Complaint Summary for Public Viewing Reports for:
PIKES PEAK DIALYSIS CENTER
Friday, December 24, 2010 9:58 PM
Intake ID:   CO00011959
Facility:   PIKES PEAK DIALYSIS CENTER
Date of Complaint:   5/20/2010
Date of Investigation:   5/20/2010
Total Number of Allegations for Complaint: 1

Allegation: 1

Type: Resident/Patient/Client Neglect

Findings: Substantiated

Allegation Detail: The Health Facilities and Emergency Medical Services Division received information that the facility used another patient's dialyzer while dialyzing her/him. The patient whose dialyzer was used has MRSA.
The facility failed to report this to the HFEMSD Occurrence reporting section as neglect per Chapter II Licensure requirements.

Findings Detail: On 5/20/10 through 5/24/10 an unannounced onsite complaint investigation was conducted. The facility staff did not know this was a reportable occurrence. The facility was cited for failing to comply with the Chapter II Licensure requirements. Cross Reference to CO # 11957.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/compreport.aspx?id=120506&ft=esrd&comp=CO00011959&bk=


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5/24/2010 Survey Tag 0403 Detail for:
PIKES PEAK DIALYSIS CENTER
Friday, December 24, 2010 10:26 PM
Survey Date: 5/24/2010

Regulation Number:0403

Regulation Title: PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU

Regulation Description: The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer's recommendations.

Surveyor Findings:


Based on facility tour and review of facility documents, it was determined that the facility failed to maintain emergency equipment per facility policy. This failure created the potential for emergency patient care to be compromised.

The findings were:
On 5/20/10 at approximately 9:00 a.m. a facility tour was conducted. On the patient treatment floor, there were two emergency evacuation carts (one on the north side and one on the south side). On each cart there were inventory sheets that also contained a section for weekly checks of the locks on the carts as well as a notation of the oxygen tanks reading of fullness.
A review of the facility's inventory sheets was conducted and revealed the following:
The south cart was checked less frequently (not weekly) than the north cart in 2010 (13 times for the south cart and 21 times for the north cart). The south cart was not checked weekly from 3/15/10 until 4/12/10.

Facility Plan of Correction:

V403
Policy #1-02-08 “Emergency Equipment Checks” has been reviewed with the teammates with emphasis on the need to complete weekly checks on both crash carts and document. A RN will be assigned to check crash carts every Thursday. FA will audit the North, South and PD crash carts utilizing the audit tool every Friday to ensure compliance with weekly checks. Audits will be conducted weekly X 1 month and then biweekly X 1 month, followed by monthly audits. Results of audits will be reported Quality Improvement Facility Management Meetings (QIFMM) and addressed as necessary. FA is responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0403&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

 

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5/24/2010 Survey Tag 0504 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 7:42 AM
Survey Date: 5/24/2010

Regulation Number:0504

Regulation Title: PA-ASSESS B/P, FLUID MANAGEMENT NEEDS

Regulation Description: The patient's comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs.

Surveyor Findings:


Based on review of medical records, review of facility Policies and Procedures and staff interviews, the facility failed to appropriately document post-treatment assessment data in six (#3, #5, #6, #7, #9, & #10) of eight in-center hemodialysis patient medical records reviewed. The staff failed to follow facility policy for documentation of post-treatment data collection. This failure created the potential for patient care to be compromised.


The findings were:


The medical records of eight in-center hemodialyses patients were reviewed throughout the survey from 5/20/10 through 5/24/10. The following was revealed:

Sample #3 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the chairside computer documentation program (for recording data before, during, and after treatment) titled "ChairSide Snappy Flowsheet" revealed that in two (5/13/10, and 5/22/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample # 5 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in three (5/6/10, 5/15/10, and 5/20/10) of four reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample # 6 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in five (5/10/10, 5/12/10, 5/14/10, 5/17/10 and 5/19/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample # 7 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in five (5/10/10, 5/12/10, 5/14/10, 5/17/10 and 5/19/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample # 9 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in two (5/6/10 and 5/13/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample # 10 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in three (5/15/10, 5/18/10, and 5/22/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

The facilities Policies and Procedures were reviewed on 5/21/2010. The policy titled "Pre/Post Dialysis Treatment Data Collection" stated, in pertinent part:
"1. Patient data will be obtained and documented by the patient care staff...
5. Data collection may include the following:
Weight
Blood pressure
Cardiac status
Respiratory status
Peripheral edema
Vascular access
Mental status
Patient subjective statement
Ambulatory status..."

The policy titled "Post Treatment Patient Assessment" stated, in pertinent part:
"1. The patient care staff will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings...
6. All findings, interventions, and patient responses are documented in the patient's medical record."

An interview was conducted on 5/24/2010 at approximately 3:10 p.m. with the acting facility administrator. S/he stated that the standard of practice for the facility is to, at a minimum, place data in the data collection portion of the post-treatment data collection and assessment section. S/he stated that that data collection is usually completed by the patient care technician and placed into the ChairSide Snappy program by the technician. S/he also stated that "it is an issue that was identified and is being worked on."

Facility Plan of Correction:

V504
The Clinical Services Specialist (CSS) and FA reviewed Policy#1-03-10 “Pre/Post Treatment Data Collection” and #1-03-12 “Post Treatment Patient Assessment” with the teammates on 6/10 and 6/11/10. The focus of this review was the importance of obtaining and documenting basic data on each patient post dialysis. This information is to be compared with pre-dialysis findings and addressed as necessary. FA or designee to audit patient flow sheets on every patient weekly, utilizing the post treatment audit tool, for a period of 2 months, then 50% for 1 month. Thereafter, the post treatment audit tool will be used to conduct a random sampling of 10% of the post treatment sheets monthly by the FA/designee. The results of the audits will be reviewed at the monthly QA meetings. FA/designee is responsible for ongoing compliance with the above stated policy and procedure.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0504&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0582 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 9:18 AM

Survey Date: 5/24/2010

Regulation Number:0582

Regulation Title: H-IDT OVERSEES HOME TRAINING

Regulation Description: The interdisciplinary team must oversee training of the home dialysis patient, the designated caregiver, or self-dialysis patient before the initiation of home dialysis or self-dialysis (as defined in §494.10) and when the home dialysis caregiver or home dialysis modality changes.

Surveyor Findings:


Based on staff interviews and review of facility documents, it was determined that the facility failed to adequately document the training provided to another facility's staff that would be performing peritoneal dialysis on one of the facility's patients.
The findings were:
On 5/21/10 at approximately 8:40 a.m. an interview was conducted with staff that performed home training. The staff agreed that documentation of the other facility's staff by the home training nurse could be improved upon and was not sufficient. The staff member stated that the lack of documentation was recently noted by the facility in an internal audit and was being improved upon currently.
The medical record of a patient that had received home peritoneal dialysis in a long-term care facility (Sample Patient #2) was reviewed on 5/20/10. A nursing progress note was reviewed that was dated 3/24/10. It states, "Trained staff at [facility name] on Baxter cycler. To start CCPD tonight." The note was the only record of training completed with personnel that would be performing peritoneal dialysis on this patient.

Facility Plan of Correction:

V582
The importance of the need to adequately document training provided to the staff of other facilities, such as long-term care facilities, that would be performing peritoneal dialysis on the patient has been reviewed with the home dialysis teammates.
A training tool has been developed to document the content of training provided by the dialysis home nurse to the Long Term Care Facility. This tool will be implemented by 6/30/10 and include, but not be limited to, a signed learning contract, a post test, and a DVD on such training. Part of the training tool that has been developed to train the Long Term Care staff includes a comprehensive overview including sign and symptoms frequently seen with PD patients. Will also ensure the Long Term Care staff has the 24 hour on call PD nurse information available to answer any questions the Long Term Care staff may have. FA/designee will audit record of such patients post training to ensure compliance. Results of audits will be reported in QIFMM and addressed as necessary. FA is responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0582&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0626 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 9:26 AM
Survey Date: 5/24/2010

Regulation Number:0626

Regulation Title: QAPI-COVERS SCOPE SERV/EFFECTIVE/IDT INVOL

Regulation Description: 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.

Surveyor Findings:


Based on review of facility documents, staff interviews and review of medical records, it was determined that the facility failed to identify and correct deficiencies in the completeness of medical records as part of the QAPI program. Missing physician orders and progress noted in patient medical records could cause potential negative patient outcomes.

The findings were:

A review of the facility's internal documents was conducted on 5/21/10. Minutes from the Quality Improvement & Facility Management Meeting (QIFMM) dated 5/4/10 were reviewed. The section titled Quality Management Audits included a section for medical record file audits and indicated they are to be performed monthly. In the section was an area for the percentage of charts audited to be input. These sections were left blank for all of the year 2010. There is no mention of physician progress notes or orders not being present or leaving the facility.
The medical records of eight in-center hemodialysis patients were reviewed throughout the survey from 5/20/10 through 5/24/10. In three (#5, #6, and #7) of eight records original physician progress notes and written physician orders were absent from the chart for the month of April, 2010. The facility was unable to provide the absent physician progress notes and written physician orders.
An interview with the medical director was conducted on 5/19/2010 at approximately 3:30 PM. S/he stated the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers against the facility's policies. S/he also stated that the providers had been removing the rounding sheets on a regular basis and that office staff from their offices would return the sheets after the office was done with them.

Facility Plan of Correction:

V626
The Governing Body will ensure the facility maintains an effective, data driven, quality assessment and performance improvement program (QIFMM) that includes a monthly medical record review. Policy #3-02-01Medical Record Maintenance has been reviewed with the facility team with emphasis on the need for a monthly review of 10% of the medical records and that medical records are to remain in the facility at all times, until such time they are archived in an approved medical records storage company. AA’s are to complete all filing and audit 100% of the patient charts by 06/21/10, followed by monthly audits of 10% of the charts.
These medical records audits will be documented on the QIFMM form and reviewed in QIFMM meeting with action plans developed and implemented as needed.
A letter was written to XXX Nephrology Associates on May 20, 2010 by the Medical Director, stating that no documents are to be removed from the facility from that date forward. FA and Medical Director are responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0626&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0634 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 9:32 AM
Survey Date: 5/24/2010

Regulation Number:0634

Regulation Title: QAPI-INDICATOR-MEDICAL INJURIES/ERRORS

Regulation Description: The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification.

Surveyor Findings:


Based on review of facility documents and staff interviews, it was determined that the facility failed to implement process changes to ensure that an individual patient's dialyzer would not be used on another patient.
The findings were:
A review of the facility's internal documents was conducted on 5/20/10.
On 4/5/10, sample patient #1 was being dialyzed. It was realized by the reuse technician that the dialyzer belonging to sample patient #2 was used on sample patient #1. This was determined after sample patient #1 had completed dialysis and had left the facility. Sample patient #2 was determined to have a history of MRSA (Methicillin-resistant Staphylococcus aureus) infection and was not currently receiving hemodialysis in the facility.
Two corrective action forms dated 4/5/10 for the patient care technicians involved in setting up the dialysis machine for the patient with the wrong patient's dialyzer on 4/5/10 were reviewed.
Minutes from the Quality Improvement & Facility Management Meeting (QIFMM) dated 5/4/10 were reviewed. There was a mention of the wrong patient dialyzer being used in a section titled "Adverse Occurrence Reporting". A plan of action was identified in that section, and stated "Teammate (TM) in-service held 4/29/10 to review that TM will not sign off dialyzer until patient is in their chair as well as having patient read/read to them their dialyzer."
A facility document titled "Teammate in-service April 29, 2010" was reviewed. The document contains a topic regarding dialyzers being checked by teammates as well as a sign-in sheet with all the staff of the facility listed. It states, "Dialyzers MUST be verified by 2 teammates (PCT/RN) for the correct name, and type immediately before being started on dialysis. Do NOT sign off dialyzer until patient is sitting in the chair. Make sure you show the patient their dialyzer, reading the name to them."
The facility's policies were reviewed on 5/20/10. The policies regarding the verification of re-use dialyzers were not revised after the incident on 4/5/10.
On 5/21/10 a revised policy titled "Prescription Verification and Safety Checks" was received by the surveyors. The policy was approved by the medical director and governing body after revision. The policy was revised by adding to the section titled "Prescription Verification". The addition states, in pertinent parts, "After verification is complete by two teammates, teammates will initial the dialyzer label located on the patient dialyzer."
An interview with the facility administrator was conducted on 5/20/10 at approximately 2:00 p.m. S/he stated that the incident was reviewed after it occurred and was determined to be a employee education issue, rather than a system's issue. S/he stated that there was no change in the facility's policies and procedures in response to the error and in regards to any additional checks or oversight.
An interview with the acting facility administrator was conducted on 5/24/10 at approximately 11:30 AM. S/he stated that the staff have been writing their initials on the patient's dialyzer as an additional measure to ensure the 2-person check is completed in accordance with the facility's policies and procedures. The nurse has been checking to ensure the two employees' initials are present on the dialyzer.

