Davita Dale City

“Dialysis Emergency Equipment CFR(s): §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This Standard is not met as evidenced by: 42042 Based on observations, interviews, and document review, it was determined the facility failed to ensure all necessary emergency equipment was safely secured and readily available for use as evidenced by two empty, unsecured oxygen tanks. The findings include: The surveyor inspected the emergency code cart on 04/28/2025 at 2:46 pm. The surveyor observed two unsecured oxygen tanks leaning on treatment floor wall. The surveyor met with Staff Member #2 (Registered Nurse) on 04/28/2025 at 3:25 pm who confirmed they were unable to verify tank capacity due to no pressure gauges being found on either oxygen tank. Following surveyor questioning regarding the appropriate storage of oxygen tanks, the staff member confirmed the aforementioned tanks “shouldn’t be here”. On 04/29/2025 at 9:19 am, the surveyor disseminated the findings to both Staff Member #1 (Facility Administrator) and Staff Member #5 (Administrative Assistant) during interview. Staff Member #1 verbalized understanding and confirmed that the aforementioned oxygen tanks were empty and stored inappropriately according to facility procedures. On 04/29/25 at 9:58 am, Staff Member #1 supplied the surveyor with the facility policy titled, “Emergency Equipment Checks” [Policy: 1-02-08] (with last revision date of 10/2024), which stated, in part, “The oxygen tank(s) will be ...stored in compliance with local and/or state regulations.”

“IC-HBV-VACCINATE PTS/STAFF CFR(s): 494.30(a)(1)(i) Hepatitis B Vaccination Vaccinate all susceptible patients and staff members against hepatitis B. This Standard is not met as evidenced by: 42042 Based on interview and document review, it was determined the facility failed to vaccinate all susceptible patients against the Hepatitis B virus when indicated for one (1) of six (6) patients (Patient #2). The findings include: On 04/29/2025 at 10:50 am, the surveyor initiated medical record review for Patient # (1-6). During review of Patient #2’s chart, the surveyor observed a signed patient consent for the administration of Hepatitis B (Hep. B”) Vaccine dated 03/21/2025. During review of the patient’s serum labs collected on 03/11/2025, the surveyor identified that the patient was not immune to the Hepatitis B virus-as evidenced by a Hep. B Surface Antibody of “3.31 mIU/mL” indicating the patient was susceptible to the virus and thus not immune. In the afternoon of 04/29/2025, the surveyor met with Staff Member #1 for interview to inquire why the patient had not received any of the three Hepatitis B Vaccination series despite being susceptible-and not immune-to the virus and having already consented to being vaccinated. The surveyor was provided the facility policy titled, “Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance [Policy: 1-05-02] (last revision date of 04/2024) which indicated that patients should be vaccinated for Hep B when susceptible and indicated, following patient consent.”

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 42042 Based on interview and document review, it was determined the facility failed to deliver dialysis treatment in accordance with the prescribed treatment time for one (1) of six (6) patients reviewed. The findings include: The survey reviewed treatment flowsheet documentation of Patient #1 on 04/29/25 at 1:38 pm with the assistance of Staff Member #14 (Manager of Clinical Services). The surveyor observed a treatment order for the patient to receive four hours of in-center hemodialysis (ICHD) treatment. During review of the patient’s ICHD for 04/23/2025, the surveyor observed treatment started at 1:00 pm and ended at 4:20 pm. The surveyor conducted interview with Staff Member #14 in the afternoon of 04/29/2025 regarding the variance who stated that a clinical note should be documented. The surveyor confirmed with Staff Member #14 that there was no such documentation found. On 04/29/2025 at 2:29 pm, the surveyor reviewed the facility policy titled, “Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment [sic]” [Policy: 1-03-08] (with last revision date of 04/2024). On page two, the policy stated that the prescription components to include the ordered treatment time/duration is verified by staff.”

“POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This Standard is not met as evidenced by: 42042 Based on interview and document review, it was determined the facility failed to complete an interdisciplinary plan of care for two (2) of six (6) patients reviewed (Patients #1, 4). The findings include: On 04/29/2025 at 10:50 am, the surveyor initiated medical record review for Patient # (1-6). During review of Patient #1’s care plans, the surveyor located a care plan performed on 03/17/2025 in which the patient was determined to be in “unstable” status. The surveyor confirmed with Staff Member #1 that there was no signature from the provider. Additionally, while reviewing the Plan of Care for Patient #4, the surveyor was unable to locate an annual care plan for the 2023 calendar year. The surveyor met with Staff Member #1 in the afternoon of 04/29/2025 who confirmed they were unable to locate a care plan for Patient #4 for the 2023 year. The surveyor was provided the facility policy titled, “Interdisciplinary Team (IDT) Patient Assessment and Plan of Care [sic]” [Policy: 1-14-01] (last revision date of 10/2024) which stated that a comprehensive patient plan of care assessment will be conducted “at least annually for stable patients”. The same policy stated that the facility’s interdisciplinary team (IDT) should document participation in the patient’s care plan and include “at a minimum ...a physician or Non-Physician Practitioner (NPP) [sic]”.”

“GOV-RESPONDS TO NW REQUEST/WORKS TOWARD GOALS CFR(s): 494.180(i) The governing body receives and acts upon recommendations from the ESRD network. The dialysis facility must cooperate with the ESRD network designated for its geographic area, in fulfilling the terms of the Network’s current statement of work. Each facility must participate in ESRD network activities and pursue network goals. This Standard is not met as evidenced by: 42042 Based on interview and document review, it was determined the facility failed to maintain an ongoing collaborative relationship with the ESRD network by not accessing the monthly quality improvement reports from the ESRD Network. The findings include: On 04/28/2025 at 2:05 pm, the surveyor contacted Staff Member #4 (Quality Insights Patient Engagement Specialist) via email regarding supplemental facility background information. On 04/28/25 at 3:43 pm, the surveyor received email response from Staff Member #4 who reported a concern regarding the facility not accessing the “ESRD [End-Stage-Renal-Disease] Quality Improvement Report” on a monthly basis. Staff Member #4 wrote that facilities were required to review and implement the report into monthly QAPI (Quality Assurance and Performance Improvement) meetings. On 04/29/2025 at 9:19 am, the surveyor met with both Staff Member #1 and Staff Member #5 for interview. Both staff members verbalized understanding of the surveyor findings without further comment. The surveyor met with Staff Member #1 to request a facility policy regarding relationship with the local ESRD network to include monthly quality data. At the time of exit conference on 04/30/2025, no such policy was provided to the surveyor.”