Davita Southpoint Dialysis

“PR-PARTICIPATE IN CARE;DISC/REFUSE TX CFR(s): 494.70(a)(5) The patient has the right to- (5) Be informed about and participate, if desired, in all aspects of his or her care, and be informed of the right to refuse treatment, to discontinue treatment, and to refuse to participate in experimental research; This Standard is not met as evidenced by: 38766 Based on policy review, medical record reviews, and staff interviews, the facility staff failed to provide patients with an advanced notice of their POC meeting for 6 of 7 ICHD patients (Patients #1, #2, #3, #4, #5, and #6). The findings include: Review on 07/29/2025, of the facility’s policy, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” revised 10/2024, revealed “PURPOSE: ...ASSESSMENT: ...PLAN OF CARE: [space] 8. The facility’s interdisciplinary team will develop and implement a written, individualized comprehensive plan of care ...9. The plan of care will address, but not be limited to, the following: ...in-center hemodialysis ...Home hemodialysis ...peritoneal dialysis ...” The review failed to reveal how and when the facility staff would notify patients of their POC meeting. 1. An open medical record review on 07/31/2025 indicated that Patient #1 was admitted to the ICHD program on 06/10/2025. The review revealed that the most recent POC meeting took place on 07/23/2025. It was noted that an invitation letter for this meeting was also dated 07/23/2025. The records did not show that the patient had received advanced notice regarding the POC meeting. An interview on 07/31/2025 at 1245 with the Registered Dietitian revealed that the facility did not invite patients to their plan of care meeting ahead of time because the POC meetings were conducted at the chairside during IDT rounds. The interview revealed that if a patient wanted their family to attend, the patient would request a meeting with the team. An interview on 07/31/2025 at 1420 with the MCS revealed that patients were expected to be notified in advance of upcoming POC meetings and given the option to meet either at chairside or in private. The interview revealed that advanced notice would give the patient the option of inviting a family member or a care partner. 2. An open medical record review on 07/31/2025 indicated that Patient #2 was admitted to the ICHD program on 11/20/2024. The review revealed that the most recent POC meeting took place on 01/23/2025. It was noted that an invitation letter for this meeting was also dated 01/23/2025. The records did not show that the patient had received advanced notice regarding the POC meeting. An interview on 07/31/2025 at 1245 with the Registered Dietitian revealed that the facility did not invite patients to their plan of care meeting ahead of time because the POC meetings were conducted at the chairside during IDT rounds. The interview revealed that if a patient wanted their family to attend, the patient would request a meeting with the team. An interview on 07/31/2025 at 1420 with the MCS revealed that patients were expected to be notified in advance of upcoming POC meetings and given the option to meet either at chairside or in private. The interview revealed that advanced notice would give the patient the option of inviting a family member or a care partner. 3. An open medical record review on 07/31/2025 indicated that Patient #3 was admitted to the ICHD program on 07/07/2023. The review revealed that the most recent POC meeting took place on 11/22/2024. It was noted that an invitation letter for this meeting was also dated 11/22/2024. The records did not show that the patient had received advanced notice regarding the POC meeting. An interview on 07/31/2025 at 1245 with the Registered Dietitian revealed that the facility did not invite patients to their plan of care meeting ahead of time because the POC meetings were conducted at the chairside during IDT rounds. The interview revealed that if a patient wanted their family to attend, the patient would request a meeting with the team. An interview on 07/31/2025 at 1420 with the MCS revealed that patients were expected to be notified in advance of upcoming POC meetings and given the option to meet either at chairside or in private. The interview revealed that advanced notice would give the patient the option of inviting a family member or a care partner. 4. An open medical record review on 07/30/2025 indicated that Patient #4 was admitted to the ICHD program on 02/24/2021. The review revealed that the most recent POC meeting took place on 03/19/2025. It was noted that an invitation letter for this meeting was also dated 03/19/2025. The records did not show that the patient had received advanced notice regarding the POC meeting. An interview on 07/31/2025 at 1245 with the Registered Dietitian revealed that the facility did not invite patients to their plan of care meeting ahead of time because the POC meetings were conducted at the chairside during IDT rounds. The interview revealed that if a patient wanted their family to attend, the patient would request a meeting with the team. An interview on 07/31/2025 at 1420 with the MCS revealed that patients were expected to be notified in advance of upcoming POC meetings and given the option to meet either at chairside or in private. The interview revealed that advanced notice would give the patient the option of inviting a family member or a care partner. 5. An open medical record review on 07/30/2025 indicated that Patient #5 was admitted to the ICHD program on 10/27/2022. The review revealed that the most recent POC meeting took place on 01/15/2025. It was noted that an invitation letter for this meeting was also dated 01/15/2025. The records did not show that the patient had received advanced notice regarding the POC meeting. An interview on 07/31/2025 at 1245 with the Registered Dietitian revealed that the facility did not invite patients to their plan of care meeting ahead of time because the POC meetings were conducted at the chairside during IDT rounds. The interview revealed that if a patient wanted their family to attend, the patient would request a meeting with the team. An interview on 07/31/2025 at 1420 with the MCS revealed that patients were expected to be notified in advance of upcoming POC meetings and given the option to meet either at chairside or in private. The interview revealed that advanced notice would give the patient the option of inviting a family member or a care partner. 6. An open medical record review on 07/30/2025 indicated that Patient #6 was admitted to the ICHD program on 06/24/2013. The review revealed that the most recent POC meeting took place on 08/28/2024. It was noted that an invitation letter for this meeting was also dated 08/28/2024. The records did not show that the patient had received advanced notice regarding the POC meeting. An interview on 07/31/2025 at 1245 with the Registered Dietitian revealed that the facility did not invite patients to their plan of care meeting ahead of time because the POC meetings were conducted at the chairside during IDT rounds. The interview revealed that if a patient wanted their family to attend, the patient would request a meeting with the team. An interview on 07/31/2025 at 1420 with the MCS revealed that patients were expected to be notified in advance of upcoming POC meetings and given the option to meet either at chairside or in private. The interview revealed that advanced notice would give the patient the option of inviting a family member or a care partner.”