Facility Plan of Correction:

V634 The Governing Body will ensure the facility maintains an effective, data driven, quality assessment and performance improvement program (QIFMM) that includes a review of medical errors identification. Adverse occurrences will be reviewed in QIFMM meeting with action plans developed and implemented as needed. Policy changes will be made if indicated. After internal review of cited incidents a plan of action was put in place that required that the teammate not sign off dialyzer until the patient is in their chair. Policy # 01-03-02 “Prescription Verification and Safety Checks” was revised to include written verification on the dialyzer while the patient is present, by 2 teammates. A governing body meeting which included the Medical Director was held on 05/20/2010 approving the new policy. Documentation of this meeting is on file in the facility. All teammates were in-serviced on this policy on 05/21/2010 and 05/22/2010. The Charge Nurse/Clinical Coordinator is observing the PCT's for compliance with verification while the patient is in the chair. In addition, audits will be conducted on 100% of reuse dialyzers X 1 month followed by auditing of 50% of reuse dialyzers X 1 month, to ensure compliance. The dialyzer audits were implemented on 06/08/2010. These audits are being conducted by the reuse technician and given to the FA for review daily. Results of audits will be reported in QIFMM and addressed as necessary. FA is responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0634&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0710 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 9:37 AM

Survey Date: 5/24/2010

Regulation Number:0710

Regulation Title: CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR

Regulation Description:

Surveyor Findings:


Based on the number and nature of deficiencies cited, the facility failed to comply with the Condition for Coverage of Medical Director. The facility's Medical Director failed to ensure providers practicing in the facility were adhering to facility policies in regards to security, completeness, and centralization of medical records. The medical director also failed to be involved in the quality improvement process in ensuring medical errors were not repeated.
The facility failed to meet the following standards under the condition of Medical Director:
V 0711 Medical Director and QAPI.
The facility failed to ensure the Medical Director was involved in the resolution of quality issues identified in the quality improvement program.
V 0715 Medical Director responsible to ensure all providers adhere to policies and procedures.
The Medical Director failed to ensure all policies and procedures were adhered to by all individuals who treat patients in the facility.

Facility Plan of Correction:

V710
Members of the Governing Body (GB) have reviewed the Statement of Deficiencies (SOD) and formulated the Plan of Correction (POC). The standards under Condition: Medical Director (V710) that is not met as well as other standards contains specifics of corrective plans. The Medical Director is accountable to the GB and will ensure the security of medical records, be involved in the quality improvement process in evaluation and prevention of medical errors, and ensure teammates adhere to policies and procedures.
The Clinical Services Specialist (CSS) will have pre QAPI and QIFMM meetings with the FA’s X 6 months to ensure all plans of correction are documented correctly. Clinical Services Specialist (CSS) to attend QAPI meetings X 6 months to ensure Medical Director Participation. Administrative Assistant (AA) will attend QAPI meetings to record the meeting and POC’s developed by the IDT during the meetings.
The Governing Body will meet monthly x 3 to ensure compliance with POC. Further compliance to the POC will be reviewed during monthly QA meetings and reported to the Governing Body no less than semi- annually. The Facility administrator (FA) representing the GB will be responsible for ensuring implementation and ongoing compliance with this POC.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0710&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 9:43 AM
Survey Date: 5/24/2010

Regulation Number:0711

Regulation Title: MD RESP-MED DIR QUAL/ACCOUNTABLE TO GOV BODY

Regulation Description: The dialysis facility must have a medical director who meets the qualifications of §494.140(a) to be responsible for the delivery of patient care and outcomes in the facility. The medical director is accountable to the governing body for the quality of medical care provided to patients.

Surveyor Findings:


Based on a review of facility documents, it was determined the facility failed to ensure the Medical Director was involved in the resolution of quality issues identified in the quality improvement program.

The findings were:

A review of the facility's internal documents was conducted on 5/20/10.
On 4/5/10, sample patient #1 was being dialyzed. It was realized by the reuse technician that the dialyzer belonging to sample patient #2 was used on sample patient #1. This was determined after sample patient #1 had completed dialysis and had left the facility. Sample patient #2 was determined to have a history of MRSA (Methicillin-resistant Staphylococcus aureus) infection and was not currently receiving hemodialysis in the facility.
Two corrective action forms dated 4/5/10 for the patient care technicians involved in setting up the dialysis machine for the patient with the wrong patient's dialyzer on 4/5/10 were reviewed.
Minutes from the Quality Improvement & Facility Management Meeting (QIFMM) dated 5/4/10 were reviewed. There was a mention of the wrong patient dialyzer being used in a section titled "Adverse Occurrence Reporting". A plan of action was identified in that section, and stated "Teammate (TM) in-service held 4/29/10 to review that TM will not sign off dialyzer until patient is in their chair as well as having patient read/read to them their dialyzer."
A facility document titled "Teammate in-service April 29, 2010" was reviewed. The document contains a topic regarding dialyzers being checked by teammates as well as a sign-in sheet with all the staff of the facility listed. It states, "Dialyzers MUST be verified by 2 teammates (PCT/RN) for the correct name, and type immediately before being started on dialysis. Do NOT sign off dialyzer until patient is sitting in the chair. Make sure you show the patient their dialyzer, reading the name to them."
The facility's policies were reviewed on 5/20/10. The policies regarding the verification of re-use dialyzers were not revised after the incident on 4/5/10.
On 5/21/10 a revised policy titled "Prescription Verification and Safety Checks" was received by the surveyors. The policy was approved by the medical director and governing body after revision. The policy was revised by adding to the section titled "Prescription Verification". The addition states, in pertinent parts, "After verification is complete by two teammates, teammates will initial the dialyzer label located on the patient dialyzer."
In summary, after the facility had identified that an error took place in which a dialyzer from one patient was used on another patient, the facility's Medical Director did not make any changes to the facility's policies or procedures. There was no evidence that the Medical Director was involved in the efforts to prevent an error similar to the one identified from occurring again.

Facility Plan of Correction:

V711
The Medical Director is accountable to the GB and will ensure the security of medical records, be involved in the quality improvement process in evaluation and prevention of medical errors, and ensure teammates adhere to policies and procedures. Adverse occurrences will be reviewed in QIFMM meeting with action plans developed and implemented as needed. Policy changes will be made if indicated. After internal review of cited incidents a plan of action was put in place that required that the teammate not sign off dialyzer until the patient is in their chair. Policy # 01-03-02 “Prescription Verification and Safety Checks” was revised to include written verification on the dialyzer while the patient is present, by 2 teammates. A governing body meeting which included the Medical Director was held on 05/20/2010 approving the new policy. Documentation of this meeting is on file in the facility. All teammates were in-serviced on this policy on 05/21/2010 and 05/22/2010. The Charge Nurse/Clinical Coordinator is observing the PCT's for compliance with verification while the patient is in the chair. In addition, audits will be conducted on 100% of reuse dialyzers X 1 month followed by auditing of 50% of reuse dialyzers X 1 month, to ensure compliance. The dialyzer audits were implemented on 06/08/2010. These audits are being conducted by the reuse technician and given to the FA for review daily. Results of audits will be reported in QIFMM and addressed as necessary. The Clinical Services Specialist (CSS) will have pre QAPI and QIFMM meetings with the FA’s X 6 months to ensure all plans of correction are documented correctly. Clinical Services Specialist (CSS) to attend QAPI meetings X 6 months to ensure Medical Director Participation. Administrative Assistant (AA) will attend QAPI meetings to record the meeting and POC’s developed by the IDT during the meetings. FA and Medical Director are responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0711&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0711 Detail for:
5/24/2010 Survey Tag 0715 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 9:50 AM
Survey Date: 5/24/2010

Regulation Number:0715

Regulation Title: MD RESP-ENSURE ALL ADHERE TO P&P

Regulation Description: The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;

Surveyor Findings:


Based on review of medical record reviews and staff interviews it was determined that the medical director failed to ensure all policies and procedures were adhered to by all individuals that treat patients in the facility. This practice of removing physician progress notes and written orders had the potential for causing negative patient outcomes.

The findings were:

The medical records of eight in-center hemodialysis patients were reviewed throughout the survey from 5/20/10 through 5/24/10. In three (#5, #6, and #7) of eight records original physician progress notes and written physician orders were absent from the chart for the month of April, 2010. The facility was unable to provide the absent physician progress notes and written physician orders.
An interview with the medical director was conducted on 5/19/2010 at approximately 3:30 p.m. S/he stated that the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers against the facility's policies.

Facility Plan of Correction:

V715
The Medical Director is accountable to the GB and will ensure the security of medical records, be involved in the quality improvement process in evaluation and prevention of medical errors, and ensure teammates adhere to policies and procedures.

Policy #3-02-01Medical Record Maintenance has been reviewed with the facility team with emphasis on the need for a monthly review of 10% of the medical records and that medical records are to remain in the facility at all times, until such time they are archived in an approved medical records storage company. AA’s are to complete all filing and audit 100% of the patient charts by 07/15/2010, followed by monthly audits of 10% of the charts. These medical records audits will be documented on the QIFMM form m reviewed in QIFMM meeting and any action plans developed and implemented as needed. A letter was written to XXX Nephrology Associates on May 20, 2010 by the Medical Director, stating that no documents are to be removed from the facility from that date forward. FA and Medical Director are responsible for ongoing compliance with POC.
CSS to have pre QAPI and QIFMM meetings with the FA’s X 6 months to ensure all plans of correction are documented correctly. CSS to attend QAPI meetings X 6 months to ensure Medical Director participation. AA’s will attend QAPI meetings to record the meeting meetings and POC’s developed by the IDT during the meetings.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0715&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0725 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 9:57 AM
Survey Date: 5/24/2010

Regulation Number:0725

Regulation Title: CFC-MEDICAL RECORDS

Regulation Description:

Surveyor Findings:


Based on the number and nature of deficiencies cited, the facility failed to comply with the Condition for Coverage of Medical Records. The facility failed to maintain complete and accurate records and protect them against loss and unauthorized use.
The facility failed to meet the following standards under the condition of Medical Records:

V 0726 Maintenance of a complete, accurate, and accessible record on all patients.
The facility failed to maintain a complete, accurate, and accessible patient record on all patients. Original physician progress notes and physician orders left the premises of the facility and were absent from the patient's record during review of the patients' records. This failure created the potential for patient care to be compromised.
V 0727 Protection of patient's record.
The facility failed to ensure the patients' medical records were protected from loss, destruction, or unauthorized use. Original physician orders and progress notes left the premises and were not available during review of the patients' records during the survey.
V 0729 Completion of patient records promptly.
The facility failed to appropriately complete medical records in eight of eight in-center hemodialysis patients' medical records reviewed. Entries were lacking documentation of the time of the entries. This failure created the potential for patient care to be compromised.
V 0730 Centralization of clinical information.
The facility failed to maintain a centralized patient record that was accessible to all members of the interdisciplinary team. This failure created the potential for patient care to be compromised.

Facility Plan of Correction:

V725 Members of the Governing Body (GB) have reviewed the Statement of Deficiencies (SOD) and formulated the Plan of Correction (POC). The standards under Condition: Medical Records (V725) that is not met as well as other standards contains specifics of corrective plans. The Medical Director is accountable to the GB and will ensure the security of medical records, be involved in the quality improvement process in evaluation and prevention of medical errors, and ensure teammates adhere to policies and procedures.
Policy #3-02-01Medical Record Maintenance has been reviewed with the facility team with emphasis on the need for a monthly review of 10% of the medical records and that medical records are to remain in the facility at all times, until such time they are archived in an approved medical records storage company. Policy #3-02-02 Medical Record Preparation Charting Guidelines has been reviewed with the teammates with the emphasis on that all entries are to be dated and signed at the time of entry.
AA’s are to complete all filing and audit 100% of the patient charts by 6/21/10followed by monthly audits of 10% of the charts. In addition compliance will be evidenced by random audits conducted by the FA of monthly physician Rounding Reports X 3 months. Results of audits will be reported in QIFMM and addressed as necessary. FA and Medical Director are responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0725&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0726 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 3:55 PM
Survey Date: 5/24/2010

Regulation Number:0726

Regulation Title: MR-COMPLETE, ACCURATE, ACCESSIBLE

Regulation Description: The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.

