Davita Valdosta Home Training

“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: 49321 Based on observation, staff interview, and a review of Policy and Procedure (P&P), it was determined that the Infection Control Committee failed to ensure that the staff cleaned one of one large sharps container in Peritoneal Dialysis (PD) Training Room 2, after each patient use and replaced when it was 3/4 full. This breach of infection control was observed in one of three PD Training Rooms and had the potential to lead to the cross-transmission of bloodborne pathogens and other infections. The facility census was 12. Findings include: During a tour of the facility with the Facility Administrator on 8/18/24 at 9:15 a.m., the following was revealed: - There was a large sharps container in PD Training Room 2 sitting on the floor under the left arm of the treatment chair. The sharps container edges had splattered blood and the container was full. The lid was pulled back and contaminated needles were exposed/in the opening of the container and pointing up. The Facility Administrator acknowledged the above findings, but did not offer any comments. A review of Policy 4-03-07 titled, “Segregation of Medical Waste” revised October 2023 showed: 6. Sharps containers are to be sealed when 3/4 full and placed in designated area for medical waste pickup. A review of Policy 1-05-01 titled, “Infection Control For Dialysis Facilities” revised April 2023 showed the following: DISINFECTION 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area. iii. Cleaning of visible blood should be performed when first observed.”

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 49321 Based on observation and staff interview, it was determined that the facility failed to maintain a sanitary and safe environment as evidenced by dirty floors and damaged baseboard and door. These environmental concerns were observed in one of one lobby, three of three Peritoneal Dialysis (PD) Training Rooms, one of one patient’s bathroom, and one of one hallway. This deficient practice could negatively affect the health and safety of all staff and 12 patients who were receiving dialysis treatment at this facility. Findings include: 1. The floor in the lobby was dirty. There was a medium size dead spider on the left side of the front door that led into the lobby. Under the chairs against the wall in the lobby were balls of dust. 2. The floor in the PD Training Room 1 had a white film covering it, and under the sink on the right side of the room had white powdery substance and dust. The drain sink had yellow substance/stain. 3. The floor in the PD Training Room 2 had dark streaks and was sticky. There was dust noted in the corners. 4. There were dark spots covering the entire floor in the PD Isolation Room. Under the sink at the left side of the room had white powder and dust. 5. The floor in the open area leading into the training rooms had dark spots and white film covering the entire floor. The hall leading to the back door had film and dark spots on it. 6. The patient’s bathroom located near the back door, had ten inches of baseboard that was separated from the wall. There were brown/rust stains noted in the toilet bowl. 7. The floor behind the nurse’s station, going into the nurse’s work area was sticky and had dark spots. There was dust under the desk and behind the copy machine. There were three chairs with the arm rests torn down to the foam. 8. The back door was separated from the frame at the bottom (approximately 2 inches gap). There was light coming through the gap between the door and the frame. While touring the facility with the Facility Administrator on 9/18/24 at 9:15 a.m., she acknowledged the findings and stated the facility needed a deep cleaning.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 49321 Based on observation and staff interviews, it was determined that the facility failed to display a copy of the Patient’s Rights and a copy of the mechanism for filing a complaint through the State agency and ESRD (End Stage Renal Disease) Network in the facility lobby for the patients to access. The census was 12. Findings include: On 9/17/24 at 10:15 a.m., during the facility’s entrance, it was observed in the lobby area that no Patient’s Rights was posted, and no contact information (address and/or phone number) was displayed for the ESRD Network or State agency if the patients feel the need to file a complaint. During an interview with the Administrative Assistant on 9/17/24 at 10:30 a.m., it was revealed that she pulled the information down from the lobby a week ago to see if anything had changed at the ESRD Network and has not put the Patient’s Rights and ESRD Network information back on display in the lobby. The Facility Administrator was notified of the above findings during the tour of the facility on 9/18/24 at 9:15 a.m., and did not offer any comments.”

“QAPI-INDICATOR-NUTRITIONAL STATUS CFR(s): 494.110(a)(2)(ii) The program must include, but not be limited to, the following: (ii) Nutritional status. This Standard is not met as evidenced by: 49321 Based on a review of the Fiscal Year (FY) 2025 Quarterly Dialysis Facility Report [QDFR: A report prepared for ESRD facilities from the Centers for Medicare and Medicaid Services (CMS), to provide a comparative summary of treatment patterns and patient outcomes for End Stage Renal Disease patients, as compared to other facilities in the U. S.], a review of the facility’s Quality Assessment and Performance Improvement (QAPI) meeting minutes, and staff interview, it was determined that the facility failed to develop an effective QAPI program for six of six months (February - July 2024) QAPI meeting minutes reviewed, as evidenced by failure of the interdisciplinary team to adjust/revise plans of action to improve patients’ nutritional status and maximize the number of Peritoneal Dialysis (PD) patients who achieved the goal of 4.0 g/dL (grams per deciliter) for serum albumin. A low serum albumin in patients on PD is a widely accepted marker of poor outcome, more frequent hospitalization, and increased mortality. The facility census was 12. Findings include: A review of the FY 2025 QDFR for this facility revealed that PD patients whose serum albumin was less than (<) 4.0 g/dL was 78.8%, whereas the US average was 51.8 %. A review of the facility’s monthly serum albumin outcomes for PD patients with serum albumin < 4.0g/dL from February 2024 to July 2024, were as follows: February 2024 - 71 % of patients had serum albumin <4.0 g/dL March 2024 - 54 % of patients had serum albumin <4.0 g/dL April 2024 - 75 % of patients had serum albumin <4.0 g/dL May 2024 - 55 % of patients had serum albumin <4.0 g/dL June 2024 - 55 % of patients had serum albumin <4.0 g/dL July 2024 - 83 % of patients had serum albumin <4.0 g/dL A review of the monthly QAPI meeting minutes revealed a lack of modification in the plan of action to ensure improvements in the PD patients’ albumin levels. During an interviewed on 9/19/24 at 12:48 p.m., the Facility Administrator stated that hospitalization was decreasing albumin levels.”

