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 012506 (X3) Date Survey Completed 04/13/2023
Name of Provider or Supplier Dothan Dialysis Street Address, City, State 216 Graceland Drive, Dothan, 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)
V0544 POC-ACHIEVE ADEQUATE CLEARANCE
CFR(s): 494.90(a)(1)

Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.


This STANDARD is not met as evidenced by:
Based on review of medical records (MR), facility policies, and staff interviews, it was determined the facility failed to ensure the staff: 1. Followed the physician's orders for BFR (Blood Flow Rate) and DFR (Dialysate Flow Rate). 2. Developed and implemented an individualized Plan of Care (POC) to address in center Hemodialysis (HD) Kt/V (adequacy) of less than 1.2. This affected four of five MR's reviewed, including PI (Patient Identifier) # 4, PI # 1, PI # 2, PI # 5, and had the potential to negatively affect all patients who dialyze at this facility. Findings include: Facility Policy Title: Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment Policy Number: 1-03-08 Revision Date: April 2021 Purpose: To obtain and document baseline and ongoing information about the patient before, during, and after the dialysis treatment through data collection and nursing assessment... Policy: 1. Patient data will be obtained and documented by the patient care technician (PCT), or a licensed nurse... 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation ... Intradialytic Data Collection/ Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT, or licensed nurse includes: ...b. At a minimum, obtain and document the following: ...iii. Blood and dialysate flows... Facility Policy: Interdisciplinary Team (IDT) Patient Assessment and POC Policy Number: 1-14-01 Revision Date: April 2023 Purpose: To provide guidance for the development of patient assessment and POC for IDT teammates. Policy: Assessment: ...2. The IDT is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient's treatment plan and expectations for care. ...6. The adequacy of the patient's dialysis prescription will be assessed on an ongoing basis as follows: For HD patients, at least monthly calculations of delivered Kt/V or an equivalent measure... 7. A comprehensive re-assessment of each patient and a revision in the POC will be conducted: ...At least monthly for unstable patients... POC: 8. The facility's IDT will develop and implement a written, individualized comprehensive POC that specifies the services necessary to address the patient's needs...and will include measurable and expected outcomes and estimated timetables to achieve these outcomes... 9. The POC will address...the following: ...An in-center HD Kt/V of a least 1.2... 1. PI # 4 was admitted to the facility on 1/11/21 with a diagnosis of End Stage Renal Disease (ESRD). Review of the IDT Rounding Worksheet (RW) revealed HD Treatment Orders dated 4/5/23 which included BFR 450 and DFR 600. Review of the Treatment Details Report (TDR) dated 4/8/23 revealed from 8:56 AM until treatment end at 10:22 AM, the BFR was 350. There was no reason documented why the BFR was not 450 and no physician's order for BFR 350. Review of the TDR dated 4/11/23 revealed from treatment start at 6:15 AM until treatment end at 10:15 AM the BFR was 400. There was no reason documented why the BFR was not 450 and no physician's order for BFR 400. An interview was conducted on 4/13/23 at 11:40 AM with Employee Identifier (EI) # 1, Facility Administrator (FA), who confirmed on HD treatments dated 4/8/23 and 4/11/23 the staff failed to follow the physician's order for BFR. 2. PI # 1 was admitted to the facility on 2/25/21 with a diagnosis of ESRD. Review of the IDT RW revealed HD Treatment Orders dated 3/15/23 which included BFR 300. Review of the TDR dated 4/3/23 revealed from treatment start at 10:50 AM until treatment end at 2:52 PM, the BFR was 350. There was no reason documented why the BFR was not 300 and no physician's order for BFR 350. An interview was conducted on 4/13/23 at 11:34 AM with EI # 1 who confirmed staff failed to follow the physician's order for BFR. 40119 3. PI # 2 was admitted to the facility on 1/30/23 with a diagnosis of ESRD. Review of the IDT RW revealed HD Treatment Orders dated 3/10/23 which included BFR 450. Review