Surveyor Findings:


Based on medical record review and staff interviews, it was determined that the facility failed to maintain a complete, accurate, and accessible patient record on all patients. This failure created the potential for patient care to be compromised.
The findings were:
The medical records of eight in-center hemodialysis patients were reviewed throughout the survey from 5/20/10 through 5/24/10. In three (#5, #6, and #7) of eight records original physician progress notes and written physician orders were absent from the chart for the month of April, 2010. The facility was unable to provide the absent physician progress notes and written physician orders.
An interview with the medical director was conducted on 5/19/10 at approximately 3:30 p.m. S/he stated that the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers (physicians and allied health personnel) against the facility's policies.

In summary, the facility allowed original documents to leave the premises and the documents were not available to all members of the interdisciplinary team at all times. This failure created the potential for patient care to be compromised.

Facility Plan of Correction:

V726 The Governing Body will ensure the facility maintains an effective, data driven, quality assessment and performance improvement program (QIFMM) that includes a monthly medical record review. Policy #3-02-01Medical Record Maintenance has been reviewed with the facility team with emphasis on the need for a monthly review of 10% of the medical records and that medical records are to remain in the facility at all times, until such time they are archived in an approved medical records storage company. AA’s are to complete all filing and audit 100% of the patient charts by 6/21/10 followed by monthly audits of 10% of the charts.

These medical records audits will be documented on the QIFMM form and reviewed in QIFMM meeting with action plans developed and implemented as needed.
A letter was written to XXX Nephrology Associates on May 20, 2010 by the Medical Director, stating that no documents are to be removed from the facility from that date forward. FA and Medical Director are responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0726&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0727 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 4:08 PM


Survey Date: 5/24/2010

Regulation Number:0727

Regulation Title: MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL

Regulation Description: The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient's record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program.

Surveyor Findings:


Based on staff interviews and review of medical records, it was determined that the facility failed to ensure that the patients' medical records were protected from loss, destruction, or unauthorized use.
The findings were:
The medical records of eight in-center hemodialysis patients were reviewed throughout the survey from 5/20/10 through 5/24/10. In three (#5, #6, and #7) of eight records original physician progress notes and written physician orders were absent from the chart for the month of April, 2010. The facility was unable to provide the absent physician progress notes and written physician orders.
An interview with the medical director was conducted on 5/19/10 at approximately 3:30 p.m. S/he stated that the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers (physicians and allied health personnel) against the facility's policies.

In summary, the facility failed to ensure that original documents that were part of the patient's medical records remained on premises. The facility failed to ensure that the patients' medical records were protected from possible theft or misuse by unauthorized individuals.

Facility Plan of Correction:

V727
The Governing Body will ensure the facility maintains an effective, data driven, quality assessment and performance improvement program (QIFMM) that includes a monthly medical record review. Policy #3-02-01Medical Record Maintenance has been reviewed with the facility team with emphasis on the need for a monthly review of 10% of the medical records and that medical records are to remain in the facility at all times, until such time they are archived in an approved medical records storage company. AA’s are to complete all filing and audit 100% of the patient charts by 6/21/10, followed by monthly audits of 10% of the charts.
These medical records audits will be documented on the QIFMM form and reviewed in QIFMM meeting with action plans developed and implemented as needed.
A letter was written to XXX Nephrology Associates on May 20, 2010 by the Medical Director, stating that no documents are to be removed from the facility from that date forward. FA and Medical Director are responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0727&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0729 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 4:04 PM
Survey Date: 5/24/2010

Regulation Number:0729

Regulation Title: MR-COMPLETE RECORDS PROMPTLY

Regulation Description: (1) Current medical records and those of discharged patients must be completed promptly.

Surveyor Findings:


Based on review of medical records, the facility failed to appropriately complete medical records in eight (#1, #3, and #5 through #10) of eight in-center hemodialysis patient medical records reviewed. This failure created the potential for patient care to be compromised.
The findings were:
The medical records of eight in-center hemodialysis patients were reviewed throughout the survey from 5/20/10 through 5/24/10. The "Physician Orders and Progress Notes" were reviewed for the previous six months to approximately one year. It was noted that all physician orders and progress notes were not timed. Also, the physician orders that were noted by nurses were not timed when orders were taken off, only dated.

Facility Plan of Correction:

V729
Policy #3-02-02 Medical Record Preparation Charting Guidelines has been reviewed with the teammates with the emphasis on that all entries are to be timed dated and signed at the time of entry.
AA’s are to complete all filing and audit 100% of the patient charts by 6/21/10 followed by monthly audits of 10% of the charts. In addition compliance will be evidenced by random audits conducted by the FA of monthly physician Rounding Reports X 3 months. Results of audits will be reported in QIFMM and addressed as necessary. FA and Medical Director are responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0729&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0730 Detail for:
PIKES PEAK DIALYSIS CENTER
Saturday, December 25, 2010 4:10 PM
Survey Date: 5/24/2010

Regulation Number:0730

Regulation Title: MR-CENTRALIZE ALL INFO;IDT HAS ACCESS

Regulation Description: (2) All clinical information pertaining to a patient must be centralized in the patient's record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient's condition and prescribed treatment.

Surveyor Findings:


Based on medical record review and staff interviews, it was determined that the facility failed to maintain a centralized patient record. This failure created the potential for patient care to be compromised.
The findings were:
The medical records of eight in-center hemodialysis patients were reviewed throughout the survey from 5/20/10 through 5/24/10. In three (#5, #6, and #7) of eight records original physician progress notes and written physician orders were absent from the chart for the month of April, 2010. The facility was unable to provide the absent physician progress notes and written physician orders.
An interview with the medical director was conducted on 5/19/10 at approximately 3:30 p.m. S/he stated that the physician rounding sheets (which contained physician progress notes and written orders) were part of the patients' medical records and were being removed by providers (physicians and allied health personnel) against the facility's policies.

In summary, the facility allowed original documents to leave the premises. The documents were not available to all members of the interdisciplinary team at all times. This failure created the potential for patient care to be compromised.

Facility Plan of Correction:

V730 The Governing Body will ensure the facility maintains an effective, data driven, quality assessment and performance improvement program (QIFMM) that includes a monthly medical record review. Policy #3-02-01Medical Record Maintenance has been reviewed with the facility team with emphasis on the need for a monthly review of 10% of the medical records and that medical records are to remain in the facility at all times, until such time they are archived in an approved medical records storage company. AA’s are to complete all filing and audit 100% of the patient charts by 6/21/10, followed by monthly audits of 10% of the charts.
These medical records audits will be documented on the QIFMM form and reviewed in QIFMM meeting with action plans developed and implemented as needed.
A letter was written to XXX Nephrology Associates on May 20, 2010 by the Medical Director, stating that no documents are to be removed from the facility from that date forward. FA and Medical Director are responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0730&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0750 Detail for:
PIKES PEAK DIALYSIS CENTER
5/24/2010 Survey Tag 0750 Detail for:
PIKES PEAK DIALYSIS CENTER
Sunday, December 26, 2010 8:00 AM
Sunday, December 26, 2010 8:00 AM
Survey Date: 5/24/2010

Regulation Number:0750

Regulation Title: CFC-GOVERNANCE

Regulation Description:

Surveyor Findings:


Based on the number and nature of the deficiencies cited, staff interviews, and review of patient records, policies/procedures, personnel/credential files, meeting minutes and other facility documents, the governing body (as the entity ultimately responsible for the governance and operation of the facility and responsible for the health care and safety of patients) failed to ensure that the facility maintained complete medical records, and that facility staff followed facility policies/procedures, and that the Medical Director was involved in the oversight of providers adherence to facility policies/procedures and with the quality improvement process for ensuring that medical errors were not repeated. The Governing Body failed to provide a comprehensive and proactive leadership to ensure the facility met the requirements for the health and safety of the patients.

The findings were:

1. Cross Reference to the QAPI Standard tags V626 and V634 for findings related to the facility's failure to "identify and correct deficiencies in the completeness of medical records as part of the QAPI program" and "implement process changes to ensure that a wrong patient's dialyzer would be used on another patient."

2. Cross Reference to the Medical Director Condition Tag V710 and Standard Tags V711 and V715 for findings related to the Medical Director's failure to "ensure that providers practicing in the facility were adhering to facility policies in regards to security, completeness, and centralization of medical records" as well as the Medical Director's failure to "be involved in the quality improvement process in ensuring that medical errors were not repeated."
3. Cross Reference to the Medical Record Condition Tag V725 and Standard Tags V726, V727, V729, and V730 for findings related to the facility's failure to "maintain complete and accurate records and protect them against loss and unauthorized use".

Facility Plan of Correction:

V750
The Governing Body will provide comprehensive and proactive leadership to ensure the facility meets the requirements for the health and safety of the patients. An in-service on the Governing Body process and documentation of said meeting was conducted by the
Regional Operations Director (ROD) on 06/15/2010. The Governing Body will ensure the facility maintains an effective, data driven, quality assessment and performance improvement program (QIFMM) that that is led by the Medical Director and ensures the security of medical records, includes the evaluation and prevention of medical errors, to include but not be limited to dialyzers being used by the wrong patients, and ensures teammates adhere to policies and procedures.
Policy #3-02-01Medical Record Maintenance has been reviewed with the facility team with emphasis on the need for a monthly review of 10% of the medical records and that medical records are to remain in the facility at all times, until such time they are archived in an approved medical records storage company. Policy #3-02-02 Medical Record Preparation Charting Guidelines has been reviewed with the teammates with the emphasis on that all entries are to be timed, dated and signed at the time of entry. A letter was written to XXX Nephrology Associates on May 20, 2010 by the Medical Director, stating that no documents are to be removed from the facility from that date forward. FA and Medical Director are responsible for ongoing compliance with POC. AA’s are to complete all filing and audit 100% of the patient charts by 6/21/10, followed by monthly audits of 10% of the charts. In addition compliance will be evidenced by random audits conducted by the FA of monthly physician Rounding Reports X 3 months. Results of audits will be reported in QIFMM and addressed as necessary. FA and Medical Director are responsible for ongoing compliance with POC.

Adverse occurrences will be reviewed in QIFMM meeting with action plans developed and implemented as needed. Policy changes will be made if indicated. After internal review of cited incidents a plan of action was put in place that required that the teammate not sign off dialyzer until the patient is in their chair. Policy # 01-03-02 “Prescription Verification and Safety Checks” was revised to include written verification on the dialyzer while the patient is present, by 2 teammates. A governing body meeting which included the Medical Director was held on 05/20/2010 approving the new policy. Documentation of this meeting is on file in the facility. All teammates were in-serviced on this policy on 05/21/2010 and 05/22/2010. The Charge Nurse/Clinical Coordinator is observing the PCT's for compliance with verification while the patient is in the chair. In addition, audits will be conducted on 100% of reuse dialyzers X 1 month followed by auditing of 50% of reuse dialyzers X 1 month, to ensure compliance. The dialyzer audits were implemented on 06/08/2010. These audits are being conducted by the reuse technician and given to the FA for review daily. Results of audits will be reported in QIFMM and addressed as necessary. FA is responsible for ongoing compliance with POC.

The Governing Body will meet monthly x 3 to ensure compliance with POC. Further compliance to the POC will be reviewed during monthly QA meetings and reported to the Governing Body no less than semi- annually. The Facility administrator (FA) representing the GB will be responsible for ensuring implementation and ongoing compliance with this POC.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0750&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0765 Detail for:
PIKES PEAK DIALYSIS CENTER
Sunday, December 26, 2010 8:36 AM
Survey Date: 5/24/2010

Regulation Number:0765

Regulation Title: GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED

Regulation Description: The facility's internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient's designated representative will be informed of steps taken to resolve the grievance.

Surveyor Findings:


Based on review of facility documents and staff interviews, the facility failed to keep a record of patient grievances. This failure created the potential for not addressing patient's issues, and violating the patient's rights.

The findings were:

On 5/20/10 at approximately 10:45 a.m., an interview was conducted with the facility administrator. S/he stated that the facility hasn't kept records of patient complaints since 2008. S/he explained that this was due to a change in administration and was improving since April, 2010.

A review of the facility's patient grievance log took place on 5/20/10 at approximately 10:30 a.m. The earliest entry available was for 4/1/10 and was one of two grievances that made up the entire patient grievance log for 2009 and 2010.

