Davita Hopefield 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 3 of 4 sampled patients (Patient 1,2 and 3) 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 treatment disconnection and evacuation during an emergency and has the potential to negatively impact the health and well-being of the 32 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 02/27/25, chart review for Patient 1, 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. During an interview on 02/27/25 at 12:04 PM, Staff A, Facility Administrator (FA), confirmed that education on emergency evacuation locations were not provided to Patient 1, 2 and 3. Staff A stated that policy requires the facility to provide emergency preparedness training to patients at admission, annually, and as needed. Staff A 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.”

“PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS CFR(s): 494.80(a)(1) The patient’s comprehensive assessment must include, but is not limited to, the following: (1) Evaluation of current health status and medical condition, including co-morbid conditions. This Standard is not met as evidenced by: 50529 Based on policy review and treatment record review, the facility failed to obtain pre-treatment standing blood pressures for 2 of 3 (Patient 1 and 2) sampled ambulatory in-center dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so) patients. Failure to monitor patients’ baseline vital sign parameters could result in blood pressure concerns going unrecognized and unaddressed and negatively impact the health and well-being of the 25 in-center patients who received dialysis treatments at the facility. Findings Include: Review of a policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, showed, “ ...Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse ...Sitting and standing BP [blood pressure] measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flowsheet) ...” Patient 1 Review of a treatment sheet dated, 02/14/25, showed mobility status as, “Ambulates - No Assistance Needed.” The facility failed to obtain a pre-treatment standing blood pressure without documented rationale as required per facility policy. Review of a treatment sheet dated, 02/20/25, showed mobility status as, “Ambulates - No Assistance Needed.” The facility failed to obtain a pre-treatment standing blood pressure without documented rationale as required per facility policy. Review of a treatment sheet dated, 02/24/25, showed mobility status as, “Ambulates - No Assistance Need.” The facility failed to obtain a pre-treatment standing blood pressure without documented rationale as required per facility policy. Patient 2 Review of a treatment sheet dated, 02/14/25, showed mobility status as, “Ambulates - No Assistance Needed.” The facility failed to obtain a pre-treatment standing blood pressure without documented rationale as required per facility policy. Review of a treatment sheet dated, 02/24/25, showed mobility status as, “Ambulates - No Assistance Needed.” The facility failed to obtain a pre-treatment standing blood pressure without documented rationale as required per facility policy.”

“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 policy review and document review, the facility failed to ensure patients’ blood flow rate (BFR) and/or dialysis flow rate (DFR) were administered as prescribed by a physician for 3 of 3 (Patient 1, 2, and 3) dialysis (a medical procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so) patients. Failure to administer BFR and/or DFR as prescribed placed patients at risk of poor dialysis outcomes and/or increased mortality rates and could negative impact the health and well-being of the 25 patients who received in-center treatments at this facility. Findings Include: Review of a policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” revised April 2024, showed, “ ...If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented, and the licensed nurse informed ...” Patient 1 Review of Patient 1’s treatment record from 02/12/25 to 02/24/25 showed a prescribed BFR of 450 mL/min and DFR of 600 mL/min. On 02/12/25 at 6:29 AM and 6:59 AM, the DFR was documented at 610 mL/min. Documentation failed to show rationale for the change to prescribed DFR. On 02/14/25 at 6:31 AM, the DFR was documented at 610 mL/min. At 7:01 AM, the DFR was documented at 590 mL/min. Documentation failed to show rationale for the change to prescribed DFR. On 02/17/25 at 6:44 AM, the DFR was documented at 580 mL/min. At 9:14 AM, the DFR was documented at 610 mL/min. Documentation failed to show rationale for the change to prescribed DFR. On 02/20/25 at 6:25 AM, the DFR was documented at 610 mL/min. At 7:55 AM to 8:26 AM, the DFR was documented at 610 mL/min. From 8:44 AM to 9:25 AM, the BFR was documented at 350 mL/min. Documentation failed to show rationale for the change to the prescribed DFR and BFR. On 02/24/25 at 6:34 AM, the DFR was documented at 610 mL/min. At 10:25 AM, the DFR was documented at 610 mL/min. At 7:04 AM, the BFR was documented at 400 mL/min and remained at 400 mL/min until end of treatment at 10:25 AM. Documentation failed to show rationale for the change to the prescribed DFR and BFR. Patient 2 Review of Patient 2’s treatment record from 02/12/25 to 02/24/25 showed a prescribed DFR of 600 ml/min and BFR of 350 mL/min. On 02/12/25 at 10:26 AM, the BFR was documented at 320 mL/min. At 10:56 AM to 1:16 PM, the BFR was documented at 300 mL/min. At 9:56 AM, the DFR was documented at 590 mL/min. At 10:26 AM to 10:56 AM, the DFR was documented at 610 mL/min. Documentation failed to show rationale for the change to the prescribed DFR and BFR. On 02/17/25 at 12:00 PM, the DFR was documented at 580 mL/min. At 12:30 PM, the DFR was documented at 0 mL/min. At 1:43 PM, the DFR was documented at 590 mL/min. At 2:30 PM, the DFR was documented at 590 mL/min. Documentation failed to show rationale for the change to the prescribed DFR. Review of Patient 2’s treatment sheet on 02/24/25 showed a prescribed BFR of 400 mL/min. At 12:38 PM, the BFR was documented at 390 mL/min. At 2:08 PM, the BFR was documented at 390 mL/min. At 2:38 PM to 3:08 PM, the BFR was documented at 350 mL/min. At 12:38 PM, the DFR was documented at 590 mL/min. At 12:53 PM to 1:08 PM, the DFR was documented at 0 mL/min. At 3:38 PM, the DFR was documented at 610 mL/min. Documentation failed to show rationale for the change to the prescribed BFR and DFR. Patient 3 Review of Patient 3’s treatment record from 02/12/25 to 02/24/25 showed a prescribed DFR of 600 ml/min and BFR of 400 mL/min. On 02/10/25 at 8:23 AM, the BFR was documented at 350 mL/min. At 8:27 AM, the BFR was documented at 340 mL/min. At 8:57 AM, the BFR was documented 360 mL/min. At 9:27 the BFR was documented at 300 mL/min and remained at 300 mL/min to end of treatment at 10:52 AM. Documentation failed to show rationale for the change to the prescribed BFR. On 02/20/25 at 8:39 AM to 10:43 AM, the BFR was documented at 350 mL/min. At 7:09 AM, the DFR was documented at 610 mL/min. At 8:09 AM, the DFR was documented at 590 mL/min. Documentation failed to show rationale for the change to the prescribed BFR and DFR.”

“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 3 of 4 patients (Patient 1, 2, and 3) 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 32 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, Annual Patient Emergency Preparedness Training, Quarter Fire Dills with signature, signed Health Insurance Portability and Accountability Act (HIPAA) Permission to Discuss, Patient Authorization and Financial Responsibility, Insurance Counseling, Advanced Directives, ePrescribe, HIE opt in, and Electronic Communication 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, 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, and signed Patient Rights consent. During an interview on 02/27/25 at 12:04 PM, Staff A, Facility Administrator (FA) stated that the expectation would be for chart audits to be completed monthly, but audits haven’t been getting done due to staffing. Staff A stated that typically, an Administrative Assistant would be responsible for making sure charts are set-up appropriately. Staff A stated, “Since we don’t [have an administrative assistant] this task falls on me but gets overlooked for more time sensitive issues. Staff A confirmed that the facility was not able to provide any monthly medical record audit sheets.”