Davita NE Philadelphia Dialysis Center

“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: 40929 Based on a review of the facility Medical Records (MR), facility policy, and an interview with the facility administrator, the facility did not conduct fire safety drills according to facility policy for six (6) of seven (7) MRs. MR# 1, 3, 4, 5, 6, & 7. Findings include: A review of facility policy occurred on 8/14/25 at approximately 10:00 AM and revealed the following: Policy titled, “Facility Emergency Management Plan 4-07-01” stated, “Training and Education...Patients...Quaterly...Fire safety Prepardness and Emergency take-off procedures...” A review of Medical Records was conducted on 8/13/25 starting at approximately 10:15 AM and revealed the following: MR#1 Admission date 6/5/23 did not have a fire safety drill conducted for quarter 2 of 2025. MR#3 Admission date 4/16/21 did not have a fire safety drill conducted for quarter 2 of 2025. MR#4 Admission date 6/5/21 did not have a fire safety drill conducted for quarter 4 of 2024 and quarter 2 of 2025. MR#5 Admission date 4/12/16 did not have a fire safety drill conducted for quarter 4 of 2024 and quarter 2 of 2025. MR#6 Admission date 10/17/21 did not have a fire safety drill conducted for quarter 4 of 2024 and quarter 2 of 2025. MR#7 Admission date 12/24/24 did not have a fire safety drill conducted for quarter 2 of 2025. An interview with the facility administrator conducted on 8/14/25 at approximately 3:00 PM confirmed the above findings.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 40929 Based on review of facility policies/procedure, medical records (MR), hemodialysis (HD) treatment records, and interviews with the facility administrator (FA), the facility failed to follow its policy for monitoring vital signs during HD, for four (4) of seven (7) MR reviewed: MR# 2, 3, 5 & 7. Findings include: A review of facility policy occurred on 8/14/25 at approximately 10:00 AM and revealed the following: Policy titled “Pre-Intra-Post-Treatment Data Collection, Monitoring and Nursing Assessment. Policy 1-03-08” stated, “Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes but is not necessarily limited to....measurement of blood pressure (BP).. sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet)...” A review of Medical Records was conducted on 8/13/25 starting at approximately 10:15 AM and revealed the following: MR #2. Start of Care at facility: 6/18/25. HD (hemodialysis) Treatments on 7/30/25, 8/1/25 and 8/4/25 lists mobility status as “Ambulates-No assistance needed”. Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals. HD (hemodialysis) Treatment on 8/11/25 lists mobility status as “Ambulates- No assistance needed”. Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals or post-treatment vitals. MR#3. Start of Care at facility: 4/16/21. HD (hemodialysis) Treatments on 7/30/25 and 8/1/25 lists mobility status as “Ambulates-No assistance needed”. Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals. HD (hemodialysis) Treatment on 8/6/15 and 8/8/25 lists mobility status as “Ambulates- No assistance needed”. Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals or post-treatment vitals. HD (hemodialysis) Treatment on 8/11/25 lists mobility status as “Ambulates- No assistance needed”. Treatment did not include a standing Blood Pressure (BP) in the post-treatment vitals. MR#5. Start of Care at facility: 4/12/16. HD (hemodialysis) Treatment on 7/30/25, 8/1/25, 8/4/25, 8/6/25, 8/8/25 and 8/11/25 lists mobility status as “Wheelchair” Ambulatory as “Ambulatory-No assistance needed”. Clinical Manager confirmed patient is able to stand. Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals or post-treatment vitals on the dates listed above. MR#7. Start of Care at facility: 12/24/24. HD (hemodialysis) Treatment on 8/4/25 lists mobility status as “Ambulates- No assistance needed”. Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals or post-treatment vitals. HD (hemodialysis) Treatments on 7/30/25, 8/6/25, 8/8/25 and 8/11/25 lists mobility status as “Ambulates-No assistance needed”. Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals. An interview conducted with Facility Administrator on 8/14/25 at approximatley 3:00PM confirmed the above findings.”