Facility Plan of Correction:

V765
All teammates were in-serviced on the grievance policies #3-01-06 “Patient Grievance”, #3-1-06A “Addressing Patient Grievances: DaVita Teammates” and #3-01-6B “Patient Grievance Procedure” on 06/10/2010 with instructions on how to address and document these issue. Grievances logs are now located at the North RN station, South RN station, SW office and FA office. All individual grievances will be addressed by the FA or designee within 10 days of receipt. Findings will be discussed by the IDT at weekly core team meetings and also reviewed and documented in QIFMM. FA is responsible for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0765&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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5/24/2010 Survey Tag 0770 Detail for:
PIKES PEAK DIALYSIS CENTER
Sunday, December 26, 2010 8:41 AM
Survey Date: 5/24/2010

Regulation Number:0770

Regulation Title: GOV-TRANSFER AGREEMENT W/HOSP FOR INPT CARE

Regulation Description: (3) The dialysis facility must have an agreement with a hospital that can provide inpatient care, routine and emergency dialysis and other hospital services, and emergency medical care which is available 24 hours a day, 7 days a week. The agreement must: (i) Ensure that hospital services are available promptly to the dialysis facility ' s patients when needed. (ii) Include reasonable assurances that patients from the dialysis facility are accepted and treated in emergencies.

Surveyor Findings:


Based on review of the facility's "Patient Transfer Agreement Pursuant To EMTALA"(Emergency Medical Treatment And Active Labor Act) it was determined the facility failed to have an updated, effective transfer agreement with a hospital. Specifically, the agreement in pertinent part, stated: 1. TERM. "This agreement shall be affective from the date stipulated in the first sentence of this Agreement for a period of one (1) year and shall be automatically renewed for successive one (1) year periods, not to exceed a total of five (5) years." The effective date on the agreement was September 15th, 2001. An updated agreement was not provided by the facility.

Facility Plan of Correction:

V770
A new Hospital Transfer Agreement was drafted by DaVita legal department and sent to the CEO’s of XXX1 and XXX2 hospitals. The Agreement from XXX1 Hospital has been signed by the ROD and CEO and forwarded back to legal for full execution. We are still awaiting Agreements from CEO of XXX2 Hospital as of this date.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0770&eid=BEYN11&ft=esrd&id=120506&bdg=00&reg=FV10

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Intake ID:   CO00011960
Facility:   PRINTERS PLACE DIALYSIS CENTER
Date of Complaint:   5/18/2010
Date of Investigation:   5/18/2010
Total Number of Allegations for Complaint: 1

Allegation: 1

Type: Resident/Patient/Client Neglect

Findings: Substantiated

Allegation Detail: The Health Facilities and Emergency Medical Services Division received information that the facility used another patient's dialyzer while dialyzing her/him. The patient whose dialyzer was used has Hep C.
The facility failed to report this to the HFEMSD Occurrence reporting section as neglect per Chapter II Licensure requirements.


Findings Detail: On 5/20/10 through 5/24/10 an unannounced onsite complaint investigation was conducted. The facility staff did not know this was a reportable occurrence. The facility was cited for failing to comply with the Chapter II Licensure requirements. Cross Reference to CO # 11958.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/compreport.aspx?id=12050W&ft=esrd&comp=CO00011960&bk=

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5/25/2010 Survey Tag 0001 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Sunday, December 26, 2010 11:13 AM
Survey Date: 5/25/2010

Regulation Number:0001

Regulation Title: Survey Details

Regulation Description:

Surveyor Findings:


Section 1 - Statutory Authority and Applicability
1.2 A dialysis treatment clinic, as defined herein, shall comply with all applicable federal and state statutes and regulations, including but not limited to, the following:
(B) 6 CCR 1011-1, Chapter II, General Licensure Standards, including Part 7, Single Used Disposable Medical Devices.

This REGULATION was not met as evidenced by:
Based on review of medical records and staff interviews the facility failed to comply with Chapter II General Licensure Reporting requirements in one sample patient. The facility failed to report an incident of patient neglect to the Colorado Department of Public Health and Environment as required by statutes. This failure created the potential for a negative patient outcome.

The facility failed to comply with the following licensure requirements for Chapter II:

3.2 OCCURRENCE REPORTING
Notwithstanding any other reporting required by state law or regulation, each health care entity licensed pursuant to 25-1.5-103 shall report to the Department the occurrences specified at 25-1-124 (2) C.R.S.
3.2.1 The following occurrences shall be reported to the department in the format required by the Department by the next business day after the occurrence or the health care entity becomes aware of the occurrence:
3.2.1 (5) Any occurrence involving neglect of a patient or resident, as described in section 26-3.1-101 (4)(b) C.R.S.;

Review of medical records on 5/19/2010 revealed that sample patient #2 received sample patient #1's dialyzer during a routine dialysis treatment. In addition, sample patient #2 had the incorrect type of dialyzer used for his treatment. Sample patient #1 was positive for Hepatitis C and, because of the dialyzer error, sample patient #2 then had the risk of being exposed to Hepatitis C.

Interview with the facility's Regional Operations Director (ROD) on 5/18/2010 at 12:25 p.m., revealed that the dialyzer incident with sample patient #2 was not reported by the facility as an occurrence to the Colorado Department of Public Health and Environment as required by statutes. The ROD stated that, after consulting with the corporation's lawyers, it was determined that the incident did not meet the reporting standards. This failure did not ensure that quality management and assurance was maintained by the facility.




Facility Plan of Correction:

S001
The Dialysis Company and facility
Governing Body strive to maintain a
safe, functional and comfortable
environment and focus on indicators
related to improving patient outcomes
and the prevention and reduction of
medical errors. We take the cited
incidents very seriously and consider
the variances from policy to be
unacceptable practice. The facility requested informal
reconsideration of this citation. The
Colorado Department of Public Health
and Environment (CDPHE) responded
and sustained the citation by letter dated
September 21, 2010. The facility
continues to believe that there was no
Reportable Occurrence of Neglect
because there was no actual patient harm,
history of neglect, or intentional
misconduct. Nonetheless, in light of
CDPHE's letter of September 21, 2010,
the facility has revised its policies as set
forth in the plan of correction.

The facility will comply with the
reporting requirements as listed and
defined in Colorado Department of Public
Health and Environment Occurrence
Reporting Manual.
The facility's Governing Body has
developed and plans to implement a
policy entitled “Occurence
Reporting” (Policy) (attached) regarding
this process. FA and the Governing Body
are responsible for ongoing compliance
with POC. Training of relevant staff on
the Policy will be conducted on or before
the completion date.



Adverse Occurrence Reporting Manual
DaVita Inc.
Facility Specific Policy Facility # 546
Property of DaVita Inc. Confidential and Copyrighted © 2010
Title: Occurrence Reporting Policy
_____________________________________________________________
Purpose: To establish the process for occurrence reporting to the State of Colorado as required by Colorado licensure law and regulations.
Policy:
1.
Any “Unexpected Event” that is inconsistent with the routine operation of a dialysis facility may be a “Reportable Occurrence,” as defined by this policy.
2.
All Unexpected Events will be promptly reported to the Facility Administrator (FA)/Manager or designee. The teammate involved in the Unexpected Event or who witnessed the Unexpected Event will document the details of the Unexpected Event as the teammate observed and not report opinions or details reported to him/her by third parties.
3.
The FA/Manager or designee is responsible for complying with any state-specific requirements for reporting of all adverse occurrences.
4.
Dialysis facilities licensed in Colorado are required to report certain Reportable Occurrences (identified below) to the Colorado Department of Public Health and Environment (“CDPHE”). C.R.S. § 25-1-125(2)(e).
5.
The FA/Manager or designee will review the details of the Unexpected Event to determine if it constitutes a Reportable Occurrence. Only events that constitute a Reportable Occurrence are to be reported to the CDPHE.
6.
The FA/Manager or designee may consult the Colorado Occurrence Reporting Manual to determine if the Unexpected Event meets the elements set forth in the Reporting Manual and therefore is a Reportable Occurrence. The FA/Manager or designee may also consult Colorado regulations at 6 C.C.R. 1011-1, Ch. II, § 3.2 to assist in determining whether an Unexpected Event must be reported as a Reportable Occurrence.
7.
If it is determined that a Reportable Occurrence has occurred, the FA/Manager or designee will report to CDPHE as per the current processes described in the online Colorado Occurrence Reporting Manual.
Definitions:
“Unexpected Event” is an event or an occurrence that is inconsistent with the routine operation of a dialysis facility.
Origination Date: October 2010
Revision Date:
Page 1 of 3
Adverse Occurrence Reporting Manual
DaVita Inc.
Facility Specific Policy Facility # 546
Property of DaVita Inc. Confidential and Copyrighted © 2010
“Reportable Occurrence” is an Unexpected Event that must be reported to the CDPHE pursuant to C.R.S. 25-1-124(2). Reportable Occurrences include the following:
1.
Any occurrence that results in the death of a patient and is required to be reported to the coroner per section 30-10-606, C.R.S, as arising from an unexplained cause or under suspicious circumstances.
2.
Any occurrence that results in any of the following serious injuries to a patient:
a.
Brain or spinal cord injuries;
b.
Life-threatening complications of anesthesia or life-threatening transfusion errors or reactions; or
c.
Second- or third degree burns involving twenty percent or more of the body surface area of an adult patient or fifteen percent or more of the body surface area a child patient.
3.
Any time a patient of the facility cannot be located following a search of the facility, the facility grounds, and the area surrounding the facility and there are circumstances that place the patient’s health, safety, or welfare at risk or, regardless of whether such circumstances exist, the patient has been missing for eight hours.
4.
Any occurrence involving physical, sexual, or verbal abuse of a patient as described in section 18-3-202, 18-3-203, 18-3-204, 18-3-206, 18-3-402, 18-3-403, as it existed prior to July 1, 2000, 18-3-404, or 18-3-405, C.R.S., by another patient, an employee of the facility or a visitor to the facility.
5.
An occurrence involving neglect of a patient by a caretaker (“Caretaker Neglect”) as described in C.R.S. § 26-3.1-101 (4) (b). Caretaker Neglect occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, or supervision is not secured for an at-risk adult or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise. An “at-risk adult” is an individual eighteen years of age or older who is susceptible to mistreatment or self-neglect because the individual is unable to perform or obtain services necessary for the individual's health, safety, or welfare or lacks sufficient understanding or capacity to make or communicate responsible decisions concerning the individual's person or affairs. There was an incident of Caretaker Neglect if one of the following three elements occurred with respect to a patient who qualified as an at-risk adult:
a.
Failure to provide any care or services as provided above resulting in actual harm;
b.
Staff member has a history in the past 12 months of similar neglect and had been counseled and/or re-educated; or
c.
Staff member intentionally failed to follow standard of practice and/or facility policy with significant potential for harm.
6.
Any occurrence involving misappropriation of a patient’s property.
Origination Date: October 2010
Revision Date:
Page 2 of 3
Adverse Occurrence Reporting Manual
DaVita Inc.
Facility Specific Policy Facility # 546
Property of DaVita Inc. Confidential and Copyrighted © 2010
Origination Date: October 2010
Revision Date:
Page 3 of 3
7.
Any occurrence in which drugs intended for use by patients are diverted to use by other persons.
8.
Any occurrence (i) involving the malfunction or intentional or accidental misuse of patient equipment that occurs during treatment or diagnosis of a patient, and (ii) that significantly adversely affects or if not averted would have significantly adversely affected a patient of the facility.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0001&eid=I5E711&ft=esrd&id=12050W&bdg=00&reg=93NB
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5/25/2010 Survey Tag 0200 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Sunday, December 26, 2010 11:22 AM
Survey Date: 5/25/2010

Regulation Number:0200

Regulation Title: RO-MONITOR/ALARM/PREVENT UNSAFE H20 USE

Regulation Description: 5.2.7 Reverse osmosis: alarm/prevent use of unsafe water Refer to RD62:2001, 4.3.7 Reverse osmosis: Reverse osmosis devices shall be equipped with on-line monitors that allow determination of rejection rates and product water conductivity. The product water conductivity monitor should activate audible and visual alarms when the product water conductivity exceeds the preset alarm limit. The audible alarm must be audible in the patient care area when reverse osmosis is the last chemical purification process in the water treatment system. Monitors that measure resistivity or TDS may be used in place of conductivity monitors. 6.2.7 Reverse osmosis: Reverse osmosis systems should be monitored daily using continuous-reading monitors that measure product water conductivity (or total dissolved solids (TDS)). 5.2.7 Reverse osmosis: Refer to RD62:2001, 4.3.7 Reverse osmosis: When a reverse osmosis system is the last chemical purification process in the water treatment system, it [should] include a means to prevent patient exposure to unsafe product water, such as diversion of the product water to drain, in the event of a product water conductivity or rejection alarm.

Surveyor Findings:


Based on observation and staff interview it was determined the facility failed to have an audible alarm that was audible in the patient care area. The failure of not having an audible alarm created the potential for negative patient outcome.

On 5/18/10 at approximately 1:30 p.m., during a tour and observation of the patient care area it was noted the water alarm was not audible when the visual alarm light was flashing.

