Davita Oak City Dialysis

“PA-ASSESS LAB PROFILE CFR(s): 494.80(a)(3) The patient’s comprehensive assessment must include, but is not limited to, the following: (3) Laboratory profile, This Standard is not met as evidenced by: 38766 Based on review of facility policies, medical records, and staff interviews, the facility failed to follow the physician’s orders regarding the collection of monthly laboratory blood levels for one of the seven in-center patients assessed (Patient #3). Findings included: Review on 12/03/2025 of the facility policy titled, “PHYSICIAN ORDERS FOR PATIENT CARE,” revised October 2024, revealed, “...PURPOSE: To verify that orders are properly documented, transcribed, verified, and implemented in a timely manner for patient care... General Admission Orders: ... 29. Admission Orders must, at a minimum, include the following: ... b Laboratory orders.” A review on 12/04/2025 of the facility’s Laboratory Order Set indicated that patients’ albumin levels should be assessed monthly. An open medical record review on 12/03/2025 for Patient #3 revealed a 57-year-old male admitted on 09/22/2025. The review of the Core Survey Data Worksheet analyzed laboratory results of facility patients from September to November. It was found that Patient #7 had albumin level results recorded on September 22, 2025, and November 25, 2025. Additionally, the review revealed that Patient #7 did not have an albumin blood level test performed in October. An interview on 12/03/2025 at 1315 with the Manager of Clinical Services (MCS) revealed that the Registered Dietitian was responsible for reporting any missing albumin value to the Clinical Coordinator (CC) and the clinic Facility Administrator (FA). The CC and the FA were tasked with ensuring that the lab tests were conducted and the results obtained. The MCS indicated that the albumin level should be measured monthly at a minimum and redrawn as needed based on the RD’s recommendation. The interview confirmed that the albumin level was missed in October 2025.”

