Davita Forest Hill Avenue Dialysis

“IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK CFR(s): 494.30(a)(1)(i) Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory. This Standard is not met as evidenced by: 49355 Based on observation, interview and policy review, it was determined the facility staff failed to wear eye protection while performing patient care activities when there is a potential for contact with the patient’s bodily fluids. The findings include: On 04/15/2024 between the times of 10:30 a.m. and 4:00 p.m. and on 04/16/2024 between the times of 10:00 a.m. and 12:00 p.m., Staff Member #10 was rarely observed by this surveyor with any eye protection on, goggles or a face shield, while performing patient care. The goggles were frequently up on the staff member’s head, holding hair back. An interview with Staff Member #2 on 04/16/2024 at 10 a.m., confirmed the need for Staff Member #10 to wear some form of eye protection, either goggles or a face shield while performing patient care. When asked, Staff Member #2 stated they preferred the face shield for better coverage, but either form of eye protection was acceptable. A review of the facility’s policy, “Infection Control for Dialysis Facilities,” policy 1-05-01, with a revision date of April 2023, states, in part: ... “PPE (i.e., gown, gloves, eye protection, face shield) 5. Appropriate PPE will be worn whenever there is potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas.” The above concern was discussed at the exit conference of 04/16/2023 at 12:30 p.m. with Staff Members #1, 2 and 3.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 49355 Based on three (3) infection control observations and policy review, it was determined that facility staff failed to ensure that the dialysis stations and chairs were appropriately disinfected between patient usage. The findings include: On 04/15/2024 at 10:37 a.m., Staff Member #15 was observed cleaning station #11 and failed to clean the prime waste container, did not clean the shelf and did not clean the sides of the chair and under the tables. On 04/15/2024 at 10:53 a.m., Staff Member #14 was observed cleaning station #1 and failed to clean the prime waste container, did not clean the sides of the chair and under the tables. On 04/15/2024 at 10:41 a.m., Staff Member #9 did not clean the shelf at station #13. The above observations were discussed with Staff Members #1, 2 and 3 on 04/15/2024 at 4:p.m.. A review of the facility’s policy, “Infection Control for Dialysis Facilities,” policy #1-05-01, with a revision date of April 2023, reads, in part, ... “Disinfection ... 13. At the end of each treatment, the dialysis station will be cleaned and disinfected. a. Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g. dialysis chair, ...) ...countertops). ... ii. Priming containers are to be emptied prior to disinfection.” The above observations were discussed at the exit conference on 04/16/2023 at 12:30 p.m. with Staff Members #1, 2 and 3.”

“IC-STAFF EDUCATION-CATHETERS/CATHETER CARE CFR(s): 494.30(a)(2) Recommendations for Placement of Intravascular Catheters in Adults and Children I. Health care worker education and training A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections. B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters. II. Surveillance A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site. Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients. VI. Catheter and catheter-site care B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections]. This Standard is not met as evidenced by: 49355 Based on four (4) infection control observations, interview, and document review, it was determined the facility staff failed to ensure aseptic technique when initiating/discontinuing dialysis via a central venous catheter (CVC). The findings include: On 04/15/2024 at 11:30 a.m., the surveyor observed Staff Member #14 initiating dialysis on Patient #1 with a CVC at station #6. The staff member performed open hub disinfection on each of the lumen hubs for approximately seven (7) seconds. At 11:45 a.m., the surveyor observed Staff Member #11 initiating dialysis on Patient #8 with a CVC at station #15. The staff member performed open hub disinfection on each of the lumen hubs for approximately 4 seconds. On 04/15/2024 at 3:00 p.m., while discontinuing dialysis, this surveyor observed Staff Member #11 perform open hub disinfection on Patient #1 at station #6. The staff member disinfected each of the lumen hubs for approximately 3 seconds. At 3:45 p.m., Staff Member #11 performed an open hub disinfection of Patient #4’s CVC at station #15 while discontinuing dialysis. The staff member disinfected each hub for approximately 2 seconds. The above observations were discussed with Staff Members #1, 2 and 3 at 4:05 p.m. on 04/15/2023. The staff members agreed the above findings were not per policy. A review of the facility’s policy, entitled, “Central Venous Catheter (CVC) With Clearguard HD Antimicrobial End Caps Procedure,” procedure #1-04-02B, with a revision date of October 2023, reads, in part: ... “Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason. ... 16. ... One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds.... ... Upon Completion of Dialysis ... 33. ... Scrub the sides, threads and end of hub thoroughly with friction for 15 seconds,....” The above observations were discussed at the exit conference on 04/16/2024 at 12:30 p.m. with Staff Members #1, 2 and 3.”

“PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This Standard is not met as evidenced by: 49355 Based on observation and interview, it was determined the facility staff failed to ensure it maintained a safe environment for patients and staff by failing to secure the treatment floor door. The findings include: Upon entering the facility on 04/15/2024 at 10:00 a.m., the door separating the patient waiting room from the administrative area was propped open with a rubber wedge door stop. The door has a key pad lock on it. After entering the treatment floor and being escorted into the adjacent conference room by Staff Member #1, the door separating the treatment area from the administrative offices was also propped open with a rubber wedge door stop. The observations were reviewed with Staff Members #1, 2 and 3 on 04/15/2024 at 4:05 p.m. and the concerns for patient and staff safety and security were discussed. The above concern was discussed again at the exit conference on 04/16/2024 at 12:30 p.m. with the same staff members.”

“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: 49355 Based on medical record review, interview and document review, it was determined the facility staff failed to monitor patient’s intradialytic vitals per policy in one (1) out of seven (7) in-center hemodialysis patient records reviewed and failed to document notification to the licensed nurse of a post-treatment weight +/- 1 kg of the target weight (TW) weight in six (6) out of 7 in-center hemodialysis patient records reviewed. The findings include: The six (6) most frequent flowsheets were reviewed for seven (7) in-center hemodialysis patients. Patient #1: On 04/05/2024, during the 3.5 hour treatment, this patient was not monitored, per policy, for a total of two (2) hours. There were two one-hour periods during the treatment, where vitals were not recorded and there was no mention in the post treatment notes that such information was missing. On 04/01/2024, the PTW was recorded as 105.1 kilograms (kg) as compared to the TW of 101.6 kg, a difference of 3.5 kg. No notation of this variance was made in the post treatment note. On 04/03/2024, the PTW was 104.3 kg as compared to the TW of 101.6 kg, a difference of 2.7 kg. No notation of this variance was made in the post treatment note. On 04/05/2024, the PTW was 103.9 kg as compared to the TW of 101.6 kg, a difference of 2.3 kg. No notation of this variance was made in the post treatment note. On 04/08/2024, the PTW was 105 kg as compared to the TW of 101.6 kg, a difference of 3.4 kg. No notation of this variance was made in the post treatment note. 04/12/2024, the PTW was 106.5 kg as compared to the TW of 101.6 kg, a difference of 4.9 kg. No notation of this variance was made in the post treatment note. Patient #2: This patient, diagnosed with Acute Kidney Injury (AKI), started dialysis on 03/15/2024. While reviewing the last six (6) flowsheets available, it was noted that the patient never met the assigned TW, before or after treatment. The patient’s last treatment post weight and the patient’s pre treatment weight were always less than the desired TW. On 04/02/2024, the patient’s post treatment weight from the last treatment on 03/30/2024 was 69.7 kg, the pre-treatment weight for 04/02/2024 was 60.2 kg and the TW was 74.5 kg. No notation of this discrepancy was made in the post treatment note. On 04/04/2024, the patient’s post treatment weight from the last treatment on 04/02/2024 was 65.3 kg, the pre-treatment weight for 04/04/2024 was 62.2 kg and the TW was 74.5 kg. No notation of this discrepancy was made in the post treatment note. On 04/06/2024, the patient’s post treatment weight from the last treatment on 04/04/2024 was 59.5 kg, the pre-treatment weight for 04/06/2024 was 67.6 kg and the TW was 74.5 kg. No notation of this discrepancy was made in the post treatment note. On 04/09/2024, the patient’s post treatment weight from the last treatment on 04/06/2024 was 65.8 kg, the pre-treatment weight for 04/09/2024 was 65.7 kg and the TW was 74.5 kg. No notation of this discrepancy was made in the post treatment note. On 04/11/2024, the patient’s post treatment weight from the last treatment on 04/09/2024 was 67.4 kg, the pre-treatment weight for 04/11/2024 was 67.4 kg and the TW was 74.5 kg. No notation of this discrepancy was made in the post treatment note. On 04/13/2024, the patient’s post treatment weight from the last treatment on 04/11/2024 was 