Davita Market Commons Dialysis Center

“MICROB MONITOR-SAMPLE BEFORE DISINFECT CFR(s): 494.40(a) 7.2 Microbial monitoring methods 7.2.1 General: samples before disinfect Samples should always be collected before sanitization/disinfection of the water treatment system and dialysis machines. This Standard is not met as evidenced by: 30011 Based on record reviews, interviews, and review of facility policy and procedure, the dialysis facility failed to ensure that microbiological sample testing was obtained prior to sanitation/disinfection of the facility’s water treatment system. The findings include: Record review on 11/28/23 at 11:00 AM of the facility’s “Monthly Microbial Corrective Action Form” dated 07/13/23 revealed culture samples were collected from the following sites: First H2O (water) out, Bicarb H2O out, Dry Acid H2O out, Last H2O out, and three dialysis machines at 9:00 AM on 07/13/2023. Further review of the facility’s CWP (Continuous Water Pressure) RO (Reverse Osmosis) Unit Chemical Disinfection log revealed a chemical disinfection was initiated on 07/10/23 at 7:28 PM which was 3 days prior to the collection date for the culture samples. Review of BMT 1’s Annual Skills Checklist dated 12/20/22 revealed BMT 1 was checked off by a trainer to: “Perform culture and endotoxin sample collection per policies and procedures”. During an interview on 11/29/23 at 1:18 PM, Biomedical Technician (BMT) 1 stated, “I honestly don’t know when the cultures were collected in relation to the disinfections. We disinfect on Mondays”. Facility policy, entitled, “Water Culture Policy”, revealed “4. Routine water cultures are collected monthly and within 72 (seventy-two) hours prior to scheduled disinfection of distribution systems. Monthly is defined as within a calendar month...”.”

“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: 30011 Based on record reviews, interviews, and review of the facility’s policy and procedure, the dialysis facility failed to ensure staff signed the patient’s plan of care the day of the Interdisciplinary (IDT) meeting for 2 of 3 peritoneal dialysis (PD) home therapy patients. (Patient 1 and 2) The findings include: Record review on 11/28/23 at 10:35 AM of PD Patient 1 revealed Patient 1 was admitted to the home therapy program on 08/17/23 with a diagnosis of Type 2 Diabetes Mellitus (DM) with diabetic chronic kidney disease. Review of the patient’s chart revealed the “Patient Plan of Care” IDT meeting was held on 09/19/23. Further review revealed the Registered Nurse (RN) and Dietician signed the plan of care (POC) on 09/25/23, the Medical Director (MD) on 09/27/23, Patient 1 on 10/02/23, and no date noted for the Master Social Worker. During an interview on 11/29/23 at 2:47 PM, home therapy Registered Nurse (RN) 1 stated, “We are supposed to sign the IDT the same day as the meeting”. Record review on 11/28/23 at 11:32 AM for PD Patient 2 revealed Patient 2 was admitted to the home therapy program on 08/04/23 with a diagnosis of acute kidney failure. Review of the patient’s chart revealed the “Patient Plan of Care” IDT meeting was held on 09/22/23. Further review revealed the RN signed the POC on 09/25/23, the patient on 10/16/23, and there was no signature by the MD (Medical Director). During an interview on 11/29/23 at 3:10 PM, home therapy RN 1 verified the findings. Facility policy, titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care”, revealed, “14. The patient’s plan of care will be completed by facility’s interdisciplinary team, including patient or personal representative and be signed by team members including the patient or the patient’s personal representative...”.”

“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: 30011 Based on record reviews, interviews, and review of the facility’s policy and procedure, the dialysis facility failed to ensure a plan of care was completed within 30 calendar days after admission or 13 outpatient hemodialysis treatments for 2 of 8 in-center dialysis patients. (Patient 8 and 9) The findings include: Record review on 11/28/23 at 3:18 PM for Patient 8 revealed Patient 8 was admitted to the dialysis facility on 04/04/23 with a diagnosis of end stage renal disease (ESRD). Review of the patient’s chart revealed the “Patient Plan of Care (POC)” was completed on 05/11/23 which was past 30 calendar days of admission and 13 outpatient hemodialysis treatments. During an interview on 11/30/23 at 9:20 AM, the Facility Administrator (FA) verified the findings. Record review on 11/28/23 at 10:41 AM for Patient 9 revealed Patient 9 was admitted to the dialysis facility on 04/27/23 with a diagnosis of Type 2 Diabetes Mellitus with diabetic kidney disease. Review of the patient’s chart revealed the patient’s POC was completed on 06/08/23 which was past 30 calendar days of admission and 13 outpatient hemodialysis treatments. During an interview on 11/30/23 at 9:30 AM, the FA verified the findings. Facility policy, entitled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care”, revealed, “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) beginning with the first outpatient dialysis treatment or per state guidelines...”.”