Davita Largo Town Center Dialysis

“PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This Standard is not met as evidenced by: 47759 Based on review of policies and procedures, review of selected patients’ plan of care, patient interviews and staff interviews, the facility’s governing body failed to ensure that an initial comprehensive assessment has been conducted on all new patients within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first outpatient dialysis session. This failure placed the affected patient at potential risk of harm and denied patients right to a minimum standard of care. Findings included: On 02/15/2024 at 04:00 p.m., during record review of the facility’s Interdisciplinary team (IDT) Patient Assessment and Plan of Care (Policy 01-14-01) page 4 number 10 states “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.” On 02/15/2024 at 01:00 p.m., during record review of the selected patients’ Plan of care (PoC), the surveyor observed the following: 1. Two (2) of the Nine (9) selected patients (22%) did not have a 30 day plan of care completed- [Patient B and I] a. To confirm this finding, the surveyor interviewed Patient B. On 02/15/2024 at 12 p.m., [Patient B] stated that he has “not had a plan of care meeting” with the interdisciplinary team. 2. Patient I was admitted to the facility on 09/2022. During record review, when the surveyor requested for the 30 day PoC for [Patient I] due 10/2022, the Facility Administrator presented a PoC that was completed on 12/8/2022 which was approximately 2 months late. On 02/15/2024 at 04:10 p.m., the Facility Administrator (FA) corroborated that the interdisciplinary team need to conduct a plan of care meeting for Patients B and E as soon as possible. As for Patient I, the FA corroborated that the PoC was late and should have been completed within 30 calendar days of the patient’s admission date.”

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- (1) At least annually for stable patients; This Standard is not met as evidenced by: 47759 Based on review of policies and procedures, review of selected patients’ plan of care and staff interview, the facility’s governing body failed to ensure a complete, comprehensive reassessment of all stable patients and a plan of care (POC) was done annually. This failure prolongs the time it takes for the interdisciplinary team to reassess, reevaluate, and revise the affected patients’ treatment plan. Findings included: On 02/15/2024 at 04:00 p.m., during record review of the facility’s Interdisciplinary team (IDT) Patient Assessment and Plan of Care (Policy 01-14-01) page 8 states that annual assessments will be conducted “1 year after the 90 Day reassessment or unstable reassessment. Ongoing annual reassessments will be completed 1 year after the annual reassessment.” On 02/15/2024, at 01:00 p.m., during review of patients’ plans of care (PoC), it was noted that 3 of the 9 selected patients’ plans of care reviewed, (33%) were not performed according to the facility’s policy. The review demonstrated the following: 1. Patient A’s annual plan of care for the year 2023 was late by 2-3 months. a. In 2022, Patient A’s plan of care was completed on 05/02/2022 b. In 2023, Patient A ‘s plan of care was completed on 07/25/2023, which was approximately 2-3 months late. 2. Patent C’s annual plan of care for the year 2023 was late by 3 months. a. In 2022, Patient C’s plan of care was completed on 12/20/2022. b. In 2023, Patient C’s plan of care was completed on 03/21/2023, which was approximately 3 months late. 3. Patient G’s annual plan of care for the year 2023 was not completed. a. In 2022, Patient G’s plan of care was completed on 09/07/2022. b. In 2023, no plan of care was documented for Patient G for the year 2023. On 02/15/2024 at 04:10 p.m., the Facility Administrator (FA) corroborated that the stated plans of care were late and the Interdisciplinary team will need to work care plan timeliness.”

“POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This Standard is not met as evidenced by: 47759 Based on review of policies and procedures, review of selected patients’ medical records and staff interview, the facility’s governing body failed to conduct a quality of life assessment survey at regular intervals, or more frequently on an as-needed basis on 3 out of the 9 selected patients (33%). This failure decreases the interdisciplinary team’s ability to address the patient’s psychosocial needs and “achieve and sustain” an appropriate psychosocial status Findings Included: On 02/15/2024 at 03:00 p.m. during record review of the facility’s Quality of Life Assessment Survey (03-01-10), page 1 number 1 states “The Quality of Life (QOL) assessment survey is to be administered by the Social Worker to patients within four (4) months of initiating treatment, on an as needed basis, and repeated at least annually thereafter.” Number 2 states “If a patient refuses to complete the Kidney Disease Quality of Life Instrument (KDQOL)-36 at any time, the Social Worker needs to document the refusal in the KDQOL Psychosocial condition in the electronic medical record.” On 02/15/2024 at 03:00 p.m., during record review of the selected sampled patients, the following were discovered: 1. Patient C, who was admitted to the facility on September 2022, did not have a KDQOL completed until February 23, 2023, approximately 1 month after the due date 2. Patient H, whose last KDQOL was completed on 12/2022, did not have a KDQOL completed until January 2024; Approximately 1 month after the due date. 3. Patient I, whose last KDQOL was completed on 12/2022, did not have a KDQOL completed until January 2024; Approximately 1 month after the due date. On 02/15/2024 at 04:10 p.m, the Facility Administrator corroborated that Patients C, H and I had late KDQOL documentation.”

“GOV-RN, MSW, & RD AVAIL TO MEET PT NEEDS CFR(s): 494.180(b)(1) The governing body or designated person responsible must ensure that- The registered nurse, social worker and dietitian members of the interdisciplinary team are available to meet patient clinical needs; This Standard is not met as evidenced by: 47759 Based on staff interview and record review, the facility’s governing body failed to ensure that all members of the interdisciplinary team (registered nurse, social worker and dietitian) were available to meet patient clinical needs. This failure placed the patients at potential risk of harm and denied the patients right to a minimum standard of care. Findings Included: On 02/15/2024 at 04:15 p.m., during interview with the Facility Administrator, the surveyor discovered that the Social Worker resigned effective September 8, 2023. From September 8, 2023 through January 01, 2024, the facility did not have Social Worker coverage. This lack of coverage affected patient care by: (1) failing to complete the Kidney Disease Quality of Life Instrument (KDQOL) on time and per policy. -See Vtag 552 for a cross reference (2) failing to complete plans of care on time and per policy. -See Vtag 516 and Vtag 519”