65 kg, the pre-treatment weight for 04/13/2024 was 68 kg and the TW was 74.5 kg. No notation of this discrepancy was made in the post treatment note. These findings for Patient #2 were discussed with Staff Member #2 at 10:00 a.m. on 04/16/2024. Staff Member #2 informed this surveyor that on 04/13/2024, Staff Member #5 adjusted the TW down to 68 kg after the dialysis treatment on that same day. Patient #4: On 04/01/2024, the PTW was recorded as 77.3 kg as compared to the TW of 75.5 kg, a difference of 1.8 kg. No notation of this variance was made in the post treatment note. On 04/03/2024, the PTW was 77.2 kg as compared to the TW of 75.5 kg, a difference of 1.7 kg. No notation of this variance was made in the post treatment note. On 04/05/2024, the PTW was 77.1 kg as compared to the TW of 75.5 kg, a difference of 1.6 kg. No notation of this variance was made in the post treatment note. On 04/10/2024, the PTW was 76.9 kg as compared to the TW of 75.5 kg, a difference of 1.4 kg. No notation of this variance was made in the post treatment note. Patient #5: On 04/02/2024, the PTW was recorded as 71.9 kg as compared to the TW of 69.0 kg, a difference of 2.9 kg. No notation of this variance was made in the post treatment note. On 04/04/2024, the PTW was 72.0 kg as compared to the TW of 69.0 kg, a difference of 3.0 kg. No notation of this variance was made in the post treatment note. On 04/06/2024, the PTW was 71.8 kg as compared to the TW of 69.0 kg, a difference of 2.8 kg. No notation of this variance was made in the post treatment note. On 04/09/2024, the PTW was 72.1 kg as compared to the TW of 69.0 kg, a difference of 3.1 kg. No notation of this variance was made in the post treatment note. On 04/11/2024, the PTW was 70.9 kg as compared to the TW of 69.0 kg, a difference of 1.9 kg. No notation of this variance was made in the post treatment note. On 04/13/2024, the PTW was 71.2 kg as compared to the TW of 69.0 kg, a difference of 2.2 kg. No notation of this variance was made in the post treatment note. Patient #6: On 04/01/2024, the PTW was recorded as 72.7 kg as compared to the TW of 69.0 kg, a difference of 3.7 kg. No notation of this variance was made in the post treatment note. On 04/03/2024, the PTW was 73.0 kg as compared to the TW of 69.0 kg, a difference of 4.0 kg. No notation of this variance was made in the post treatment note. On 04/05/2024, the PTW was 72.2 kg as compared to the TW of 69.0 kg, a difference of 3.2 kg. No notation of this variance was made in the post treatment note. On 04/08/2024, the PTW was 71.7 kg as compared to the TW of 69.0 kg, a difference of 2.7 kg. No notation of this variance was made in the post treatment note. Patient #7: On 04/01/2024, the PTW was recorded as 91.4 kg as compared to the TW of 90.0 kg, a difference of 1.4 kg. No notation of this variance was made in the post treatment note. On 04/05/2024, the PTW was 91.7 kg as compared to the TW of 90.0 kg, a difference of 1.7 kg. No notation of this variance was made in the post treatment note. On 04/08/2024, the PTW was 92.7 kg as compared to the TW of 90.0 kg, a difference of 2.7 kg. No notation of this variance was made in the post treatment note. On 04/10/2024, the PTW was 91.4 kg as compared to the TW of 90.0 kg, a difference of 1.4 kg. No notation of this variance was made in the post treatment note. All of the above findings were discussed with Staff Member #5 at 9:00 a.m. on 04/16/2024 and with Staff Member #2 at 10:00 a.m. on 04/16/2024 A review of the facility’s policy, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy #1-03-08, revision date April 2024, states, in part: ... “Policy 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse a. Data collection includes but is not necessarily limited to: ... iv. Patient weight ... 2. The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse (RN).... ... a. The assessment includes the following components: i. Review of patient ... data collection.... ... Pre-Treatment Data Collection Assessment 4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse (refer to ‘Abnormal Findings’ section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. ... Abnormal Findings ... the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient’s medical record. ... Fluid Status: ... Post-treatment: If patient is above or below 1 kg from the target weight” These findings were reviewed at the exit conference on 04/16/2024 at 12:30 p.m. with Staff Members #1, 2 and 3.”