of the TDR dated 3/10/23 revealed from treatment start at 12:12 PM until treatment end at 3:07 PM, the BFR was 400. There was no reason documented why the BFR was not 450 and no physician's order for BFR 400. Review of the RN (Registered Nurse) Comprehensive Assessment Report dated 3/10/23 revealed documentation of a Kt/V on 3/6/23 of 0.76 and "...meets adequacy goal." Review of the Physician Comprehensive Encounter dated 3/13/23 revealed documentation PI # 2's adequacy had not been met for the month and a Kt/V on 3/10/23 of 0.93 Review of the IDT meeting and POC dated 3/13/23 revealed no documentation the IDT developed and implemented interventions and goals to address in center HD Kt/V of less than 1.2. Review of the TDR dated 3/13/23 revealed from treatment start at 12:15 PM until treatment end at 2:54 PM, the BFR was 400. There was no reason documented why the BFR was not 450 and no physician's order for BFR 400. Review of the TDR dated 3/20/23 revealed from treatment start at 12:34 PM until treatment end at 2:31 PM, the BFR was 400. There was no reason documented why the BFR was not 450 and no physician's order for BFR 400. Review of the RN Comprehensive Assessment Report dated 4/7/23 revealed documentation of a Kt/V on 3/6/23 of .76, on 3/10/23 of 0.93 and on 3/13/23 of 0.91. Further review revealed documentation of "meets adequacy goal." Review of the IDT meeting and POC dated 4/10/23 revealed no documentation the IDT developed and implemented interventions and goals to address in center HD Kt/V of less than 1.2. An interview was conducted on 4/13/23 at 12:02 PM with EI # 10, Senior Manager of Clinical Services, who confirmed there was no documentation of the reason the treatment BFR was not documented per the physician orders on 3/10/23, 3/13/23 and 3/20/23. EI # 10 also confirmed there was no documentation the IDT developed and implemented interventions and goals to address in center HD Kt/V of less than 1.2 in the patient's POC. 41624 4. PI # 5 was admitted to the facility on 11/23/22 with a diagnosis of ESRD. Review of HD Treatment Orders dated 3/28/23 included BFR 400 and DFR 800. Review of the TDR dated 3/28/23 revealed treament began at 7:06 AM with BFR of 400 and DFR of 850. DFR was 790 from 7:26 AM to 8:46 AM, DFR was 840 from 9:06 AM to 9:46 AM, DFR was 780 at 10:06 AM, DFR was 790 at 10:26 AM, and DFR was 840 at end of treatment 10:38 AM. There was no documentation why the BFR was not at the ordered rate of 400. Review of the TDR dated 3/30/23 revealed from treatment start at 7:20 AM until treatment end at 10:54 AM the BFR was 200. The DFR was 590 at start of treatment 7:20 AM, 610 from 7:40 AM to 8:20 AM, DFR was 600 at 8:40 AM, DFR was 610 at 9:00 AM, DFR was 600 at 9:20 AM, DFR was 600 at 10:00 AM, DFR was 610 from 10:20 AM until end of treatment at 10:54 AM. There was no documentation why the BFR was not at the ordered rate of 400, and no documentation why the DFR was not at the ordered rate of 800. Review of the TDR dated 4/1/23 revealed DFR at start of treatment 7:24 AM was 590, DFR was 610 at 7:44 AM, DFR was 600 from 8:04 AM to 8:25 AM, DFR was 610 at 8:45 AM, DFR was 600 from 9:25 AM to end of treatment at 10:58 AM. There was no documentation why the DFR was not at the ordered rate of 800. Review of the TDR dated 4/4/23 revealed BFR was 210 from start of treatment at 7:28 AM to end of treatment at 11:02 AM. The DFR at start of treatment 7:28 AM was 580, DFR was 610 from 7:48 AM to end of treatment at 11:02 AM. There was no documentation why the BFR was not at the ordered rate of 400, and no documentation why the DFR was not at the ordered rate of 800. Review of HD Treatment Orders dated 4/6/23 included BFR 250 and DFR 800. Review of the TDR dated 4/6/23 revealed BFR was 230 from start of treatment at 7:19 AM to end of treatment at 10:18 AM. There was no documentation why the BFR was not at the ordered rate of 250. Review of the TDR dated 4/8/23 revealed BFR was 200 from beginning of treatment at 8:01 AM to end of treatment at 10:54 AM. There was no documentation why the BFR was not at the ordered rate of 250. An interview was conducted on 4/13/23 at 11:47 AM with EI # 1 who confirmed the staff failed to follow the physician's orders for the BFR and/or DFR on 3/28/23, 3/30/23, 4/1/23, 4/4/23, 4/6/23, and 4/8/23,