“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 six of seven sampled in-center hemodialysis records reviewed (Patients #4, #6, #7, #5, #8, and #3). Findings included: A review on 07/29/2025 of the policy and procedure “Prescribed Treatment Time not Met”, revised 10/2025, 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 12/03/2025 for Patient #4 revealed a 66-year-old male admitted to the facility for ICHD treatments on 05/28/2022. 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 11/10/2025 revealed that the patient received dialysis for 221 minutes (19 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/12/2025 revealed that the patient received dialysis for 215 minutes (25 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/14/2025 revealed that the patient received dialysis for 222 minutes (18 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/19/2025 revealed that the patient received dialysis for 216 minutes (24 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/21/2025 revealed that the patient received dialysis for 207 minutes (33 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 11/10/2025, 11/12/2025, 11/14/2025, 11/19/2025, and 11/21/2025. The review revealed that no completed AMA form was found for the early termination of treatments on 11/10/2025, 11/12/2025, 11/14/2025, 11/19/2025, and 11/21/2025. An interview on 12/04/2025 at 1150 with PCT/CCHT #2 revealed that 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. The interview indicated that the RN and the patient should sign the form and that it should be kept in the patient’s record. 2. Medical record review on 12/03/2025 for Patient #6 revealed a 54-year-old male admitted to the facility for ICHD treatments on 08/13/2024. 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 11/10/2025 revealed that the patient received dialysis for 223 minutes (17 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/17/2025 revealed that the patient received dialysis for 182 minutes (58 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/19/2025 revealed that the patient received dialysis for 162 minutes (78 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 11/10/2025, 11/17/2025, and 11/19/2025. The review revealed that no completed AMA form was found for the early termination of treatments on 11/10/2025, 11/17/2025, and 11/19/2025. An interview on 12/04/2025 at 1150 with PCT/CCHT #2 revealed that 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. The interview indicated that the RN and the patient should sign the form and that it should be kept in the patient’s record. 3. Medical record review on 12/03/2025 for Patient #7 revealed a 75-year-old female admitted to the facility for ICHD treatments on 01/22/2025. 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 11/10/2025 revealed that the patient received dialysis for 207 minutes (33 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/14/2025 revealed that the patient received dialysis for 223 minutes (17 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/17/2025 revealed that the patient received dialysis for 204 minutes (36 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/21/2025 revealed that the patient received dialysis for 212 minutes (28 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 11/10/2025, 11/14/2025, 11/17/2025, and 11/21/2025. The review revealed that no completed AMA form was found for the early termination of treatments on 11/10/2025, 11/14/2025, 11/17/2025, and 11/21/2025. An interview on 12/04/2025 at 1150 with PCT/CCHT #2 revealed that 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. The interview indicated that the RN and the patient should sign the form and that it should be kept in the patient’s record. 4. Medical record review on 12/03/2025 for Patient #5 revealed a 27-year-old male admitted to the facility for ICHD treatments on 10/02/2025. 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 11/11/2025 revealed that the patient received dialysis for 210 minutes (30 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/18/2025 revealed that the patient received dialysis for 214 minutes (26 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/22/2025 revealed that the patient received dialysis for 211 minutes (29 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 11/11/2025, 11/18/2025, and 11/22/2025. The review revealed that no completed AMA form was found for the early termination of treatments on 11/11/2025, 11/18/2025, and 11/22/2025. An interview on 12/04/2025 at 1150 with PCT/CCHT #2 revealed that 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. The interview indicated that the RN and the patient should sign the form and that it should be kept in the patient’s record. 5. Medical record review on 12/04/2025 for Patient #8 revealed a 66-year-old male admitted to the facility for ICHD treatments on 11/12/2020. 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 11/13/2025 revealed that the patient received dialysis for 226 minutes (14 minutes less than the prescribed 240 minutes). The review of the treatment sheet dated 11/15/2025 revealed that the patient received dialysis for 225 minutes (15 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 11/13/2025 and 11/15/2025. The review revealed that no completed AMA form was found for the early termination of treatments on 11/13/2025 and 11/13/2025. An interview on 12/04/2025 at 1150 with PCT/CCHT #2 revealed that 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. The interview indicated that the RN and the patient should sign the form and that it should be kept in the patient’s record. 6. Medical record review on 12/03/2025 for Patient #3 revealed a 57-year-old male admitted to the facility for ICHD treatments on 09/22/2025. 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 11/17/2025 revealed that the patient received dialysis for 225 minutes (15 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 11/17/2025. The review revealed that no completed AMA form was found for the early termination of treatment on 11/17/2025. An interview on 12/04/2025 at 1150 with PCT/CCHT #2 revealed that 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. The interview indicated that the RN and the patient should sign the form and that it should be kept in the patient’s record.”

“POC-INITIAL IMPLEMENTED-30 DAYS/13 TX CFR(s): 494.90(b)(2) Implementation of the initial plan of care must begin within the latter of 30 calendar days after admission to the dialysis facility or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session. This Standard is not met as evidenced by: 38766 Based on facility policy review, clinical record review, and staff interview, the facility failed to complete a thirty-day initial comprehensive reassessment in one of three newly admitted sampled in-center patients (patient #3). The findings include: Review on 12/03/2025 of the facility’s policy titled “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,” revised October 2024, revealed, “...4. A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines...Plan of Care: ...10. 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) ...” An open medical record review on 12/03/2025 for patient #3 revealed that the patient was admitted to the facility on 09/22/2025. The review indicated that the facility completed the initial comprehensive assessment for the patient on 11/12/2025, which was 51 calendar days and 23 dialysis sessions after the first dialysis treatment. Further review of the clinical record revealed that the facility did not complete the initial comprehensive assessment (30-day assessment) within 30 calendar days of admission. An interview on 12/03/2025 at 1020 with the social worker reported that there was a glitch in the computer system and that the computer did not schedule the plan of care. The interview revealed that the SW had manually scheduled the plan of care. The SW stated that the computer system was the only way the clinic tracked patients’ care plans that were due. The interview confirmed that the patient’s initial care plan should have been completed within the first 30 days of admission or within the first 13 treatments. The interview confirmed that the facility did not follow the plan of care policy.”