Davita Cross Keys Dialysis

“ESRD EP Training Program CFR(s): §494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to include the social worker and dietician in the facility emergency preparedness training to ensure they were fully prepared in the event of an emergency. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 57. Findings included: 1. Review of the facility emergency preparedness information showed it did not contain documentation that showed the facility social worker or dietician were included in the facility’s emergency preparedness training. 2. During an interview on 7/29/25 at 8:20 AM, the dietician said she has been the dietician at this facility since September of 2024 and she did not recall formal training on emergency preparedness. 3. During an interview on 7/29/25 at 8:45 AM the social worker said she has been the social worker at this facility for seven months and she did not recall formal training on emergency preparedness. 4. During an interview on 7/29/25 at 10:15 AM, the group facility administrator said the dietician and social worker are sometimes at other facilities and staff need to ensure they are at this facility when they conduct emergency preparedness training for staff.”

“IC-ASEPTIC TECHNIQUES FOR IV MEDS CFR(s): 494.30(b)(2) [The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and This Standard is not met as evidenced by: 17026 Based on observations and staff interview, the facility staff failed to ensure protein therapy and two containers of test strips were not expired. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 57. Findings included 1. Observation on 7/29/25 at 8:11 AM of the medication refrigerator in the treatment area showed 1000 milliliters of Intradialytic Parenteral Nutrition (IDPN) protein therapy (specialized nutritional therapy for dialysis patients) that expired 6/10/25. 2. Observation on 7/28/25 at 11:28 AM of the water room showed approximately 25 residual test strips that expired 2/19/25. 3. Observation on 7/28/25 at 11:35 AM of the treatment area showed approximately 25 pH (potential of hydrogen) test strips (used to measure how acidic or basic a substance is) that expired 10/31/24. 4. During an interview on 7/29/25 at 11:05 AM, the group facility administrator said staff need to ensure the supplies were not expired.”

“RO-CHEMICAL ANALYSIS-FREQUENCY CFR(s): 494.40(a) 6.2.7 Reverse osmosis: Chemical analysis: frequency Chemical analysis for the contaminants listed in 4.1.1 (Table 1) should be done when the RO system is installed, when membranes are replaced, and at not less than annual intervals thereafter to ensure that the limits specified in 4.1.1 are met (see Table 1). Chemical analyses should be done when seasonal variations in source water suggest worsening quality or when rejection rates fall below 90 %. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to conduct an annual chemical analysis of the water in 2024 to determine if the water had any potentially harmful contaminants. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 57. Findings included: 1. Review of the facility’s chemical analysis of the water showed staff did the most recent chemical analysis of water on 10/25/23. The documentation did not show staff completed a chemical analysis of the water in 2024. 2. During an interview on 7/29/25 at 1:25 PM, the biomedical technician said he could not find documentation that showed staff completed a chemical analysis of the water in 2024, but staff should conduct that annually.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 17026 Based on record review and staff interview, the facility staff failed to follow the physician order for the blood flow rate or dialysate flow rate for two patients (Patient # 19 and # 42) out of six clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 57. Findings included: 1. Review of the treatment flow sheet dated 6/19/25 for Patient # 19 showed the physician directed staff to set the blood flow rate at 350 and the dialysate flow rate at 600, but staff set the blood flow rate at 400 and the dialysate flow rate at 800 for the patient’s dialysis treatment. 2. Review of the treatment flow sheet dated 7/23/25 for Patient # 42 showed the physician directed staff to set the blood flow rate at 400, but staff set the blood flow rate at 350 for the patient’s dialysis treatment. 3. During an interview on 7/29/25 at 11:05 AM, the group facility administrator said staff should follow the physician order for the blood flow rate and dialysate flow rate.”

“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: 17026 Based on record review and staff interview, the facility staff failed to conduct a pre registered nurse assessment within one hour of a patient starting on dialysis treatment for three patients (Patient # 19, # 42, and # 47) out of six clinical records reviewed. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 57. Findings included: 1. Review of the treatment flow sheet dated 6/24/25 for Patient # 19 showed staff started the patient on dialysis treatment at 12:30 PM but did not conduct the pre registered nurse assessment until 2:32 PM. 2. Review of the treatment flow sheet dated 7/23/25 for Patient # 42 showed staff started the patient on dialysis treatment at 10:39 AM but did not conduct the pre registered nurse assessment until 12:26 PM. 3. Review of the treatment flow sheet dated 7/22/25 for Patient # 47 showed staff started the patient on dialysis treatment at 10:34 AM but did not conduct the pre registered nurse assessment until 12:22 PM. 4. During an interview on 7/29/25 at 11:05 AM, the group facility administrator said staff should conduct the pre registered nurse assessment within one hour of a patient starting on dialysis treatment.”

“MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL CFR(s): 494.170(a) The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient’s record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program. This Standard is not met as evidenced by: 17026 Based on observations and staff interview, the facility staff failed to ensure the medical records were secured and not accessible to patients or visitors. This had the potential to effect all patients on dialysis and cause an increase in complications. The facility census was 57. Findings included: 1. Observation on 7/28/25 at 11:15 AM showed the door to the treatment area propped open and accessible to anyone that walked in the front door of the facility. 2. Observations on 7/28/25 at 11:40 AM, 12:32 PM, 1:31 PM, and 2:28 PM of the medical records room showed the door to the room propped open. Further observation showed the medical records room adjacent to the dialysis treatment area and accessible to anyone in the dialysis treatment area. 3. Observation on 7/30/25 at 7:24 AM of the medical records room showed the door to the room propped open. 4. During an interview on 7/29/25 at 11:05 AM, the group facility administrator agreed that the medical records need to remain secured and not accessible to any patients or visitors.”