“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: 49355 Based on interview and document review, it was determined that the facility staff failed to document the reason and notification to the licensed nurse of any deviation in the prescribed in blood flow rate (BFR) for six (6) out of seven (7) patients sampled. The findings include: On 04/15/2024, this surveyor reviewed the last 6 flow sheets for 7 in-center hemodialysis patients. Patient #1: On 04/05/2024, the prescribed BFR was 400 ml/min. After the first hour of a 3.5 hour treatment, the BFR was decreased to 249 ml/min. There was no notation on the flow sheet as to the reason for the discrepancy or if the nurse had been notified of the change. Patient #3: On 04/10/2024, the prescribed BFR was 400 ml/min. The patient’s BFR was run at 349 ml/min for the entire 3.5 hour treatment duration. There was no notation on the flow sheet as to the reason for the discrepancy or if the nurse had been notified of the change. Patient #4: On 04/03/2024, the prescribed BFR was 400 ml/min. The patient’s BFR was run at 300 ml/min throughout the entire 3 hour treatment cycle. There was no notation on the flow sheet as to the reason for the discrepancy or if the nurse had been notified of the change. On 04/10/2024, the prescribed BFR was 400 ml/min. After the first hour of the 3 hour treatment, the patient’s BFR was decreased to 350 ml/min for the remainder of the treatment cycle. There was no notation on the flow sheet as to the reason for the discrepancy or if the nurse had been notified of the change. On 04/12/2024, the prescribed BFR was 400 ml/min. The patient’s BFR was run at 349 ml/min throughout the entire 3 hour treatment cycle. There was no notation on the flow sheet as to the reason for the discrepancy or if the nurse had been notified of the change. Patient #5: On 04/02/2024, the prescribed BFR was 400 ml/min. After the first 30 minutes of treatment, the BFR was decreased to 299-349 ml/min for the remainder of the 3.5 hour treatment. There was no notation on the flow sheet as to the reason for the discrepancy or if the nurse had been notified of the change. Patient #6: On 04/05/2024, the prescribed BFR was 450 ml/min. For the entire 3.5 hour treatment cycle, the BFR was run at 399 ml/min. There was no notation on the flow sheet as to the reason for the discrepancy or if the nurse had been notified of the change. On 04/10/2024, the prescribed BFR was 450 ml/min. For the entire 3.5 hour treatment cycle, the BFR was run at 399 ml/min. There was no notation on the flow sheet as to the reason for the discrepancy or if the nurse had been notified of the change. On 04/12/2024, the prescribed BFR was 450 ml/min. For the entire 3.5 hour treatment cycle, the BFR was run at 299 ml/min. There was no notation on the flow sheet as to the reason for the discrepancy or if the nurse had been notified of the change. Patient #7: On 04/05/2024, the prescribed BFR was 450 ml/min. For the entire 3 hour and 45 minute treatment cycle, the BFR was run at 349 ml/min. There was no notation on the flow sheet as to the reason for the discrepancy or if the nurse had been notified of the change. On 04/12/2024, the patient only received half of the prescribed treatment time (patient requested an early termination and the nurse noted this on the flow sheet). During the shortened treatment time, the prescribed BFR was 450 ml/min but the patient only received 349 - 399 ml/min BFR rate during the approximate 2 hours of treatment time. There was no notation on the flow sheet as to the reason for the BFR discrepancy or if the nurse had been notified of the change. The above concerns were discussed with Staff Member #3 at 10:00 a.m. on 04/16/2024. A review of the facility’s policy, “Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment,” policy #1-03-08, revised April 2024, states, in part: ... “Intradialytic Data Collection/Assessment ... 10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed.” The above concerns were noted at the exit conference on 04/16/2024 at 12:30 p.m. with Staff Members #1, 2 and 3.”

