Davita Renal Treatment Center-Derby

“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: 38800 Based on interview and document review, the End Stage Renal Dialysis (ESRD) facility failed to conduct the required testing of their Emergency Preparedness Plan. The ESRD facility’s failure to ensure that the required exercises to test their emergency plan has the potential for Emergency Plan gaps or failures going unidentified. Additionally, failing to conduct the required exercises leaves staff under prepared and unaccustomed to the implementation and intended functionality of the Emergency Plan. Findings Include: A review of the provided Emergency Preparedness Documentation revealed that the facility had no documented records of actual natural or man-made emergencies, and the facility failed to participate in a community based full-scale exercise or a facility based full-scale exercise. The facility also failed on the opposite years to conduct another facility based full-scale exercise; conduct a facility-based functional exercise; conduct a mock disaster drill; conduct a tabletop exercise; or participate in a workshop that was led by a facilitator. During an interview 07/18/24 between 11:30 AM and 12:30 PM, Staff A, Facility Administrator (FA) revealed that the Emergency Preparedness Plan testing had not been conducted or documented by the previous FA. Staff A, FA was present and acknowledged findings.”

“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: 50529 Based on interview, record review, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing it through a filter) treatment prescription as determined by the medical provider for 3 of 4 sampled patients (Patients 1, 3, and 4.) This deficient practice has the potential to negatively impact the effectiveness of the dialysis treatment and lead to poor clinical outcomes including increased hospitalizations and mortality rates for all patients receiving treatment at this ESRD facility. Findings Include: Review of a policy titled, “Prescribed Treatment Time Not Met,” revised 04/2024, showed, “ ... A. Completion of the Early Termination of Treatment Against Medical Advice (AMA) form. 1. The RN (Registered Nurse) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time... 3. The RN will obtain the patient’s signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient’s signature prior to rinse-back, the RN will obtain the patient’s signature on the form prior to the patient’s departure from the facility. 4. A RN must countersign all Early Termination of Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 5. If a patient refuses to sign the Early Termination of Treatment Against Medical Advice form, the RN will document the patient’s refusal with the words “patient refused” in the patient signature box along with the date. Under such circumstances, the RN will sign the form and will also obtain a witness’ signature on the form. 6. This applies only to shortened treatments ... B. Prescribed Treatment Time Not Met 1. If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient’s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient’s specific needs. Note: Shortened/Early Termination of the dialysis treatment includes all reasons the prescribed dialysis time is not met by 30 or more minutes. This includes but is not limited to, the late initiation of treatment with termination at scheduled time, early termination at the end of treatment and interruptions of dialysis during the treatment i.e., machine or access problems or use of the bathroom by the patient. 2. Reasons why a patient’s treatment may be terminated early include, but are not limited to: Medical reasons at the discretion of the charge nurse or physician; access issues, sent to ER, behavior issues, other medical issues, Patient choice (refer also to Section A), Facility emergency (power outages, weather-related emergencies, other facility wide equipment failure); and Patient transportation problems that cannot be accommodated by the facility. 3. If a patient’s treatment is shortened/early terminated, the RN will document the event in the patient’s medical record. Documentation will include, as appropriate: The amount of time by which the treatment was shortened, A description of why the treatment was shortened. Whether the patient’s nephrologist was notified. A description of the follow-up medical orders provided by the patient’s attending nephrologist (if any). A description of all other interventions planned to address the shortened treatment, including recommendations to the patient; and a copy of the Early Termination of Treatment Against Medical Advice for signed by the patient, if shortened voluntarily by patient (see Section A of this policy). 4. Additionally, if the patient’s dialysis treatment is terminated 30 or more minutes prior to the ordered treatment length, the reason must be documented in the patient treatment record at the time the treatment was terminated while reconciling/late reconciling the treatment times. 5. The facility’s FA (Facility Administrator) will verify that all shortened treatments are recorded and trended, and the FA shall verify that such records are reviewed and discussed at the Facility Health Meetings (FHM), as appropriate ...” Patient 1 Review of Patient 1’s medical record showed a 76-year-old male with a diagnosis of ESRD (End Stage Renal Disease) admitted on 03/14/24. Dialysis orders dated 07/04/24, showed a treatment time 210 minutes. On 07/13/24 at 10:48 AM, Patient 1’s treatment was terminated 89 minutes early. Review of the treatment failed to show documented evidence of physician notification for a shortened treatment equal to or greater (=/>) than 30 minutes and failed to show interventions to address shortened treatment time. On 07/02/13 at 2:42 PM, Patient 1’s treatment was terminated 10 minutes early. Review of the AMA form showed the facility failed to obtain Patient 1’s signature for a shortened treatment. Patient 3 Review of Patient 3’s medical record showed a 65-year-old male with a diagnosis of ESRD admitted on 07/12/29. Dialysis orders dated 06/20/24, showed a prescribed treatment time of 240 minutes. On 07/04/24 at 8:59 AM, Patient 3’s treatment was terminated 37 minutes early. Review of the treatment failed to show documented evidence of physician notification for a shortened treatment =/> 30 minutes and failed to show interventions to address shortened treatment time. Patient 4 Review of Patient 4’s medical record showed a 66-year-old male with a diagnosis of ESRD, admitted on 08/30/21. Dialysis orders, dated 06/04/24, showed a prescribed treatment time of 210 minutes. On 07/10/24 at 12:54 PM, Patient 4’s treatment was terminated 18 minutes early. Review of the treatment failed to show documented evidence of interventions to address shortened treatments and the facility was unable to provide documentation of an AMA signed by the patient in the medical record. On 07/08/24 at 1:01 PM, Patient 4’s treatment was terminated early 29 minutes early. Review of the treatment failed to show documented evidence of interventions to address shortened treatments and the facility was unable to provide documentation of an AMA signed by the patient in the medical record. On 07/05/24 at 12:57 PM, Patient 4’s treatment was terminated 29 minutes early. Review of the treatment failed to show documented evidence of interventions to address shortened treatments. On 07/03/24 at 11:33 AM, Patient 4’s treatment was terminated 67 minutes early. Review of the treatment failed to show documented evidence of physician notification for a shortened treatment =/> 30 minutes and failed to show interventions to address shortened treatment time. On 07/01/24 at 12:57 PM, Patient 4’s treatment was terminated 28 minutes early. Review of the treatment failed to show documented evidence of interventions to address shortened treatments and the facility was unable to provide documentation of an AMA signed by the patient in the medical record. During an interview on 07/17/24 at 12:30 PM, Staff C, Manager of Clinical Services, stated that not all patients with shortened treatments had an Against Medical Advice (AMA) form signed for each treatment as per policy. She stated that the nephrologist is only notified of shortened treatments at the end of each week by faxing an Excel spreadsheet. During an interview on 07/18/24 at 10:32 AM, Staff B, RN, stated that the facility’s policy is to have the patient sign an AMA anytime they want to shorten treatment time. A technician records the shortened treatments on an Excel spreadsheet and faxes it to the Nephrologist at the end of each week.”