Davita Mission Dialysis

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 50529 Based on observation, policy review, and interview, the facility failed to ensure that 6 of 6 sampled patients (Patient 1, 2, 3, 4,5, and 6) were provided with appropriate orientation and training to ensure patient knowledge of emergency procedures, both in and out of the facility, upon admission, quarterly, annually, and with any changes and/or updates to the facility’s Emergency Preparedness Plan. This deficient practice could inhibit safe evacuation and planned preparedness during an emergency and has the potential to negatively impact the health and well-being of the 22 patients who received treatment at this facility. Findings Include: Review of a policy titled, “Facility Emergency Management Plan (ICHD, Home),” revised October 2024, showed that patients will be provided with emergency training and education upon admission, annually, quarterly, and when there is a change and/or update to the emergency plan. Annual education and training includes the following: Facility specific emergency response procedures to include fire safety, disconnection from dialysis machine, emergency equipment, evacuation routes, and shelter in place location; What to do if an emergency occurs away from the facility to include local emergency and hazard preparedness information, copies of dialysis treatment records, medical records, immunizations, three (3) day emergency diet, alternate transportation arrangement, and where to go and who to call in an emergency. Quarterly education and training includes the following: Fire Safety Preparedness and Emergency Take-off procedures. All training is required to be documented on applicable forms. On 03/12/25 at 07:20 AM, chart review for Patient 1 failed to show documented evidence that patient was provided with assigned evacuation locations in the event of an emergency. On 03/12/25 at 07:20 AM, chart review for Patient 2 and 3 failed to show documented evidence that patients were provided with information of the facility’s emergency preparedness policies and procedures that could be verified by patient signature of receipt and understanding and failed to provide patients with assigned evacuation locations in the event of an emergency. On 03/12/25 at 04:22 PM, chart review for Patient 4 failed to show documented evidence that patient was provided with assigned evacuation locations in the event of an emergency. On 03/12/25 at 04:22 PM, chart review for Patient 5 and 6 failed to show documented evidence that patients were provided with information of the facility’s emergency preparedness policies and procedures that could be verified by patient signature of receipt and understanding and failed to provide patients with assigned evacuation locations in the event of an emergency. During an interview on 03/12/25 at 12:48 PM, Staff A, Facility Administrator (FA), Staff B, Manager of Clinical Services (MCS), and Staff G, FA, confirmed that education on emergency evacuation locations was not provided to Patient 1, 2, 3, 4, 5, and 6. Staff B stated that policy requires the facility to provide emergency preparedness training to patients at admission, annually, and as needed. Staff B stated that EP training forms need to be completed to ensure patients are provided with the most accurate information and that failure to follow policy could result in increased risk of injury, confusion, and potential fatalities in an emergency.”

“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: 50529 Based on observation, policy review and interview the facility failed to ensure staff were following infection control policies for patient hand hygiene post treatment. Failure to encourage hand washing and/or provide hand sanitizer after treatment posed the potential spread of pathogens (microorganisms that can cause disease) which could negatively impact the health and well-being of the 22 patients who received dialysis (medical treatment that removes waste products and excess fluid from the blood when the kidneys are unable to do so) treatments at the facility. Findings include: Review of a facility policy titled, “Infection Control for Dialysis Facilities,” revised 04/2023, showed, “...All teammates ...will perform hand hygiene...prior to gloving and immediately after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, after interacting with wall boxes...between patients even if the contact is casual, before touching clean areas such as supplies, supply cart and chairside keyboard/mouse...Patients and caregivers will be encouraged to wash their hands and access extremity upon entering the treatment area prior to initiation of dialysis...Perform hand hygiene after treatment before leaving treatment area...Hand washing will be performed if hands are visibly contaminated with blood ...”. Observations on 03/12/25 between 8:24 AM and 10:30 AM showed that patients entering the treatment floor were not washing their access (site in which needles are inserted to access the blood stream for dialysis treatment) prior to treatment and were not performing hand hygiene after holding sites post treatment. An observation on 03/12/25 at 9:27 AM, showed Staff F, Certified Clinical Hemodialysis Technician (CCHT), discharged a patient without providing hand sanitizer after treatment. During an interview on 03/12/25 at 9:28 AM, Staff F, CCHT, confirmed that patients are expected to be given hand sanitizer or encouraged to wash hands after treatment and removing gloves. During an interview on 03/12/25 at 1:10 PM, Staff F, CCHT, confirmed that patients are expected to wash their hands and access site prior to initiation of treatment and should be given hand sanitizer or encouraged to wash hands after treatment and removing gloves. During an interview on 03/12/25 at 1:10 PM, Staff D, Registered Nurse (RN), stated that the expectation for staff is to follow facility policy for post treatment patient hand hygiene and confirmed that failure to do so increases the risk of infection for patients, staff, and visitors. During an interview on 03/12/25 at 1:14 PM, Staff A, Facility Administrator, stated that failure to perform hand hygiene after holding dialysis sites is unacceptable and staff are expected to follow policy. Staff A confirmed that failure to perform hand hygiene increases risk for infection.”