“POC-VASCULAR ACCESS-MONITOR/REFERRALS CFR(s): 494.90(a)(5) The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement. This Standard is not met as evidenced by: 49355 Based on observation, interview, and document review, it was determined the facility staff failed to properly care for an arteriovenous (AV) graft/fistula according to the facility’s policy in one (1) out of three (3) observations. The findings include: On 04/15/2024 at 11:02 a.m., Staff Member #4 was at station #2 with Patient #15. The staff member cleansed the fistula site with antiseptic. Staff Member #4 then palpated the site for location and accessed the fistula without re-cleansing the area again with an antiseptic. The observation was discussed at 4:05 p.m. with Staff Members #1, 2 and 3, all of whom agreed that the site should have been cleansed again with antiseptic before accessing. A review of the facility’s policy, “AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose,” policy #1-04-01E revised October 2022 states, in part: ... Procedure/Rationale ... “8. Locate and palpate the needle cannulation sites prior to skin preparation. ... 13. Do not Palpate insertion site once area has been prepped. Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation.”t The above information was reviewed at the exit conference on 04/16/2024 at 12:30 p.m. with Staff Members #1, 2 and 3.”

“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: 42042 Based on document review and interview, it was determined the facility failed to ensure plans of care were complete and signed for by all appropriate interdisciplinary staff, patient, and/or patient representative for five (5) of seven (7) patients reviewed. The finding include: On 04/15/24 at 12:18 pm, the surveyor initiated the medical record review of Patient # (1-7) with the assistance of Staff Member #1. The surveyor confirmed that the Plan of Care (POC) for Patient #1, Patient #3, Patient #4, Patient #6, and Patient #7 were not signed for by all interdisciplinary (IDT) staff, the patient, and/or patient representative. The surveyor identified the following incomplete POC Assessments without documentation of signatures by all required parties: Patient #1 POC Assessment date: 02/22/24: No documentation of signature by Registered Nurse and Social Worker. Patient #3 POC Assessment date: 10/25/23: No documentation of signature by Patient and/or Patient Representative. POC Assessment date: 11/20/23: No documentation of signature by Patient and/or Patient Representative. POC Assessment date: 03/27/24: No documentation of signature by Patient and/or Patient Representative. Patient #4 POC Assessment date: 02/14/24: No documentation of signature by Patient and/or Patient Representative. POC Assessment date: 03/22/24: No documentation of signature by Patient and/or Patient Representative. Patient #6 POC Assessment date: 10/25/23: No documentation of signature by Patient and/or Patient Representative. Patient #7 POC Assessment date: 06/26/23: No documentation of signature by Patient and/or Patient Representative. The surveyor confirmed with Staff Member #2 during interview in the evening of 04/16/24 that all relevant staff--in addition to the patient or patient representative--should sign the POC assessment in order to be considered complete. Additionally, the surveyor confirmed with Staff Member #1 following medical record review that no other documentation was available for each of the five (5) patients related to the lack of signatures. On 04/15/24 at 2:23 pm, the surveyor was provided the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care” (with last revision date of 07/23) by Staff Member #2. Under “Assessment” section of page one (1), the policy defined the interdisciplinary team (IDT) as, “at a minimum, the patient or the patient’s personal representative, a Registered Nurse, a physician, or Non-Physician Practitioner (NPP) ...a social worker, and a dietician” [sic]. On page four (4) of document, the same policy stated, “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. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided”. On 04/16/24 at 12:32 pm, the surveyor discussed the aforementioned findings with Staff Member #1, Staff Member #2, and Staff Member #3 who verbalized understanding.”

