Davita Cypress Gardens Ht at Home

“MAINTENANCE PER DFU OR 2X/YR;RECORD CFR(s): 494.50(b)(1) 7.2.3 Maintenance: per DFU or semiannual/maintenance record Written maintenance procedures and a schedule of preventive maintenance activities designed to minimize equipment malfunctions should be established. In the case of purchased reprocessing equipment or safety equipment, the recommendations of the vendor should be followed unless documented experience supports alternative approaches. If the manufacturer’s recommendations are not available, reuse equipment and safety equipment should be inspected on a semiannual basis. 4 Records 4.3 Equipment maintenance record Records shall be maintained of the dates of preventive maintenance procedures and the results of scheduled testing in order to ensure the proper functioning of reprocessing equipment, environmental-control equipment, safety equipment, or other equipment. 4 Records A place should be provided for the signature or other unique mark of identification of the person ...performing preventative maintenance procedures. This Standard is not met as evidenced by: 30011 Based on observations, interviews, and review of the facility’s policy, the dialysis facility’s home therapy program failed to ensure fire extinguishers were inspected monthly. The findings include: Observations on 12/11/23 at 10:53 AM in the dialysis treatment area revealed (1) fire extinguisher in the hallway between home dialysis training room #2 and ##3, (1) fire extinguisher in the hallway by the staff breakroom, and (1) fire extinguisher in the supply room installed on 02/23 with no documentation of monthly checks for the 3 fire extinguishers. During an interview on 12/11/23 at 11:00 AM, Registered Nurse (RN) #1 stated, “Biomedical is supposed to check those monthly.” Facility policy, entitled, “Facility Emergency Management Plan”, revealed, “Fire extinguishers shall be checked monthly to verify the fire extinguisher is: i. Fully charged ii. Safety seals are not broken or missing iii. There is no evidence of physical damage, corrosion, leakage, or clogged nozzle iv. Kept in its designated place at all times except during use v. There are { }obstructions to access or visibility vi. Documented on the inspection tag or appropriate log ...”.”

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 22313 Based on patient record reviews, interview, and review of the facility’s policy and procedure, the dialysis facility’s home therapy staff failed to ensure the patient’s care plan was signed by the entire Interdisciplinary Team (IDT) for 1 of 2 patient records reviewed for timely IDT signatures. The full team failed to sign the patient’s care plan. (Patient #2) The findings include: Patient #2 is a transfer patient dated 11/2023 from an out of state facility with End Stage Renal Disease IV and Chronic Heart Failure/Pacemaker. The IDT meeting held 3/15/23 developed a new care plan for Patient #2. During record review on 12/12/23 at 10:00 AM, the patient’s care plan was signed by all IDT members present except the Social Worker who signed the patient’s care plan on 7/17/23. During an interview on 12/12/23 at 1:00 PM, the Facility Administrator verified the findings. Facility policy, titled, #5-15-02, reads, “1. The facility’s interdisciplinary team (IDT) consists of, at a minimum, the patient or patient’s representative, a registered nurse, a physician or Non-physician Practitioner, a social worker and a dietitian..”.”

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 30011 Based on patient record review and interview, the dialysis facility’s home therapy program staff failed to ensure that 2 of 3 patient treatment records were monitored to ensure home treatment protocol adherence. (Patient #1 and #3) The findings include: Record review on 12/11/23 at 1:07 PM for Patient #1 revealed the patient was admitted to the dialysis facility’s home therapy program on 07/01/22 for End Stage Renal Disease (ESRD). Review of physician orders dated 10/10/23 revealed Peritoneal Dialysis (PD) treatments on Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, and Saturday. Review of the patient’s chart revealed the patient provided his/her dialysis home treatment record documentation for October 2, 3, 4, 5, 6, 7, 8, and 9 and November 1, 2, 3, 4, 5, 6, and 7. Further review of the patient’s chart revealed there was no additional documentation of counseling and/or discussion with Patient #1 regarding the incomplete documents. During an interview on 12/12/23 at 9:27 AM, Registered Nurse (RN) #1 stated, “The patient is supposed to be bringing the completed documents in”. Record review on 12/11/23 at 2:10 PM for Patient #3 revealed the patient was admitted to the dialysis facility’s home therapy program on 10/11/23 for ESRD. Review of physician orders dated 10/11/23 revealed Peritoneal Dialysis (PD) treatments on Monday, Tuesday, Wednesday, Thursday, and Friday. Review of the patient’s chart revealed the patient started home PD treatments on 11/01/23 after training. Review of Patient #3’s chart revealed home dialysis treatment record documentation for November 1, 2, 13, 14, 16, 30, and December 4, 5, 6, and 9. Further review of the patient’s chart revealed no additional documentation of counseling and/or discussion with Patient #3 regarding the incomplete documents. During an interview on 12/12/23 at 9:44 AM, the Facility Administrator (FA) verified the findings.”

“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: 30011 Based on review of the dialysis facility’s Quality Assurance Process Improvement (QAPI) data, interview, and review of the dialysis facility’s policy and procedures, the home therapy program failed to ensure continuous monitoring of quality indicators related to mortality review. The findings include: Review of the dialysis facility’s Quality Assessment Performance Improvement (QAPI) minutes on 12/12/23 at 2:26 PM revealed the QAPI minutes did not contain any documentation related to mortality review. Review of the facility’s mortality list revealed a patient that expired 09/28/23 with no evidence of review, evaluation, and/or analysis. During an interview on 12/12/23 at 12:20 PM, the Facility Administrator stated, “We do discuss the patient death. I used to use a different outline than I do now.” Facility policy, entitled, “Continuous Quality Improvement Program”, revealed, “7. The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not be limited to, the following: Infection Control, including Vaccination rates for Hepatitis B, Influenza, and Pneumococcal, Mortality- review of deaths, Patient Satisfaction and Grievances, including KDQOL(Quality of Life) ...8. Continuous monitoring of the above indicators will be reflected in the meeting minutes ...”.”