“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: 38766 Based on policy review, medical records review, and staff interview, the facility staff failed to follow the adequacy plan of care by failing to dialyze patients at the prescribed treatment duration time and/or obtain a signed against medical advice (AMA) form for 3 of 7 sampled in-center hemodialysis records (Patients #2, #5, and #7). Findings included: A review on 07/29/2025 of the policy and procedure “Prescribed Treatment Time not Met”, revised 04/2024, revealed “... Policy: A. Completion of The Early Termination of Treatment Against Medical Advice Form 1. The RN will verify that a patient signs the Early Termination of Treatment Against Medical Advice Form any time the patient requests to terminate their treatment earlier than the prescribed run time... 3. The Rn will obtain the patient’s signature on the Early Termination Against Medical Advice form prior to the patient being rinsed back from their treatment. B. Prescribed Treatment Time Not Met ...4. A completed copy of the Early Termination of Treatment Against Medical Advice will be kept in the patient’s health record. 1. Medical record review on 07/31/2025 for Patient #2 revealed a 57-year-old female admitted to the facility for ICHD treatments on 11/20/2024. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week, lasting 225 minutes. The review of the treatment sheet dated 07/14/2025 revealed that the patient received dialysis for 136 minutes (89 minutes less than the prescribed 225 minutes). The review of the treatment sheet dated 07/24/2025 revealed that the patient received dialysis for 72 minutes (153 minutes less than the prescribed 225 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 07/14/2025 and 07/24/2025. The review revealed no completed AMA form for early termination of treatment on 07/14/2025 and 07/24/2025. An interview on 07/31/2025 at 1130 with PCT/CCHT #1 revealed that the staff should adhere to the patient’s prescribed treatment duration. If patients chose to terminate their treatment early, the staff was responsible for completing the Early Termination of Treatment Against Medical Advice form and obtaining the patient’s signature. PCT/CCHT #1 added that the form should be signed by the RN and the patient and be kept in the patient’s record. An interview on 07/31/2024 at 1420 with the CM revealed that no AMA forms were located for the patient on those days. The CM reported that an AMA form should be completed and signed by the patient and the nurse. The interview confirmed that the facility could not locate the forms and confirmed the findings. 2. Medical record review on 07/30/2025 for Patient #5 revealed a 39-year-old female admitted to the facility for ICHD treatments on 10/27/2022. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week, lasting 240 minutes. The review of the treatment sheet dated 07/19/2025 revealed that the patient received dialysis for 178 minutes (68 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 07/21/2025 revealed that the patient received dialysis for 181 minutes (59 minutes less than the prescribed 240 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 07/19/2025 and 07/21/2025. The review revealed no completed AMA form for early termination of treatment on 07/19/2025 and 07/21/2025. An interview on 07/31/2025 at 1130 with PCT/CCHT #1 revealed that the staff should adhere to the patient’s prescribed treatment duration. If patients chose to terminate their treatment early, the staff was responsible for completing the Early Termination of Treatment Against Medical Advice form and obtaining the patient’s signature. PCT/CCHT #1 added that the form should be signed by the RN and the patient and be kept in the patient’s record. An interview on 07/31/2024 at 1420 with the CM revealed that no AMA forms were located for the patient on those days. The CM reported that an AMA form should be completed and signed by the patient and the nurse. The interview confirmed that the facility could not locate the forms and confirmed the findings. 3. Medical record review on 07/29/2025 for Patient #7 revealed a 88-year-old male admitted to the facility for ICHD treatments on 11/13/2024. The review of the Physician’s dialysis orders revealed the patient’s frequency for ICHD was three times per week, lasting 210 minutes. The review of the treatment sheet dated 07/25/2025 revealed that the patient received dialysis for 191 minutes (19 minutes less than the prescribed 210 minutes). The review revealed no documentation of the rationale for the patient not running the full prescribed treatment time on 07/25/2025. The review revealed no completed AMA form for early termination of treatment on 07/25/2025. An interview on 07/31/2025 at 1130 with PCT/CCHT #1 revealed that the staff should adhere to the patient’s prescribed treatment duration. If patients chose to terminate their treatment early, the staff was responsible for completing the Early Termination of Treatment Against Medical Advice form and obtaining the patient’s signature. PCT/CCHT #1 added that the form should be signed by the RN and the patient and be kept in the patient’s record. An interview on 07/31/2024 at 1420 with the CM revealed that no AMA forms were located for the patient on those days. The CM reported that an AMA form should be completed and signed by the patient and the nurse. The interview confirmed that the facility could not locate the forms and confirmed the findings.”