“QAPI-COVERS SCOPE SERV/EFFECTIVE/IDT INVOL CFR(s): 494.110 The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility’s organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS. This Standard is not met as evidenced by: 42042 Based on document review and interview, it was determined the facility’s Quality Assessment and Performance Improvement (QAPI) program failed to evaluate and develop ongoing performance improvement interventions and action plans for identified underperforming areas. Specifically, missed treatments, hospitalizations and Central Venous Catheters greater than ninety (90) days. The finding include: On 04/16/24 at 9:50 am, Staff Member #1 assisted the surveyor in the review of the facility’s Quality Assessment and Performance Improvement (QAPI) program. Staff Member #1 presented the surveyor with the February and March 2024 documentation of the Facility Health Meetings (FHM) minutes as performed by the Continuous Quality Improvement (CQI) Committee. The surveyor received confirmation by Staff Member #1 that they served as the facility’s designated QAPI coordinator and participated in monthly FHMs. During interview, the surveyor asked the staff member about the top three (3) underperforming quality indicators for facility. Staff Member #1 stated that patients with “Missed Treatments”, “Hospitalizations”, and “Central Venous Catheters (CVCs) greater than ninety (90) days” [sic] were considered the top underperforming quality areas for facility. On 04/16/24 at 10:58 am, the surveyor met with Staff Member #1 to request the most recent past three (3) months of FHR minutes corresponding to the aforementioned three (3) quality indicators. The following are excerpts from the QAPI minutes: Missed Treatments Corporate [Davita] Goal: Less than 5.8% Actual Facility Occurrences: 9.5% Priority: High Issue Statement: Facility currently not meeting goal of less than 5.8% treatments per month “Action(s) and Interventions”: “11/2023: Slight decrease from the previous month 12/2023: Slight decrease from the previous month 1/2024: Slight decrease from the previous month 2/2024: Slight decrease from the previous month”. “IP Evaluation Plan”: “Assess/evaluate outcomes and progress during weekly IDT [interdisciplinary team]. Discuss results during monthly FHM” [sic]. The surveyor identified the following documentation on same FHR report: “Process Improvement Goal(s): Improve teammate documentation for missed treatments to enable the IDT to better focus on MVP. Reduce missed treatments by 10 missed treatments during the next period.” “Process Deep Dive: Inaccurate documentation. Patient non-compliance. Extended hospitalizations. Difficulty rescheduling due to limit[ed] space. Transportation issues as well as insurance lapse” [sic]. Hospitalizations Corporate [Davita] Goal: [None] Actual Facility Occurrences: 8 Priority: High “Issue Statement: Facility experienced 8 hospitalizations during this period, the month of Feb 24”. “Process Improvement Goal(s): Decrease hospitalizations by 2 each month”. “Process Deep Dive: During this period there were 8 hospital admits ...” [sic]. “Action(s) and Interventions: ...11/2023: Facility admits were down by 2 from the previous month 12/2023: Facility admits were down by 2 from the previous month 1/2024: Facility admits were up by 5 from the prior month 2/2024: Facility admits were down by 4 from the prior month” [sic]. “IP Evaluation Plan: Review hospitalizations with the IDT weekly. Discuss results during the monthly FHM.” CVCs [Vascular Access Sites] Greater Than 90 Days Corporate [Davita] Goal: Less than 13% Actual Facility Occurrences: 37.3% Priority: High “Issue Statement: Current facility CVC rate is 38.5%, is not meeting the DaVita goal of 13%.” “Process Improvement Goal(s): CVC rate will be consistently <= [less than or equal to] 13%” [sic]. “Process Deep Dive: 28 patients currently have CVC in use. 10 patients refusal/ no longer candidate/exhausted, 7 cannulating, 1 AKI, 10- consult/surgery, 0 workup”. “Action(s) and Interventions”: “11/2023: CVC rate down slightly from the prior month 12/2023: CVC rate down slightly from the prior month 1/2024: CVC rate up slightly from the prior month 2/2024: CVC rate up slightly from the prior month”. “IP Evaluation Plan: Discuss CVC patients weekly during IDT meeting. Assess process and interventions as indicated.” The surveyor questioned Staff Member #1 during quality review whether the process improvement and deep dive evaluations were performed each month with ongoing interventions for unique action plans. The surveyor confirmed with the staff member that tracking and trending for each quality indicator was performed monthly but that unique action plan interventions were not prioritized for each identified underperforming area on a monthly basis. In the morning of 04/16/24, the surveyor was provided the facility policy titled, “Continuous Quality Improvement Program” (with last revision date of 04/2021) by Staff Member #2. Under “Policy” header of page one (1), the document stated, in part, “The facility will measure, analyze, and track quality indicators or other aspects of performance. The program must include, but not limited to, the following: Patient Safety ...trends of adverse patient occurrences ...Vascular Access ...Hospitalizations” [sic]. The same policy continued to state the following: “Continuous monitoring of the above indicators will be reflected in the meeting minutes. Any area identified as underperforming will be reviewed to identify root causes for underperformance, will have an action plan identified that will result in performance improvement, and will track this change in performance over time to verify improvements are sustained”. On 04/16/24 at 12:32 pm, the surveyor discussed the aforementioned findings with Staff Member #1, Staff Member #2, and Staff Member #3 who verbalized understanding. Opportunity for questions and clarification provided by the surveyor without response.”