Davita Soco Dialysis

“ESRD Patient Orientation Training CFR(s): The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section. This Standard is not met as evidenced by: 46466 Based on interview, medical record and facility documentation review, the facility failed to perform and document quarterly patient fire safety training for one (1) of five (5) patients included in the survey sample. The findings include: On 7/15/24 and 7/16/24, a review of five (5) sampled patient medical records was conducted. A review of Patient #3’s medical record revealed that Patient #3’s last quarterly Fire Safety Training was conducted on 3/15/24. There was no documented evidence to support that Patient #3 received Fire Safety Training after 3/15/24. On 7/16/24, Staff Member #2 verified that there was no other documented evidence to support that Patient #3 received Fire Safety Training after 3/15/24. A review of the facility’s policy “Facility Emergency Management Plan (ICHD, Home)”, revised April 2023 stated in part: “...Training and Education. Emergency Management Plan...b. Patients...ii. Quarterly: 1. Fire Safety Preparedness...”. The findings were discussed with Staff Members #2, #4 and #7 at the exit conference on 7/16/24 at 1:00 p.m.”

“IC-TRAINING & EDUCATION CFR(s): 494.30(a)(1)(i) Infection Control Training and Education Infection control practices for hemodialysis units: intensive efforts must be made to educate new staff members and reeducate existing staff members regarding these practices. This Standard is not met as evidenced by: 46466 Based on interviews and facility document review, the facility staff failed to conduct monthly infection control (IC) audits on staff members. The findings include: On 7/16/24 at approximately 11:20 a.m., a review of the facility’s monthly IC audits was conducted. The monthly IC audits were missing from November, 2023 through April, 2024. On 7/16/24 at 11:30 a.m., Staff Member #2 confirmed that the missing monthly audits were not found and that this issue was discussed in May, 2024 during Facility’s Health Meeting. Staff Member #2 provided the Facility’s Health Meeting documentation from May 2024 that confirmed the missing IC audits issue was discussed and was to be corrected. On 7/16/24 at 11:50 a.m., Staff Members #4 stated that there was no specific facility policy regarding how often infection control audits were to be completed, but it was expected to be completed on a monthly basis. The findings were discussed with Staff Members #2, #4 and #7 at the exit conference on 7/16/24 at 1:00 p.m.”

“PR-RIGHTS POSTED,STATE/NW ONTACT INFO CFR(s): 494.70(c) The dialysis facility must prominently display a copy of the patient’s rights in the facility, including the current State agency and ESRD network mailing addresses and telephone complaint numbers, where it can be easily seen and read by patients. This Standard is not met as evidenced by: 46466 Based on observations and interviews, the facility failed to post Patient Rights information in the lobby of the facility. The findings include: On 7/15/24 at 11:00 a.m., the surveyors observed that the facility’s Patient Rights information was not posted or visible within the facility lobby area. On 7/16/24, Staff Member #7 confirmed that Patient Rights information was not posted in the lobby and/or visible to patients and visitors in other facility public space. The findings were discussed with Staff Members #2, #4 and #7 at the exit conference on 7/16/24 at 1:00 p.m.”

“QAPI-INDICATOR-PT SATIS & GRIEVANCES CFR(s): 494.110(a)(2)(viii) The program must include, but not be limited to, the following: (viii) Patient satisfaction and grievances. This Standard is not met as evidenced by: 46466 Based on interviews and facility document review, facility failed to provide evidence supporting that patient grievance outcomes were monitored and tracked as part of the facility’s quality assurance indicators. The findings include: On 7/16/24 at approximately 10:00 a.m., a review of the facility’s patient grievance log was conducted. The log documented a patient complaint dated 5/31/24 with no documentation of steps taken to resolve the complaint nor a date that the complaint was resolved. On 7/16/24 at approximately 11:45 a.m., an interview was conducted with Staff Member #2. Staff Member #2 stated that steps were taken to resolve the complaint with the patient and the complaint was addressed in the June’s Facility Health Meeting. A request was made to Staff Member #2 to provide the documentation from the June’s Facility Health Meeting minutes. Staff Member #2 was unable to provide the documented evidence prior to the surveyor’s exit. The findings were discussed with Staff Members #2, #4 and #7 at the exit conference on 7/16/24 at 1:00 p.m.”