West Hattiesburg Clinic Dialysis

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 47684 Based on staff interview, review of the facility’s document titled, “Quarterly Meeting Minutes for Quality Assurance and Performance Improvement,” (QAPI) and review of the facility’s policy and procedures, the facility’s QAPI program failed to include evidence of performance improvement initiatives, including measurements, analysis, and identification of areas for improvement that will ensure the quality of patient care and facility operations for four (4) or four (4) days of survey. Findings Include: An interview with the Clinical Manager on 12/17/2024 at 3:00 p.m., confirmed the facility participates in companywide Quality Assurance (QA) quarterly meetings but failed to have documented evidence of the facility’s Performance Improvements (PI) initiatives, goals and outcome analysis. During an interview with the facility Dietician on 12/18/2024 at 10:00 a.m., the Dietician stated “Years ago we did Quality Assurance Performance Improvement (QAPI), I’ve been here for 33 years, but we haven’t done it in a while. We haven’t done it since the Clinical Director started in that position”. An interview with the facility Social Worker on 12/18/2024 at 10:30 a.m., confirmed the facility has quarterly QA meetings with all QA team members in attendance and the team does discuss Performance Improvements, but there is no documentation that shows what the facility is working on. An interview with the facility’s Case Manager on 12/19/2024 at 11:15 a.m. confirms the facility tracks patient deaths but the data is not analyzed or reviewed for trends related to the causes of patient deaths. Review of the facility document, “QAPI Reports Minute Meetings,” dated from May 2024 to November 2024 revealed the facility does have quarterly Quality Assurance (QA) meetings, but the facility has no documented evidence of ongoing written analysis and tracking of Performance Improvement (PI) initiatives, goals, or outcomes. The QAPI minutes failed to include documentation of the facility’s on-going Performance Improvement Initiatives. The facility failed to provide documented evidence of Performance Improvement Initiatives and could not identify any initiatives the facility was working on. Review of the facility’s Policy and Procedure policy on 12/19/2024 at 11:40a.m., “Hattiesburg Clinic Dialysis Quality Assessment and Performance Improvement Program”, Policy Book Section I,E, revised 11/19 ...”the committee will meet quarterly or more frequently if deemed necessary, search for probable causes, generate and choose solutions, implement solutions, and follow-through by reexamining care standards” ... ...”Hattiesburg Clinic will continuously monitor its performances, take action that results in performance improvements, and track performance to ensure that improvements are sustained over time. Priorities for performance improvement will be set by the Medical Director. Any problems that threaten the health and safety of patients will be identified and immediately corrected” ... During the exit conference on 12/19/2024 at 1:00 p.m. with Case manager, survey findings were discussed, and no further documentation was submitted for review.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 47684 Based on staff interviews, review of the facility document titled “Quarterly Meeting Minutes for Quality Assurance and Performance Improvement,” (QAPI) and review of the facility’s policy and procedures, the facility failed to provide documentation of the facility’s Performance Improvement Initiatives, including the identification of areas for improvement, development of a plan for improvement, monitoring of its performance improvement activities, and tracking the facility’s performance to ensure improvements are sustained over time for four (4) of four (4) days of survey. Findings Include During an interview with the facility’s Clinical Manager (CM) on 12/19/2024 at 9:30 a.m., the CM stated, “ I called the Administrator who was aware the facility is going to have to do something different with documentation”. The CM confirmed the facility has no documented evidence of written Performance Improvement Initiatives to submit for review. Review of the facility’s Quality Assurance Performance Improvement (QAPI) minute meetings dated May 2024-November 2024 revealed the facility has documented evidence of meeting minutes however there was no documented evidence of Performance Improvement (PI) Initiatives submitted for review. The QAPI minutes failed to include documentation of the facility’s on-going Performance Improvement Initiatives. Review of the facility’s Policy and Procedure on 12/19/2024 at 11:40a.m., “Hattiesburg Clinic Dialysis Quality Assessment and Performance Improvement Program”, Policy Book Section I,E, revised 11/19 ...”Hattiesburg Clinic will continuously monitor its performances, take action that results in performance improvements, and track performance to ensure that improvements are sustained over time. Priorities for performance improvement will be set by the Medical Director. Any problems that threaten the health and safety of patients will be identified and immediately corrected” ... During the exit conference on 12/19/2024 at 1:00 p.m. with the Case manager, survey findings were discussed, and no further documentation was submitted for review. Cross refer V-638 494.110 (b) to V-628 494.110 (a) (2) for additional documentation for the facility’s failure to provide written Performance Improvement Plans and Outcome Assessment.”