Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 012502 (X3) Date Survey Completed 01/08/2020
Name of Provider or Supplier Tuscaloosa University Dialysis Street Address, City, State 220 15th Street, Tuscaloosa, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
V0628 QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS
CFR(s): 494.110(a)(2)

The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves.


This STANDARD is not met as evidenced by:
Based on review of the FHR (Facility Health Record), Discharge Patient Census Report, Mortality Review Form, policy and staff interview, it was determined the Quality Improvement Committee failed to analyze and trend patient's mortality and causes. This had the potential to negatively affect all patients served by this facility. Findings include: Title: Continuous Quality Improvement Program Policy: 1-14-06 Revision Date: October 2017 Purpose: To improve patient safety and outcomes...in accordance with the Quality Assessment and Performance Improvement (QAPI) requirements in the CMS (Centers for Medicare and Medicaid Services) Conditions for Coverage. Policy 1. Each dialysis facility will have a Continuous Quality Improvement (CQI) Committee.... 2. ...the CQI committee to review issues and indicators regarding facility's management and performance... 3. Written documentation and plans of action will be documented... 4. The Facility Medical Director is responsible for promoting the execution as well as participation in the Quality Improvement program... 7. The facility will measure, analyze, and track quality indicators ...not limited to, the following ...Mortality- review of deaths... 8. Continuous monitoring of the above indicators will be reflected in the meeting minutes. Any area identified as underperforming will be reviewed to identify root causes... 1. Review of the FHR documentation for Mortality 2019 was conducted on 1/8/2020 at 12:40 PM with Employee Identifier (EI) # 1, Facility Administrator. Review of the Discharge Patient Census Report from 1/1/19 to 12/31/19 revealed the facility had 11 patient's "expired". Review of the facility Mortality Review Form's revealed the following: 3 Mortality death reviews completed 3 Mortality death review incomplete (2 items per form completed) 5 Mortality death reviews not performed The surveyor how the deaths were trended, and an analysis of any contributory factors was reviewed for all deaths. There was no documentation the facility staff conducted an analysis of individual deaths to recognize trends in causes and contributory factors of deaths and no documentation the CQI Committee discussed results of facility mortality reviews. An interview was conducted on 1/8/2020 at 1:00 PM, with EI # 1, who verified the facility failed to conduct an analysis of all deaths to recognize trends for 2019.