Interview with the Water Treatment Technician on 5/18/10 revealed the alarm had been turned down in the patient care area due to the nocturnal dialysis patients. H/she stated that the patients like to sleep and the alarm was annoying to them, and that the alarm had been turned down for at least a year. The alarm was then turned up to a volume which was audible in the patient care area.

Surveyor Findings:





Facility Plan of Correction:

V200
The audible alarm was fixed on May 19th,
2009 and is fully functional. The Biomed
tech will check monthly during facility
audit to ensure the alarm is still audible
and document results. FA is responsible
for ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0200&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0504 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Sunday, December 26, 2010 11:37 AM
Survey Date: 5/25/2010

Regulation Number:0504

Regulation Title: PA-ASSESS B/P, FLUID MANAGEMENT NEEDS

Regulation Description: The patient's comprehensive assessment must include, but is not limited to, the following: Blood pressure, and fluid management needs.

Surveyor Findings:


Based on review of medical records, review of facility Policies and Procedures and staff interviews, the facility failed to appropriately document post-treatment assessment data in three (#1, #3 & #6) of six medical records reviewed. The staff failed to follow facility policy for documentation of post-treatment data collection. This failure created the potential for patient care to be compromised.

The findings were:

The medical records of six patients were reviewed throughout the survey. The following was revealed:

Sample #1 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the chairside computer documentation program (for recording data before, during and after treatment) titled "ChairSide Snappy Flowsheet" revealed that in three (5/10/10, 5/12/10 and 5/14/10) of four reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample #3 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in two (4/28/10 and 5/3/10) of six reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

Sample #6 was an adult patient receiving in-center hemodialysis. A review of the "post treatment" documentation from the "ChairSide Snappy Flowsheet" revealed that in two (2/22/10 and 3/3/10) of five reviewed flowsheets, the "Posttreatment data collection & assessment" section stated "No Data".

The facilities Policies and Procedures were reviewed on 5/19/2010. The policy titled "Pre/Post Dialysis Treatment Data Collection" stated, in pertinent part:
"1. Patient data will be obtained and documented by the patient care staff ...
5. Data collection may include the following:
Weight
Blood pressure
Cardiac status
Respiratory status
Peripheral edema
Vascular access
Mental status
Patient subjective statement
Ambulatory status ..."

The policy titled "Post Treatment Patient Assessment" stated, in pertinent part:
"1. The patient care staff will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings...
6. All findings, interventions, and patient responses are documented in the patient's medical record."

An interview was conducted on 5/25/2010 at approximately 3:10 p.m. with the facility administrator. S/he stated that the standard of practice for the facility is to, at a minimum, place data in the data collection portion of the post-treatment data collection and assessment section. S/he stated that data collection is usually completed by the patient care technician and placed into the ChairSide Snappy program by the technician. S/he also stated that "it is an issue that was identified and is being worked on."


Facility Plan of Correction:

V504
The Clinical Services Specialist (CSS) and
FA reviewed Policy #1-03-10 “Pre/Post
Treatment Data Collection” and #1-03-12
“Post Treatment Patient Assessment” with
the teammates on 6/10/10. The focus of
this review was the importance of
obtaining and documenting basic data on
each patient post dialysis. This
information is to be compared with predialysis
findings and addressed as
necessary. FA or designee to audit
patient flow sheets on every patient
weekly, utilizing the post treatment audit
tool, for a period of 1 month. Thereafter, a
random sampling of 10% of the post
treatment sheets will be done by the FA/
designee and reviewed at the monthly QA
meetings. FA/designee is responsible for
ongoing compliance with the above stated
policy and procedure.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0504&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0626 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 8:35 AM
Survey Date: 5/25/2010

Regulation Number:0626

Regulation Title: QAPI-COVERS SCOPE SERV/EFFECTIVE/IDT INVOL

Regulation Description: 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.

Surveyor Findings:


Based on review of facility documents, staff interviews and review of medical records, it was determined that the facility failed to identify and correct deficiencies in the completeness of medical records as part of the QAPI program.

The findings were:

A review of the facilities internal documents was conducted on 5/19/10. Minutes from the Quality Improvement & Facility Management Meeting (QIFMM) dated 3/2/10 were reviewed. The section titled Quality Management Audits lists that 10% of the patient records were reviewed monthly. There was no mention of physician progress notes or orders not being present or leaving the facility.

The medical records of six patients were reviewed throughout the survey. In four (#1, #2, #3, #5) of six records original physician progress notes and written physician orders were absent from the chart for the months of March and April 2010. In two (#2 and #6) of six records original physician progress notes and written physician orders were absent from the chart for the month of October 2009. In one (#2) of six records original physician progress notes and written physician orders were absent from the chart for the month of February 2010. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for April 2010 on four (#1, #2, #3 & #5) of the five patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for March 2010 on two (#1 and #2) of the four patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for February 2010 on the one (#2) patient. The facility was unable to provide the absent physician progress notes and written physician orders from October 2009.

An interview with the medical director was conducted on 5/19/2010 at approximately 3:30 PM. S/he stated that the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers against the facility's policies. S/he also stated that the providers had been removing the rounding sheets on a regular basis and that office staff from their offices would return the sheets after the office was done with them.

An interview with the Facility Administrator for the Acute Care Program was conducted on 5/19/2010 at approximately 8:30 AM. S/he stated, when asked where the physician rounding reports were for Sample patient #3, that they may be in the patient's treating physician's office.

An interview with the Facility Administrator was conducted on 5/19/10 at approximately 2:00 PM. S/he stated that the provider's office would use the rounding sheets for billing and that they were normally returned when they were done with them. S/he stated that there was no tracking process in place to determine where the rounding sheets were currently and when they were returned to the facility each month.


Facility Plan of Correction:

V626
The Governing Body will ensure the facility
maintains an effective, data driven, quality
assessment and performance improvement
program (QIFMM) that includes a monthly
medical record review. Policy
#3-02-01Medical Record Maintenance has
been reviewed with the facility team with
emphasis on the need for a monthly review
of 10% of the medical records and that
medical records are to remain in the facility
at all times, until such time they are archived
in an approved medical records storage
company. AA's are to complete all filing and
audit 100% of the patient charts by
06/21/2010, followed by monthly audits of
10% of the charts.
These medical records audits will be
documented on the QIFMM form and
reviewed in QIFMM meeting with action
plans developed and implemented as needed.
A letter was written to XXX Nephrology
Associates on May 20, 2010 by the Medical
Director, stating that no documents are to be
removed from the facility from that date
forward. FA and Medical Director are
responsible for ongoing compliance with
POC.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0626&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0634 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 8:38 AM

Survey Date: 5/25/2010

Regulation Number:0634

Regulation Title: QAPI-INDICATOR-MEDICAL INJURIES/ERRORS

Regulation Description: The program must include, but not be limited to, the following: (vi) Medical injuries and medical errors identification.

Surveyor Findings:


Based on review of facility documents and staff interviews, it was determined that the facility failed to implement process changes to ensure that an individual patient's dialyzer would not be used on another patient.

The findings were:

A review of the facility's internal documents was conducted on 5/19/10.

On 2/24/10, sample patient #2 was being dialyzed. It was realized approximately 1 1/2 hours into the treatment, that s/he was being dialyzed with sample patient #1's dialyzer. Sample patient #1 was determined to have active Hepatitis C.

A corrective action form, dated 3/2/10, for the patient care technician involved in setting up the dialysis machine for the patient with the wrong patient's dialyzer on 2/24/10 was reviewed.

Minutes from the Quality Improvement & Facility Management Meeting (QIFMM) dated 3/2/10 were reviewed. The only mention of the wrong patient dialyzer being used was in a section titled "Adverse Occurrence Reporting". No plan is identified in that section, nor is a priority level selected where available to do so. In the additional review items/notes page, is written, "Home room lesson to be held re: Dialyzer identity, Team mate meeting re policy 1-03-01, 1-03-02, 1-03-04A".

An agenda of the Team Meeting, dated 3/18/10, was reviewed. The agenda contained an Agenda topic of Dialyzer Verification that was scheduled for five minutes of the meeting. The minutes from the meeting state, in pertinent part: " ...The reuse dialyzer needs to be visually verified by 2 teammates and documented ...Failure to not verifying dialyzer and patient match is VERY SERIOUS and result in patient injury ..."

The facility's policies were reviewed on 5/19/10. The policies referred to in the QIFMM minutes were not revised after the incident on 2/24/10.

An interview with the facility administrator was conducted on 5/18/10 at approximately 12:45 p.m. S/he stated that the incident was reviewed in the QIFMM meeting and was determined to be a employee education issue, rather than a system's issue. S/he stated that there was no change in the facilities policies and procedures in response to the error and in regards to any additional checks or oversight. S/he stated that the facility began to write the last name of the patient in bigger writing on each dialyzer in black permanent marker to aid in patient identification and matching of correct dialyzers.

Another interview with the facility administrator was conducted on 5/25/10 at approximately 8:00 AM. S/he stated that the staff have been writing their initials on the patients dialyzer as an additional measure to ensure the 2-person check is completed in accordance with the facility's policies and procedures. The nurse has been checking to ensure the two employee's initials are present on the dialyzer.



Facility Plan of Correction:

The Governing Body will ensure the facility maintains an effective, data driven,
quality assessment and performance
improvement program (QIFMM) that
includes a review of medical errors
identification. Adverse occurrences will
be reviewed in QIFMM meeting with
action plans developed and implemented
as needed. Policy changes will be made if
indicated. After internal review of cited
incidents a plan of action was put in place
that required that the teammate not sign off
dialyzer until the patient is in their chair.
Policy # 01-03-02 “Prescription
Verification and Safety Checks” was
revised to include written verification on
the dialyzer while the patient is present, by
2 teammates. A governing body meeting
which included the Medical Director was
held on 05/20/2010 approving the new
policy. Documentation of this meeting is
on file in the facility. All teammates were
in-serviced on this policy on 05/21/2010
and 05/22/2010. The Charge Nurse/
Clinical Coordinator is observing the
PCT's for compliance with verification
while the patient is in the chair. In
addition, audits will be conducted on
100% of reuse dialyzers X 1 month
followed by auditing of 50% of reuse
dialyzers X 1 month, to ensure
compliance. The dialyzer audits were
implemented on 06/08/2010. These audits
are being conducted by the reuse
technician and given to the FA for review
daily. Results of audits will be reported in
QIFMM and addressed as necessary. FA is
responsible for ongoing compliance with
POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0634&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0710 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 8:44 AM
Survey Date: 5/25/2010

Regulation Number:0710

Regulation Title: CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR

Regulation Description:

Surveyor Findings:


Based on the number and nature of deficiencies cited, the facility failed to comply with the Condition for Coverage of Medical Director. The facility's Medical Director failed to ensure that providers practicing in the facility were adhering to facility policies in regards to security, completeness, and centralization of medical records. The Medical Director also failed to be involved in the quality improvement process in ensuring that medical errors were not repeated.

The facility failed to meet the following standards under the condition of Medical Director:

V 0711 Medical Director and QAPI
The facility failed to ensure that the Medical Director was involved in the resolution of quality issues identified in the quality improvement program.

V 0715 Medical Director responsible to ensure that all providers adhere to policies and procedures
The Medical Director failed to ensure that all policies and procedures were adhered to by all individuals that treat patients in the facility.


Facility Plan of Correction:

Members of the Governing Body (GB)
have reviewed the Statement of Deficiencies
(SOD) and formulated the Plan of
Correction (POC). The standards under
Condition: Medical Director (V710) that is
not met as well as other standards contains
specifics of corrective plans. The Medical
Director is accountable to the GB and will
ensure the security of medical records, be
involved in the quality improvement process
in evaluation and prevention of medical
errors, and ensure teammates adhere to
policies and procedures.
The CSS will have pre QAPI and QIFMM
meetings with the FA's X 6 months to
ensure all plans of correction are
documented correctly. CSS to attend QAPI
meetings X 6 months to ensure Medical
Director Participation. Administrative
Assistant (AA) will attend QAPI meetings
to record the meeting and POC's developed
by the IDT during the meetings.
The Governing Body will meet monthly x 3
to ensure compliance with POC. Further
compliance to the POC will be reviewed
during monthly QA meetings and reported
to the Governing Body no less than semiannually.
The Facility administrator (FA)
representing the GB will be responsible for
ensuring implementation and ongoing
compliance with this POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0710&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0711 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 8:48 AM
Survey Date: 5/25/2010

Regulation Number:0711

Regulation Title: MD RESP-MED DIR QUAL/ACCOUNTABLE TO GOV BODY

Regulation Description: The dialysis facility must have a medical director who meets the qualifications of §494.140(a) to be responsible for the delivery of patient care and outcomes in the facility. The medical director is accountable to the governing body for the quality of medical care provided to patients.

