Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012505	(X3) Date Survey Completed 07/26/2018
Name of Provider or Supplier Physicians Choice Dialysis-Montgomery	Street Address, City, State 1001 Forest Avenue, Montgomery, 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) documentation, Pre Survey DFR (Dialysis Facility Report) Extract, policy and staff interview, it was determined the Quality Improvement Committee failed to accurately analyze and trend patient's mortality and causes. This affected Patient Identifier (PI) # 9 and had the potential to negatively affect all patients who dialyzed at the facility. Findings include: Policy:1-14-06 Title: Continuous Quality Improvement Program 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 verifying the execution of the Quality Improvement program... 7. The facility will measure, analyze, and track quality indicators...not limited to, the following...Infection Control...Vascular Access...Mortality-review of deaths... 8. Continuous monitoring of the above indicators will be reflected in the meeting minutes. Any area identified as under performing will be reviewed to identify root causes...will have an action plan identified...track this change in performance ...to verify improvements are sustained... **** 1. Review of the Fiscal Year 2018 Pre-Survey DFR Extract printed 7/23/18 prior to the survey revealed this facility had a 15.4 % (percent) Death due to Infection rate and the U.S. (United States) average rate was 11.1 % which was 4.3 % above the average. Review of the 5 DaVita Mortality Review Forms provided to the surveyor 7/24/18 at 11:00 AM revealed the following documentation: 1. A death on 1/16/18, primary cause of death cardiac arrest. 2. A death on 2/20/18, primary cause of death cardiac arrest. 3. A death on 4/21/18 (PI # 4), primary cause of death cardiac arrest. 4. A death on 5/9/19, primary cause of death, # 62 (no reason documented). 5. A death on 5/29/19, primary cause of death cardiac arrest. All the death forms contained "NA" not applicable for the serial number and station number for the hemodialysis machine during the last treatment. On 7/26/18 at 10:00 AM in an interview, Employee Identifier (EI) # 2, Clinical Nurse Manager (CNM) confirmed on 4/12/18 PI # 4 was admitted to the hospital with a CVC (central venous catheter infection) as documented on the 4/12/18 inpatient history and physical. On 7/26/18 at 1:20 PM during the quality review, EI # 2 and EI # 1, Facility Administrator, was asked how the cause of death was determined, what was the analysis of the 5 deaths, and if any contributing factors were identified ? EI # 2 reported the Administrative Assistant and CNM obtains information from the family, hospital and physician and completes the DaVita Mortality Review which is discussed with the quality committee at the monthly FHR meeting. EI # 2 reported no contributing factors related the dialysis care were identified during the death review. The surveyor asked to see death certification (s) documentation and review the hospital discharge documentation. Review of the hospital death summary documentation for 2 of the 5 deaths on 7/26/18 at 1:25 PM with EI # 1 and EI # 2 revealed PI # 9 died of sepsis due to CVC infection, not cardiac arrest. Septic shock was the primary cause of death for the 5/9/18 death and not cardiac arrest as the mortality reviews indicated. The facility staff failed to thoroughly and accurately evaluate and analyze individual deaths to recognize trends in causes and contributory factors of deaths relative to infections which included PI # 9's CVC infection. An interview was conducted on 7/26/18 at 3:30 PM with EI # 1 who verified the aforementioned findings.