Davita Grant Line 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: 36681 Based on interview and record review, the facility failed to ensure one of three sampled patients (Patient 1) was involved in the initial plan of care when Patient 1 was not present during the IDT (Interdisciplinary Team) meeting. This failure had the potential for Patient 1 to not be informed of the treatment plans in order to achieve the desired goals of care. Findings: During a review of the clinical records, the records indicated Patient 1 was readmitted to the facility in June 2025 with diagnosis of End Stage Renal Disease (ESRD - irreversible kidney failure). During a review of Patient 1’ s Initial Plan of Care (POC), the IDT meeting was conducted on 9/12/25. The POC indicated, “Not reviewed with [Patient 1]” and Patient 1 was not present at the meeting. During an interview with the Facility Administrator (FA) on 12/9/25 starting at 12:01 p.m., the FA stated Patient 1 was seen by the psychiatrist in the hospital and he was deemed capable of making his own decisions. During a concurrent interview and record review with the Facility Administrator (FA) on 12/9/25 starting at 2:58 p.m., the FA confirmed Patient 1 was not present during the IDT meeting on 9/12/25. The FA stated she could not find the sign-in sheet and there was no documentation Patient 1 was informed of what was discussed during the IDT meeting. The FA further stated the IDT meeting is important to make sure there is coordination of patient’ s care with the rest of the team. A review of the facility’ s policy and procedure revised October 2024 and titled, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” indicated, “ ...The facility’ s interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient’ s personal representative ...The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient’ s treatment plan and expectations of care.””

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 36681 Based on interview and record review, the facility failed to ensure the plan of care (POC) was completed after 30 days of admission for one of 3 sampled patients (Patient 1). This failure had the potential to decrease the facility’s capability in identifying services necessary to address the patients’ needs. Findings: During a review of the clinical records, the records indicated Patient 1 was readmitted to the facility in June 2025 with diagnosis of End Stage Renal Disease (ESRD - irreversible kidney failure). During a review of Patient 1’ s POC, the POC’ s due date was on 7/23/25, the IDT (Interdisciplinary Team) meeting was on 9/12/25 and the POC was finalized on 9/23/25. During an interview with the Clinical Coordinator (CC) on 12/9/25 at 12:49 p.m., the CC stated the Initial POC should be done within 30 days after admission. During a concurrent interview and record review with the Facility Administrator (FA) on 12/9/25 at 2:58 p.m., the FA confirmed the POC was scheduled on 7/23/25 and the IDT was done 9/12/25. The FA stated she does not know the reason why the IDT meeting was late. A review of the facility’ s policy and procedure revised October 2024 and titled, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” indicated, “ ...An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines ...””