Surveyor Findings:


Based on staff interviews and review of facility documents, it was determined that the facility failed to ensure that the Medical Director was involved in the resolution of quality issues identified in the quality improvement program.

The findings were:

An interview with the facilities Medical Director was conducted on 5/18/10 at approximately 1:35 PM. S/he stated that there was an incident on 2/24/10 in which a patient was placed on a dialysis machine with another patient's dialyzer. The patient to whom the dialyzer belonged was determined to have active Hepatitis C.

A review of the facilities internal documents was conducted on 5/19/10.

Minutes from the Quality Improvement & Facility Management Meeting (QIFMM) dated 3/2/10 were reviewed. The only mention of the wrong patient dialyzer being used was in a section titled "Adverse Occurrence Reporting". No plan was identified in that section, nor was a priority level selected where available to do so. On the last page of the QIFFM minutes, in the additional review items/notes page, is written, "Home room lesson to be held re: Dialyzer identity, Team mate meeting re policy 1-03-01, 1-03-02, 1-03-04A".

An agenda of the Team Meeting, dated 3/18/10, was reviewed. The agenda contained an agenda topic of "Dialyzer Verification" that was scheduled for five minutes of the meeting. The minutes from the meeting state, in pertinent part: "...The reuse dialyzer needs to be visually verified by 2 teammates and documented...Failure to not verifying dialyzer and patient match is VERY SERIOUS and result in patient injury..."

The facilities policies were reviewed on 5/19/10. The policies referred to in the QIFMM minutes were not revised after the incident on 2/24/10.

In summary, after the facility had identified that an error took place in which a dialyzer from one patient was used on another patient, the facility's Medical Director did not make any changes to the facility's policies or procedures. There was no evidence that the Medical Director was involved in the efforts to prevent an error similar to the one identified from occurring again.


Facility Plan of Correction:

V711
The Medical Director is accountable to the
GB and will ensure the security of medical
records, be involved in the quality
improvement process in evaluation and
prevention of medical errors, and ensure
teammates adhere to policies and
procedures. Adverse occurrences will be
reviewed in QIFMM meeting with action
plans developed and implemented as
needed. Policy changes will be made if
indicated. After internal review of cited
incidents a plan of action was put in place
that required that the teammate not sign off
dialyzer until the patient is in their chair.
Policy # 01-03-02 “Prescription
Verification and Safety Checks” was
revised to include written verification on
the dialyzer while the patient is present, by
2 teammates. A governing body meeting
which included the Medical Director was
held on 05/20/2010 approving the new
policy. Documentation of this meeting is
on file in the facility. All teammates were
in-serviced on this policy on 05/21/2010
and 05/22/2010. The Charge Nurse/
Clinical Coordinator is observing the
PCT's for compliance with verification
while the patient is in the chair. In
addition, auditswill be conducted on 100%
of reuse dialyzers X 1 month followed by
auditing of 50% of reuse dialyzers X 1
month, to ensure compliance. The dialyzer
audits were implemented on 06/08/2010.
These audits are being conducted by the
reuse technician and given to the FA for
review daily. Results of audits will be
reported in QIFMM and addressed as
necessary. The Clinical Services Specialist (CSS) will have pre QAPI and QIFMM meetings with the FA's X 6 months to ensure all plans of correction are documented correctly.
Clinical Services Specialist (CSS) to attend
QAPI meetings X 6 months to ensure
Medical Director Participation.
Administrative Assistant (AA) will attend
QAPI meetings to record the meeting and
POC's developed by the IDT during the
meetings. FA and Medical Director are
responsible for ongoing compliance with
POC.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0711&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0715 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 8:56 AM
Survey Date: 5/25/2010

Regulation Number:0715

Regulation Title: MD RESP-ENSURE ALL ADHERE TO P&P

Regulation Description: The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;

Surveyor Findings:


Based on review of medical record reviews and staff interviews it was determined that the medical director failed to ensure that all policies and procedures were adhered to by all individuals that treat patients in the facility.

The findings were:

The medical records of six patients were reviewed throughout the survey. In four (#1, #2, #3, #5) of six records original physician progress notes and written physician orders were absent from the chart for the months of March and April 2010. In two (#2 and #6) of six records original physician progress notes and written physician orders were absent from the chart for the month of October 2009. In one (#2) of six records original physician progress notes and written physician orders were absent from the chart for the month of February 2010.

On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for April 2010 on four (#1, #2, #3 & # 5) of the five patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for March 2010 on two (#1 and #2) of the four patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for February 2010 on the one (#2) patient. However, the facility was unable to provide the absent physician progress notes and written physician orders for the two patients (#2 and #6) from October 2009.

An interview with the medical director was conducted on 5/19/2010 at approximately 3:30 p.m. S/he stated that the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers against the facility's policies.

An interview with the Facility Administrator for the Acute Care Program was conducted on 5/19/2010 at approximately 8:30 a.m. When asked where the physician rounding reports were for Sample patient #3, S/he stated that they may be in the patient's treating physician's office.


Facility Plan of Correction:

V715
The Medical Director is accountable to the
GB and will ensure the security of medical
records, be involved in the quality
improvement process in evaluation and
prevention of medical errors, and ensure
teammates adhere to policies and procedures.
Policy #3-02-01Medical Record
Maintenance has been reviewed with the
facility team with emphasis on the need for a
monthly review of 10% of the medical
records and that medical records are to
remain in the facility at all times, until such
time they are archived in an approved
medical records storage company. AA's are
to complete all filing and audit 100% of the
patient charts by 06/21/2010, followed by
monthly audits of 10% of the charts. These
medical records audits will be documented
on the QIFMM form and reviewed in QIFMM
meeting and any action plans developed and
implemented as needed. A letter was written
to XXX Nephrology Associates on May 20,
2010 by the Medical Director, stating that no
documents are to be removed from the
facility from that date forward. FA and
Medical Director are responsible for ongoing
compliance with POC. 6/21/10
The Clinical Services Specialist ( CSS) to
have pre QAPI and QIFMM meetings with
the FA's X 6 months to ensure all plans of
correction are documented correctly.
Clinical Services Specialist (CSS) to attend
QAPI meetings X 6 months to ensure
Medical Director participation. AA's will
attend QAPI meetings to record the meeting
minutes and POC's developed by the IDT
during the meetings.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0715&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0725 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 9:06 AM
Survey Date: 5/25/2010

Regulation Number:0725

Regulation Title: CFC-MEDICAL RECORDS

Regulation Description:

Surveyor Findings:


Based on the number and nature of deficiencies cited, the facility failed to comply with the Condition for Coverage of Medical Records. The facility failed to maintain complete and accurate records and protect them against loss and unauthorized use.

The facility failed to meet the following standards under the Condition of Medical Records:

V 0726 Maintenance of a complete, accurate and accessible record on all patients
The facility failed to maintain a complete, accurate and accessible patient record on all patients. Original physician progress notes and physician orders left the premises of the facility and were absent from the patient's record during review of the patients' records. This failure created the potential for patient care to be compromised. The failure also compromised the continuity of patient care.

V 0727 Protection of patient's record
The facility failed to ensure that the patients' medical records were protected from loss, destruction or unauthorized use. The facility also failed to ensure that patient information was kept confidential. Patient records were not safeguarded from loss or unauthorized use after business hours. Original physician orders and progress notes left the premises and were not available during review of the patients' records during the survey.

V 0729 Completion of patient records promptly
The facility failed to appropriately complete medical records in six (#1 through #6) of six medical records reviewed. Entries were lacking documentation of the time of the entries. This failure created the potential for patient care to be compromised.

V 0730 Centralization of clinical information
The facility failed to maintain a centralized patient record that was accessible to all members of the interdisciplinary team. This failure created the potential for patient care to be compromised.


Facility Plan of Correction:

V725
Members of the Governing Body (GB)
have reviewed the Statement of
Deficiencies (SOD) and formulated the
Plan of Correction (POC). The standards
under Condition: Medical Records (V725)
that is not met as well as other standards
contains specifics of corrective plans. The
Medical Director is accountable to the GB
and will ensure the security of medical
records, be involved in the quality
improvement process in evaluation and
prevention of medical errors, and ensure
teammates adhere to policies and
procedures.
Policy #3-02-01Medical Record
Maintenance has been reviewed with the
facility team with emphasis on the need for
a monthly review of 10% of the medical
records and that medical records are to
remain in the facility at all times, until
such time they are archived in an approved
medical records storage company. Policy
#3-02-02 Medical Record Preparation
Charting Guidelines has been reviewed
with the teammates with the emphasis on
that all entries are to be dated and signed at
the time of entry.
AA's are to complete all filing and audit
100% of the patient charts by
6/21/10followed by monthly audits of 10%
of the charts. In addition compliance will
be evidenced by random audits conducted
by the FA of monthly physician Rounding
Reports X 3 months. Results of audits will
be reported in QIFMM and addressed as
necessary. FA and Medical Director are
responsible for ongoing compliance with
POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0725&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0726 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 11:03 AM
Survey Date: 5/25/2010

Regulation Number:0726

Regulation Title: MR-COMPLETE, ACCURATE, ACCESSIBLE

Regulation Description: The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.

Surveyor Findings:


Based on review of Sample #1's medical record and staff interview, it was determined that a physician's order was not completed. Specifically, on 3/1/10 sample #1's Nephrologist wrote an order for "check Hepatitis C viral DNA". The order was signed off by the RN, however, the correct test was not completed.

A telephone interview was conducted on 6/2/10 at 11:15 a.m. with the Facility's Administrator. S/he stated that the nurse who noted the order was not aware of this test and only had a Hepatitis C test without the DNA drawn on the patient. S/he stated the test was drawn as ordered on 6/2/10 and the results would be sent to the patient's Nephrologist.

Surveyor Findings:


Based on medical record review and staff interviews, it was determined that the facility failed to maintain a complete, accurate and accessible patient record on all patients. This failure created the potential for patient care to be compromised.

The findings were:

The medical records of six patients were reviewed throughout the survey. In four (#1, #2, #3, #5) of six records original physician progress notes and written physician orders were absent from the chart for the months of March and April 2010. In two (#2 and #6) of six records original physician progress notes and written physician orders were absent from the chart for the month of October 2009. In one (#2) of six records original physician progress notes and written physician orders were absent from the chart for the month of February 2010. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for April 2010 on four (#1, #2, #3 & # 5) of the five patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for March 2010 on two (#1 and #2) of the four patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for February 2010 on the one (#2) patient. The facility was unable to provide the absent physician progress notes and written physician orders from October 2009.

An interview with the medical director was conducted on 5/19/10 at approximately 3:30 p.m. S/he stated that the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers (physicians and allied health personnel) against the facility's policies.

An interview with the Facility Administrator for the Acute Care Hospital Dialysis Program was conducted on 5/19/2010 at approximately 8:30 a.m. When asked where the physician rounding reports were for sample patient #3, s/he stated that they may be in the patient's treating physician's office.

On 5/19/10 at approximately 5:00 p.m., when the documents listed above were provided, the Facility Administrator stated that the documents were obtained from one of the treating physician's office.

In summary, the facility allowed original documents to leave the premises and the documents were not available to all members of the interdisciplinary team at all times. This failure created the potential for patient care to be compromised.

Facility Plan of Correction:

V726
The Governing Body will ensure the facility
maintains an effective, data driven, quality
assessment and performance improvement
program (QIFMM) that includes a monthly
medical record review. Policy
#3-02-01Medical Record Maintenance and
#3-02-03 “Orders for Patient Care” has been
reviewed with the facility team with
emphasis on the importance of following
orders as written and the need for a monthly
review of 10% of the medical records and
that medical records are to remain in the
facility at all times, until such time they are
archived in an approved medical records
storage company. AA's are to complete all
filing and audit 100% of the patient charts
by 6/21/10followed by monthly audits of
10% of the charts.
These medical records audits will be
documented on the QIFMM form and
reviewed in QIFMM meeting with action
plans developed and implemented as needed.
A letter was written to XXX Nephrology
Associates on May 20, 2010 by the Medical
Director, stating that no documents are to be
removed from the facility from that date
forward. FA and Medical Director are
responsible for ongoing compliance with
POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0726&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0727 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 11:07 AM
Survey Date: 5/25/2010

Regulation Number:0727

Regulation Title: MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL

Regulation Description: The dialysis facility must- (1)Safeguard patient records against loss, destruction, or unauthorized use; and (2) Keep confidential all information contained in the patient's record, except when release is authorized pursuant to one of the following: (i) The transfer of the patient to another facility. (ii) Certain exceptions provided for in the law. (iii) Provisions allowed under third party payment contracts. (iv) Approval by the patient. (v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program.

