s health record ....” Patient #1 ’ s medical record review on 07/29/2025 revealed the patient had orders for, and received the Energix-B Hepatitis Vaccine on 11/22/2023 and 12/22/2023. Patient #1 ’ s medical record did not include a signed consent for the Hepatitis B Vaccine. Employees #1 and 2 confirmed on 07/29/2025 that Patient #1 did not have a signed consent for the Hepatitis B vaccine prior to administration of the vaccine.”

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 49430 Based on facility policy review, record review and interviews, the facility failed to conduct a comprehensive initial assessment for a newly admitted patient (Patient #3) within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session Finding includes: 1. Policy Titled “Medical Record Quality Assurance” requires “...2. A comprehensive medical History and Physical (H&P) ...accompany the new patient on admission...in accordance with DaVita policy and state regulations...” Policy Titled “Dialysis Services and Patient History and Physical Examination” requires “...A physician preforms a medical history and physical examination on the patient within 30 days before admission or within 48 hours after admission and documents the medical history and physical examination in the patient’s medical record within 48 hours after admission ....” Medical records indicate patient was admitted 11/18/22. A History/Physical (H/P), stamped “INITIAL H&P DO NOT THIN” found in patients chart dated 11/07/2022 preformed and signed by Dr Bhala, whom is not listed as a credentialed provider at the facility. Document authenticated by signature by Dr Amir Gerges, on 01/04/2023, whom is the patient’s nephrologist at the clinic. Employee #1 confirmed, on 03/13/2024, the H/P was not authenticated within the appropriate timeframe.”

“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: 49430 Based on policy review, medical record review and staff interview, it was determined the facility failed to require a History and Physical (H&P) be done annually for 1 of 4 current patients reviewed (Patient #4). Findings include: Policy titled “dialysis services and patient history and physical examination” requires “The patient’s nephrologist...preforms a medical history and physical examination on the patient at least once every 12 months from the date of the patient’s admission...”. Patient #3 H&P signed 10/18/2022 is the latest H&P in the patient’s chart making the latest H&P greater than one (1) year (15 months). During an interview conducted 03/13/2024, Employee #1, confirmed the latest H&P in the patien’s chart is older than one (1) year.”