“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: 50529 Based on observation, policy review, and interview, the above-named End Stage Renal Disease (ESRD) facility failed to ensure a copy of the Patient Rights, including the current State Agency and ESRD network mailing addresses and telephone complaint numbers, were prominently displayed in the facility where it could easily be seen and read by patients. This deficient practice places any patient receiving services at this facility at risk of not being able to anonymously voice/file a complaint or grievance with the State Agency. Findings Include: Review of a facility policy titled, “Patient Grievance,” dated October 2024, showed, “ ...The use of this policy is not a requirement prior to filing a grievance with the State Department of Health and Human Services, the ESRD Network or other appropriate state or federal agencies ...” The policy failed to show the requirement for prominently displaying the State Agency (SA) and ESRD Network contact information and phone numbers within the facility and did not list the SA or ESRD Network contact information within the policy. An observation of the facility lobby on 03/10/25 at 10:00 AM, showed the facility failed to prominently display a copy of the Patient Rights that included the SA and ESRD network contact information with addresses and telephone complaint numbers. A tour of the facility’s treatment area on 03/10/25 at 10:30 AM, failed to show a prominently displayed copy of the Patient Rights that included the SA and ESRD network contact information with addresses and telephone complaint numbers. During an interview on 03/12/25 at 7:17 AM, Staff B, Manager of Clinical Services, confirmed that the required complaint contact information for the SA and ESRD Network was not posted in a format that could easily be seen and read by patients. Staff B stated that she thought the facility had the information posted but did not know what happened to it.”

“MR-COMPLETE, ACCURATE, ACCESSIBLE CFR(s): 494.170 The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility. This Standard is not met as evidenced by: 50529 Based on medical record review, facility policy review, and interview, the facility failed to ensure 6 of 6 patients (Patient 1, 2, 3, 4, 5, and 6) had complete and accurate medical records. Failure to maintain medical records as required could result in a lack of care coordination that could negatively impact the health and well-being for the 22 patients that received services at this facility. Review of a policy titled, “Medical Record Quality Assurance,” revised October 2024, showed, “ ...All active medical records will be reviewed at least once per year to monitor compliance with [facility] clinical and documentation policies using the Medical Record Quality Assurance (QA) Checklist (attached to this policy) ...The initial Medical Record QA Checklist is to be completed within the first 30 days of admission of new patients ...During each month, different charts should be selected to complete the required sample size (10%) with the intent to review each chart at a minimum of once a year ...Medical Record QA results are to be presented and reviewed at Facility Health Meetings (FHM) [QAPI], at a minimum of quarterly ...Ongoing problems should become the focus of facility QAPI versus Continuous Quality Improvement (CQI) programs ...”Review of an ancillary policy titled, “Medical Record QA Checklist Hemodialysis,” revised 04/2024, showed the following forms/insurance/consents as required documentation for the medical record: Emergency Evacuation Acknowledgement Form (quarterly); Annual Patient Emergency Preparedness Training Acknowledgement; Quarterly Fire Drills (Signature via Annual Patient Education Calendar/Sign in Sheet); Consent to Disclose Advance Directive; Patient Financial Responsibility; Authorization to Use or Disclose Protected Health Information; Patient Rights; Request to Receive Information by Alternative Means or Location. Patient 1 Review of Patient 1’s medical record failed to contain documented Emergency Evacuation Acknowledgement, a completed Annual Patient Emergency Preparedness Training, Quarter Fire Drills with signature, monthly education, and Telehealth Tech Consent. Patient 2 Review of Patient 2’s medical record failed to contain documented Emergency Evacuation Acknowledgement, Annual Patient Emergency Preparedness Training, Quarter Fire Dills with signature, monthly education, and Electronic Communication consent. Patient 3 Review of Patient 3’s medical record failed to contain documented Emergency Evacuation Acknowledgement, Annual Patient Emergency Preparedness Training, Quarter Fire Dills with signature, monthly education, and Telehealth Tech Consent. Patient 4 Review of Patient 4’s medical record failed to contain documented Emergency Evacuation Acknowledgement, Annual Patient Emergency Preparedness Training, Quarter Fire Dills with signature, and monthly education. Patient 5 Review of Patient 5’s medical record failed to contain documented Emergency Evacuation Acknowledgement, Annual Patient Emergency Preparedness Training, Quarter Fire Dills with signature, and monthly education. Patient 6 Review of Patient 6’s medical record failed to contain documented Emergency Evacuation Acknowledgement, Annual Patient Emergency Preparedness Training, Quarter Fire Dills with signature, monthly education, and Telehealth Tech Consent. During an interview on 03/12/25 at 1:14 PM, Staff A, Facility Administrator (FA) stated that the expectation would be for chart audits to be completed monthly and was unsure why so much documentation much missing. Staff A stated that an Administrative Assistant (AA) is responsible for making sure charts are set-up appropriately. Staff A stated that only having an AA a couple days a week was causing things to get missed and there was a need for better monitoring. Staff A confirmed that the facility was not able to provide any monthly medical record audit sheets.”