Surveyor Findings:


Based on staff interviews, facility tours, review of medical records, and review of facility documents, it was determined that the facility failed to ensure that the patients' medical records were protected from loss, destruction or unauthorized use. The facility also failed to ensure that patient information was kept confidential.

The findings were:

A facility tour was conducted on 5/18/2010 at approximately 1:00 p.m. It was noted that on the spine of each chart the patient's first and last name were written in marker and were visible from the patient care area to any individual walking past the nurses' station desk. In addition, the medical records were visible from the facility's front door when the facility was closed. There were no measures in place to secure medical records after business hours.

The medical records of six patients were reviewed throughout the survey. In four (#1, #2, #3, #5) of six records, original physician progress notes and written physician orders were absent from the chart for the months of March and April 2010. In two (#2 and #6) of six records, original physician progress notes and written physician orders were absent from the chart for the month of October 2009. In one (#2) of six records, original physician progress notes and written physician orders were absent from the chart for the month of February 2010. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for April 2010 on four (#1, #2, #3 & # 5) of the five patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for March 2010 on two (#1 and #2) of the four patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for February 2010 on the one (#2) patient. The facility was unable to provide the absent physician progress notes and written physician orders from October 2009.

An interview with the medical director was conducted on 5/19/10 at approximately 3:30 p.m. S/he stated that the physician rounding sheets that contained physician progress notes and written orders were part of the patients' medical records and were being removed by providers (physicians and allied health personnel) against the facility's policies.

On 5/19/10 the surveyors received a letter from the Medical Director, dated 5/19/10, that was addressed to one of the physicians treating patients in the facility. The letter states, in pertinent parts,
"It has recently come to my attention that you, and/or other physicians or midlevel providers have removed patient charts/labs/or other protected material from DaVita facilities...this is a violation of policy and will not continue...Please immediately return all information you may have and cease removing any more from our facilities..."

An interview with the Facility Administrator for the Acute Care Hospital Dialysis Program was conducted on 5/19/2010 at approximately 8:30 a.m. When asked where the physician rounding reports were for sample patient #3, s/he stated that they may be in the patient's treating physician's office.

On 5/19/10 at approximately 5:00 p.m., when the documents listed above were provided, the Facility Administrator stated that the documents were obtained from one of the treating physician's office.

In summary, the facility failed to ensure that original documents that were part of the patient's medical records remained on premises. It is unknown how long this practice had been going on before the Medical Director had addressed the practice of providers removing original documents from the facility. It is also unknown why the facility had permitted this practice to continue prior to the survey. The facility failed to ensure that the patients' medical records were protected from possible theft or misuse of unauthorized individuals. In addition, the facility failed to ensure that patient information was kept confidential as patients' first and last names were visible from the patient care floor and could be viewed by any and all individuals in the facility.

Facility Plan of Correction:

V727
The Governing Body will ensure the
facility maintains an effective, data driven,
quality assessment and performance
improvement program (QIFMM) that
includes a monthly medical record review.
Policy #3-02-01Medical Record
Maintenance has been reviewed with the
facility team with emphasis on ensuring the
confidentiality of the medical record and
the need for a monthly review of 10% of
the medical records and that medical
records are to remain in the facility at all
times, until such time they are archived in
an approved medical records storage
company. Pt. charts have been secured by
placing a locked bar across the medical
records shelf, so they cannot be removed
from their slots. The patient chart labels
were changed from full names to initials to
protect patient identity. A fabric covering
will be placed over the charts so they will
not be visible by 07/01/2010.
AA's are to complete all filing and audit
100% of the patient charts by 6/21/10,
followed by monthly audits of 10% of the
charts. These medical records audits will be
documented on the QIFMM form and
reviewed in QIFMM meeting with action
plans developed and implemented as
needed. A letter was written to XXX
Nephrology Associates on May 20, 2010
by the Medical Director, stating that no
documents are to be removed from the
facility from that date forward. FA and
Medical Director are responsible for
ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0727&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0729 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 11:12 AM
Survey Date: 5/25/2010

Regulation Number:0729

Regulation Title: MR-COMPLETE RECORDS PROMPTLY

Regulation Description: (1) Current medical records and those of discharged patients must be completed promptly.

Surveyor Findings:


Based on review of medical records, the facility failed to appropriately complete medical records in six (#1 through #6) of six medical records reviewed. This failure created the potential for patient care to be compromised.

The findings were:

The medical records of six patients were reviewed throughout the survey. The "Physician Orders and Progress Notes" were reviewed for the previous six months to approximately one year. It was noted that all physician orders and progress notes were not timed. The telephone and/or verbal orders written by the nurses in the nurses' progress notes were not timed either. Also, the physician orders that were noted by nurses were not timed when orders were taken off, only dated.

Facility Plan of Correction:

V729
Policy #3-02-02 Medical Record
Preparation Charting Guidelines has been
reviewed with the teammates with the
emphasis on that all entries are to be timed,
dated, and signed at the time of entry. AA's
are to complete all filing and audit 100% of
the patient charts by 6/21/10 followed by
monthly audits of 10% of the charts. In
addition compliance will be evidenced by
random audits conducted by the FA of
monthly physician Rounding Reports X 3
months. Results of audits will be reported
in QIFMM and addressed as necessary. FA
and Medical Director are responsible for
ongoing compliance with POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0729&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0730 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 11:16 AM
Survey Date: 5/25/2010

Regulation Number:0730

Regulation Title: MR-CENTRALIZE ALL INFO;IDT HAS ACCESS

Regulation Description: (2) All clinical information pertaining to a patient must be centralized in the patient's record, including whether the patient has executed an advance directive. These records must be maintained in a manner such that each member of the interdisciplinary team has access to current information regarding the patient's condition and prescribed treatment.

Surveyor Findings:


Based on medical record review and staff interviews, it was determined that the facility failed to maintain a centralized patient record. This failure created the potential for patient care to be compromised.

The findings were:

The medical records of six patients were reviewed throughout the survey. In four (#1, #2, #3, #5) of six records, original physician progress notes and written physician orders were absent from the chart for the months of March and April 2010. In two (#2 and #6) of six records, original physician progress notes and written physician orders were absent from the chart for the month of October 2009. In one (#2) of six records, original physician progress notes and written physician orders were absent from the chart for the month of February 2010. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for April 2010 on four (#1, #2, #3 & # 5) of the five patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for March 2010 on two (#1 and #2) of the four patients. On 5/19/10 at approximately 5:00 p.m., the facility was able to provide copies of the absent physician progress notes and written physician orders for February 2010 on the one (#2) patient. The facility was unable to provide the absent physician progress notes and written physician orders from October 2009.

An interview with the medical director was conducted on 5/19/10 at approximately 3:30 p.m. S/he stated that the physician rounding sheets (which contained physician progress notes and written orders) were part of the patients' medical records and were being removed by providers (physicians and allied health personnel) against the facility's policies.

An interview with the Facility Administrator for the Acute Care Hospital Dialysis Program was conducted on 5/19/2010 at approximately 8:30 a.m. When asked where the physician rounding reports were for sample patient #3, s/he stated that they may be in the patient's treating physician's office.

On 5/19/10 at approximately 5:00 p.m., when the documents listed above were provided, the Facility Administrator stated that the documents were obtained from one of the treating physician's office.

In summary, the facility allowed original documents to leave the premises. The documents were not available to all members of the interdisciplinary team at all times. This failure created the potential for patient care to be compromised.

Facility Plan of Correction:

V730
The Governing Body will ensure the facility
maintains an effective, data driven, quality
assessment and performance improvement
program (QIFMM) that includes a monthly
medical record review. Policy
#3-02-01Medical Record Maintenance has
been reviewed with the facility team with
emphasis on the need for a monthly review
of 10% of the medical records and that
medical records are to remain in the facility
at all times, until such time they are archived
in an approved medical records storage
company. AA's are to complete all filing and
audit 100% of the patient charts by 6/21/10,
followed by monthly audits of 10% of the
charts.
These medical records audits will be
documented on the QIFMM form and
reviewed in QIFMM meeting with action
plans developed and implemented as
needed.
A letter was written to XXX Nephrology
Associates on May 20, 2010 by the Medical
Director, stating that no documents are to be
removed from the facility from that date
forward. FA and Medical Director are
responsible for ongoing compliance with
POC.

See: Related_Article

See: 2nd_Related_Article

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0730&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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5/25/2010 Survey Tag 0750 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Monday, December 27, 2010 11:20 AM
Survey Date: 5/25/2010

Regulation Number:0750

Regulation Title: CFC-GOVERNANCE

Regulation Description:

Surveyor Findings:


Based on the number and nature of the deficiencies cited, staff interviews, and review of patient records, policies/procedures, personnel/credential files, meeting minutes and other facility documents, the governing body (as the entity ultimately responsible for the governance and operation of the facility and responsible for the health care and safety of patients) failed to ensure that the facility maintained complete medical records, and that facility staff followed facility policies/procedures, and that the Medical Director was involved in the oversight of providers adherence to facility policies/procedures and with the quality improvement process for ensuring that medical errors were not repeated. The Governing Body failed to provide a comprehensive and proactive leadership to ensure the facility met the requirements for the health and safety of the patients.

The findings were:

1. Cross Reference to the QAPI Standard Tags V626 and V634 for findings related to the facility's failure to "identify and correct deficiencies in the completeness of medical records as part of the QAPI program" and "implement process changes to ensure that a different patient's dialyzer would not be used on another patient."

2. Cross Reference to the Medical Director Condition Tag V710 and Standard Tags V711 and V715 for findings related to the Medical Director's failure to "ensure that providers practicing in the facility were adhering to facility policies in regards to security, completeness, and centralization of medical records" as well as the Medical Director's failure to "be involved in the quality improvement process in ensuring that medical errors were not repeated."

3. Cross Reference to the Medical Record Condition Tag V725 and Standard Tags V726, V727, V729 and V730 for findings related to the facility's failure to "maintain complete and accurate records and protect them against loss and unauthorized use".

Facility Plan of Correction:

V750
The Governing Body will provide
comprehensive and proactive leadership to
ensure the facility meets the requirements for
the health and safety of the patients. An inservice
on the Governing Body process and
documentation of said meeting was conducted
by the Regional Operations Director (ROD) on
06/15/2010. The Governing Body will ensure
the facility maintains an effective, data driven,
quality assessment and performance
improvement program (QIFMM) that is
led by the Medical Director and ensures the
security of medical records, includes the
evaluation and prevention of medical errors, to
include but not be limited to dialyzers being
used by the wrong patients, and ensures
teammates adhere to policies and procedures.
Policy #3-02-01Medical Record Maintenance
has been reviewed with the facility team with
emphasis on the need for ensuring the
confidentiality of the medical record and for a
monthly review of 10% of the medical records
and that medical records are to remain in the
facility at all times, until such time they are
archived in an approved medical records
storage company.
Pt. charts have been secured by
placing a locked bar across the medical
records shelf, so they cannot be removed from
their slots. The patient chart labels were
changed from full names to initials to protect
patient identity. A fabric covering will be
placed over the charts so they will not be
visible by 07/01/2010. A letter was written to
XXX Nephrology Associates on May 20,
2010 by the Medical Director, stating that no
documents are to be removed from the facility
from that date forward. Policy #3-02-02
Medical Record Preparation Charting
Guidelines has been reviewed with the
teammates with the emphasis that all
entries are to be timed, dated, and signed at
the time of entry. FA and Medical Director are
responsible for ongoing compliance with
POC. AA's are to complete all filing and audit
100% of the patient charts by 6/21/10,
followed by monthly audits of 10% of the
charts. In addition compliance will be
evidenced by random audits conducted by the
FA of monthly physician Rounding Reports X
3 months. Results of audits will be reported in
QIFMM and addressed as necessary. FA and
Medical Director are responsible for ongoing
compliance with POC.
Adverse occurrences will be reviewed in
QIFMM meeting with action plans developed
and implemented as needed. Policy changes
will be made if indicated. After internal
review of cited incidents a plan of action was
put in place that required that the teammate
not sign off dialyzer until the patient is in their
chair. Policy # 01-03-02 “Prescription
Verification and Safety Checks” was revised
to include written verification on the dialyzer
while the patient is present, by 2 teammates.
A governing body meeting which included
the Medical Director was held on 05/20/2010
approving the new policy. Documentation of
this meeting is on file in the facility. All
teammates were in-serviced on this policy on
05/21/2010 and 05/22/2010. The Charge
Nurse/Clinical Coordinator is observing the
PCT's for compliance with verification while
the patient is in the chair. In addition, audits
will be conducted on 100% of reuse dialyzers
X 1 month followed by auditing of 50% of
reuse dialyzers X 1 month, to ensure
compliance. The dialyzer audits were
implemented on 06/08/2010. These audits
are being conducted by the reuse technician
and given to the FA for review daily. Results
of audits will be reported in QIFMM and
addressed as necessary. FA is responsible for
ongoing compliance with POC.
The Governing Body will meet monthly x 3
to ensure compliance with POC. Further
compliance to the POC will be reviewed
during monthly QA meetings and reported to
the Governing Body no less than semiannually.
The Facility administrator (FA)
representing the GB will be responsible for
ensuring implementation and ongoing
compliance with this POC.