“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: 49321 Based on a review of the Fiscal Year (FY) 2025 Quarterly Dialysis Facility Report [QDFR: A report prepared for ESRD facilities from the Centers for Medicare and Medicaid Services (CMS), to provide a comparative summary of treatment patterns and patient outcomes for End Stage Renal Disease patients, as compared to other facilities in the U. S.], a review of the facility’s Quality Assessment and Performance Improvement (QAPI) meeting minutes, and staff interview, it was determined that the facility failed to develop an effective QAPI program for six of six months (February - July 2024) QAPI meeting minutes reviewed, as evidenced by failure of the interdisciplinary team to adjust/revise plans of action to improve patients’ anemia (a blood disorder that occurs when the body doesn’t have enough healthy red blood cells) outcomes. A low Hgb can cause tiredness, weakness, dizziness, and shortness of breath. The facility census was 12. Findings include: A review of the FY 2025 QDFR for this facility revealed that PD patients whose Hgb < 10g/dL was 25.5 % whereas the U.S. average was 22.6 % A review of the facility’s QAPI meeting minutes from February 2024 to July 2024, revealed the following percentage of patients with Hgb <10 g/dL (grams per deciliter): February 2024 - 23.1% of patients had Hgb < 10g/dL March 2024 - 50% of patients had Hgb < 10g/dL April 2024 - 42.9 % of patients had Hgb < 10g/dL May 2024 - 30.8 % of patients had Hgb < 10g/dL June 2024 38. 5 % of patients had Hgb < 10g/dL July 2024 - 23.1 % of patients had Hgb < 10g/dL A review of the monthly QAPI meeting minutes revealed the same action plan and no follow up to ensure improvements in the patient’s anemia status. During an interview with the Facility Administrator on 9/19/24 at 12:48 p.m., she acknowledged that the action plan showed no changes and stated it was because the Medical Director was not open to other erythropoiesis-stimulating agents.”

“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: 49321 Based on a review of medical records and Policy and Procedures (P&P) and staff interviews, it was determined that the Medical Director (MD) failed to ensure that staff adhered to the policy relative to History and Physical (H&P) of three of four patients (P) (P#1, P#2, and P#4) sampled. This deficient practice had the potential to negatively affect the development of P#1, P#2, and P#4’s Plans of Care. The facility census was 12. Findings include: - P#1’s H&P dated 5/18/24 was completed by Internal Medicine Nurse Practitioner who admitted P#1 to the hospital with a cough. The plan was to consult a nephrologist. There was a lack of documented evidence that the H&P was reviewed, signed, and dated by P#1’s attending nephrologist. - P#2’s H&P dated 9/10/24 was done by Internal Medicine Physician who saw P#2 when he was admitted to the hospital. There was a lack of documented evidence that the H&P was reviewed, signed, and dated by P#2’s attending nephrologist. - P#4’s H&P dated 10/13/23 was completed by Internal Medicine Physician who admitted P#4 to the hospital. The nephrologist was consulted. However, there was a lack of documented evidence that the H&P was reviewed, signed, and dated by P#4’s attending nephrologist. A review of Policy 3-02-28 titled, “History and Physical (H&P) Policy” revised 10/2021 showed the following: An H&P from another provider may be designated as the admission history and physical if it was completed within last year of patient admission and is reviewed, signed, and dated by the attending nephrologist. INCLUDING a brief note that he/she agrees with the statement in the H&P. During an interview with the Facility Administrator on 9/19/24 at 10:00 a.m., it was revealed that the facility has placed all forms of paper files in the computer. The Facility Administrator stated the current H&P was the only H&P on file for each sampled patient. During an interview with the MD, who was also the nephrologist for P#1, P#2, and P#4 on 9/23/24 at 9:15 a.m., the following was revealed: The MD stated that if he does a Comprehensive Encounter, it should count as an H&P. When this surveyor informed the MD that there was a lack of medical, surgical, social, or family history documented on the Comprehensive Encounter, the MD stated that medical, surgical, social, and family history should transfer over; and it was the facility’s fault. When asked about how an H&P that was dictated by a hospital physician was used, the MD stated, I thought we could sign and date a hospital H&P and use it as the patient’s H&P. The MD also stated he was not aware that he had to document a brief note that he agrees with the statement in the H&P.”