See: Related_Article

See: 2nd_Related_Article


http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0750&eid=COYS11&ft=esrd&id=12050W&bdg=00&reg=FV10

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4/8/2009 Survey Tag 0510 Detail for:
RELIANT RENAL CARE RRC COLORADO SPRINGS
Monday, December 27, 2010 11:27 AM
Survey Date: 4/8/2009

Regulation Number:0510

Regulation Title: PA-MSW-PSYCHOSOCIAL NEEDS

Regulation Description: The patient's comprehensive assessment must include, but is not limited to, the following: (7) Evaluation of psychosocial needs by a social worker.

Surveyor Findings:


Based on medical record review and staff interviews, the facility failed to provide adequate social services in one (#1) of one peritoneal dialysis medical record reviewed. This failure created the potential for the psychosocial needs of the patient to go unmet.

The findings were:

The medical record for sample patient #1 was reviewed on 4/8/09. The patient was admitted to the facility on 8/27/02 and was trained to do peritoneal dialysis in his/her home. The patient customarily comes into the facility on a monthly basis for laboratory draws and appointments scheduled with his/her nephrologist.

According to the medical record, the first psychosocial assessment was appropriately performed on 9/25/02. The next documentation by the social worker was five years later dated 7/7/07 and was a Social Work Update that stated: "Call to pt. who says he is doing well. Dialysis going well. No social work needs currently." There was another note by the social worker found in the chart on the Monthly Grand Round form dated 2/11/09 which stated: "Psychosocial Needs - None Currently."

Several staff members of the facility were questioned during the survey on 4/8/09 regarding the documentation in the patient's medical record and if there was further documentation that had not been filed. According to the peritoneal dialysis registered nurse, what was filed in the medical record was all the information that was available. It was not clear during the interviews why this patient had not had another psychosocial assessment while in the facility for monthly visits or why assessments had not been performed by telephone. The social worker was not available for interview due to personal circumstances.

Facility Plan of Correction:

How deficiency has beem corrected:

Social Worker Cindy Rice completed annual psychosocial assessment on 4/10/09.

Responsible party:
Cindy Rice, MSW
Social Worker Cindy Rice has been replaced by Ann Kurth,MSW. Facility manager located psychosocial notes from Cindy Rice dated 2-16-04, 5-5-04, 9-7-04, 2-24-06 and 7-7-07.

Pervention of future occurances:
Ann Kurth,MSW will meet with the patient monthly and document any psychosocial needs. Social Worker will document in the electronic medical record system. Center Director will monitor medical records monthly to ensure psychosicial documentation is completed.

Deficiency has been corrected as of 4-10-09

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0510&eid=8DED11&ft=esrd&id=1205TP&bdg=00&reg=FV10

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7/31/2007 Survey Tag 0141 Detail for:
RELIANT RENAL CARE RRC COLORADO SPRINGS
Monday, December 27, 2010 11:31 AM

Survey Date: 7/31/2007

Regulation Number:0141

Regulation Title: CEO: STAFF TRAINING

Regulation Description: The responsibilities of the chief executive officer include but are not limited to ensuring that the facility employs the number of qualified personnel needed; that all employees have appropriate orientation to the facility and their work responsibilities upon employment; and that they have an opportunity for continuing education and related development activities.

Surveyor Findings:


Based on record review and staff interview, the chief executive officer failed to ensure the facility offered the staff an opportunity for continuing education programs in 6 of 6 personnel records reviewed. The findings were:

The personnel records were reviewed on 7/31/07 and included the registered dietitian, social worker, charge/peritoneal dialysis registered nurse, director of nursing and two patient care technicians.

The registered dietitian was hired in 8/05 and had not completed any continuing education.

The social worker was hired in 6/99 and the last continuing education was completed in 5/11/05.

The charge/peritoneal dialysis registered nurse was hired in 6/00 and the last continuing education was completed in 3/4/05.

The director of nursing was hired in 3/98 and the last continuing education was completed in 3/4/05.

The first patient care technician was hired in 6/1/99 and the last continuing education was completed on 4/27/05.

The second patient care technician was hired in 12/13/05 and that was the last time the technician had education.

The director of nursing (DON) and the medical director were interviewed on 7/31/07 at approximately 11:30 a.m. The medical director stated he was aware of the lack of continuing education with the personnel. However, the director further stated he would be offering education as soon as possible.

In summary, the failure to provide the opportunity for continuing education for facility staff created the potential for adverse patient outcomes.

Facility Plan of Correction:

CEU's were completed and placed into the proper employee files.

The registered dietitian has completed the following continuing education activites: 7/26/07 Optimizing the Treatment Hyperphosphatemia, 5/3/07 earned 1.0 CUE for Vascular Calcification in the CKD patient, 4/13/07 participated in the 2007 in CDA Annual Meeting and Exhibition State conference, 6/14-15/07 participated in Lillian Fountai Smith conference for Nutrition Educations for 10 CPE.

The social worker has completed 1.0 CEU on Herioin: Abuse and Addiction on 8/20/07.

The Charge/peritioneal nurse completed 2/18/07 attended the 27th Annual Dialysis Conference and obtained 18 CEUs. She attended 10/12/06 Conflict Management and Confrontation workshop for .6 CEU. Attended Fundamentals of Peritoneal Dialysis on 5/22/06 for 4.5 CEUs.

The DON completed Conflict Management and Confrontation workshop for 0.6 CEU on 10/12/06, completed online water treatment sessions 100, 200, 300, and 305 on 10/17/06,earned 1.2 CEUs for The Continued Importance of Preserving Logn-term Reanl Funcion Posttransplantation on 1/5/06.

Tech #1 completed online water treatment for dialysis sessions 100, 202, 203, 204, 205, 206, 301, and 305 on 10/17-19/06.

Tech #2 completed online water treatment for dialysis sessions 100, 202, 203, 204, 205, 206, 301, and 305 on 10/17-19/06.

To ensure that continuing education is being completed, a quarterly review of employee files will be completed by the DON. She will note the results on a checklist that will be placed in the QA manual.

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0141&eid=S6DD11&ft=esrd&id=1205TP&bdg=00&reg=FV09

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7/31/2007 Survey Tag 0159 Detail for:
RELIANT RENAL CARE RRC COLORADO SPRINGS
Monday, December 27, 2010 11:37 AM
Survey Date: 7/31/2007

Regulation Number:0159

Regulation Title: PATIENT CARE POLICIES: DEVELOPMENT/REVIE

Regulation Description: Policies concerning the provision of dialysis and other ESRD services to patients are developed by the physician responsible for supervising and directing the provision of ESRD services, or the facility's organized medical staff (if there is one), with the advice of (and with provision for review of such policies from time to time, but at least annually by) a group of professional personnel associated with the facility, including, but not limited to, one or more physicians and one or more registered nurses experienced in rendering ESRD care.

Surveyor Findings:


Based on policy and procedure review and staff interview, the facility failed to review their policies and procedures on an annual basis. The findings were:

The policy and procedure manual for patient care policies was reviewed on 7/30/07. There was a cover sheet in front of the manual which stated: "This Acute Policies and Procedures Manual has been reviewed and accepted. Any additions, updates, or deletions will be noted on this sheet and date entered. This manual will be reviewed annually." The last date these policies and procedures were updated and reviewed was 5/27/05.

The director of nursing (DON) was interviewed on 7/31/07 at approximately 9:30 a.m. The DON stated they had fallen behind in this process and agreed an annual review should be done.

In summary, the failure to annually review and update patient care policies had the potential to affect all patients served by the facility.

Facility Plan of Correction:

The policy and prodedure manual has been reviewed and verified by the Medical Director, DON, PD Nurse and Biomed Technician on 8/21/07.

The Board of Directors will annual review the P & P manual.

Note new policies that have been added.

Policies added: Policy of Bicarb System, Facility Cleaning Policy, and an Emergency preparedness Quarterly summary.

Quarterly Emergrency Preparednes in-service/training will be completed by all dialysis staff members. This will be monitored by quarterly QA audit conducted by the DON.

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0159&eid=S6DD11&ft=esrd&id=1205TP&bdg=00&reg=FV09

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7/31/2007 Survey Tag 0265 Detail for:
RELIANT RENAL CARE RRC COLORADO SPRINGS
Monday, December 27, 2010 11:40 AM
Survey Date: 7/31/2007

Regulation Number:0265

Regulation Title: PE: FUNCTIONAL/SANITARY /COMFORTABLE

Regulation Description: The facility is maintained and equipped to provide a functional, sanitary and comfortable environment with an adequate amount of well-lighted space for the service provided.

Surveyor Findings:


Based on observations made during tours of the facility from 7/30/07 to 7/31/07 and staff interview, the facility failed to maintain and provide a functional, sanitary and comfortable environment in the peritoneal dialysis (PD) training room. The findings were:

During a tour of the facility on 7/30/07, it was difficult to enter the PD training room. There was a cart in front of the doorway with an empty box on top of it. Just inside the door to the right, there were 34 oxygen containers, size #2, being stored along the wall. Further inside the room there was a cardboard box on the floor that contained new sharps containers. The rest of the room appeared very unkempt and unsanitary.

During the remainder of the survey, various observations revealed no change in the condition of the PD training room.

These findings were brought to the attention of the medical director on 7/31/07 at approximately 11:30 a.m. The medical director agreed the room needed to be ready at all times for interviewing potential PD patients as well as continued training for the PD patients the facility now has.

In summary, the failure to maintain a functional and sanitary environment had the potential to have an adverse effect on all the PD patients.

Facility Plan of Correction:

The PD training room has been cleaned. The oxygen tanks have been removed.

On 8/21/07 a policy was added to the Policy and Procedure manual to ensure that the room remains clean and clutter free the charge nurse on duty will check patient areas at the end of every working day. All staff members have been instructed not to use PD room as storage area.

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0265&eid=S6DD11&ft=esrd&id=1205TP&bdg=00&reg=FV09

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7/31/2007 Survey Tag 0280 Detail for:
RELIANT RENAL CARE RRC COLORADO SPRINGS
Monday, December 27, 2010 11:44 AM
Survey Date: 7/31/2007

Regulation Number:0280

Regulation Title: EMERGENCY PREP: PERIODIC DRILLS

Regulation Description: All personnel are trained, as part of their employment orientation, in all aspects of preparedness for any emergency or disaster. The emergency preparedness plan provides for orientation and regular training and periodic drills for all personnel in all procedures so that each person promptly and correctly carries out a specific role in case of an emergency.

Surveyor Findings:


Based on record review and staff interview, the facility failed to conduct periodic fire drills for facility personnel and patients. Furthermore, the facility failed to have a policy and procedure developed regarding conducting fire drills with facility staff and patients. The findings were:

During the entrance conference on 7/30/07, a log of fire drills was requested for review during the recertification survey. However, there was no documentation available regarding fire drills having been performed.

The director of nursing (DON) was interviewed on 7/30/07 at 2:00 p.m. The DON stated that fire drills had not been conducted for several years, and furthermore, could not find documentation actual drills had ever been done. The DON further stated the facility would be implementing a policy and procedure immediately as well as doing quarterly drills.

In summary, the failure to conduct periodic fire drills increased the potential for unpreparedness of staff to assist patients in the case of a real fire.

Facility Plan of Correction:

All Summit Kidney Center dialysis employees have attended a current Fire Safety lecture and training provided by the CSFD on 8/21/07. Items covered were 911 situations, violence/bomb policies, weather conditions,hazardous material release and basic fire emergencies policies. Each staff member practiced with a fire extinguisher.


Hazmat training has begun to be implemented for all dialysis employees.


To ensure that all employees are informed of emergency preparedness procedures, quarterly in-services and training will be provided.

The in-services will be provided by various sources: medical companies, city agencies, and medical professionals, etc.. . The DON will be responsible to assure the training will occur.

Quarterly In-services/training will be noted in QA manual for each employee.

http://www.hfemsd1.dphe.state.co.us/hfd2003/dtl3.aspx?tg=0280&eid=S6DD11&ft=esrd&id=1205TP&bdg=00&reg=FV09

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