Initial Comments:Based on the findings of an unannounced, onsite Medicare complaint investigation survey conducted March 24, 2026, Justin Drive Dialysis was identified to have the following standard level deficiency that was determined to be in compliance with the requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.
Plan of Correction:
494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P
Name - Component - 00
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;
Observations:
Based on a review of Facility Policies, Medical Record reviews (MR) and staff interview it was determined the medical director failed to ensure the policy Pre-intra-post treatment data collection, monitoring and nursing assessment was followed for four (4) of five (5) MR reviewed (MR#1, MR#2, MR#3, MR#4)
Review of policy Pre-intra-post treatment data collection, monitoring and nursing assessment on 3/24/26 at 2:00 PM states, "The nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse...The licensed nurse will round on those patients without abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation or sooner if required by state law."
A review of medical records on 2/24/26 at 12:00 PM revealed the following:
MR#1: Davita start date 3/4/25. Treatment flow sheet dated 3/16/26 showed the patient started treatment at 10:19 AM the patient was not assessed by the RN until 11:23 AM (1 hour, 4 minutes later). Treatment flow sheet dated 3/19/26 showed the patient started treatment at 10:13 AM, the patient was not assessed by the RN until 12:05 PM (1 hour, 52 minutes later).
MR#2: Davita start date 3/4/25. Treatment flow sheet dated 3/19/26 showed the patient started treatment at 5:37 AM, the patient was not assessed by the RN until 7:08 AM (1 hour, 31 minutes later).
MR#4: Davita start date 3/4/25. Treatment sheet dated 3/10/26 shows the patient started treatment at 9:38 AM, the patient was not assessed by the RN until 1:38 PM post treatment (4 hours later). The patient ended treatment at 1:17 PM. There was no pre-treatment assessment documented by the RN. Treatment flow sheet dated 3/19/26 showed the patient started treatment at 9:40AM, the patient was not assessed by the RN until 1:36 PM post treatment (3 hours, 56 minutes later). The patient ended treatment at 1:37 PM. There was no pre-treatment assessment documented by the RN.
Interview with the RN (employee #1) during treatment floor observations on 3/24/26 at 10:30 revealed the RN must conduct and assess the patient within one hour of the patient starting treatment.
Interview with the facility administrator on 3/24/26 at approximately 2:15 PM confirmed the above findings.
Plan of Correction:V0000 The Governing Body of DaVita Justin Drive Dialysis has reviewed the deficiency statement resulting from a complaint investigation which was completed March 24,2026. The Governing Body has approved and respectfully submits this plan of correction.
V0715 Governing Body meeting was held with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 03/24/26. The Governing Body reviewed Policy COMP-DD-017 "Medical Director Qualifications and Responsibilities" with the Medical Director, who acknowledges that he/she is responsible to ensure 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 non-physician providers.
The Facility Administrator or designee held mandatory in-services for all clinical teammates. Surveyor observations were reviewed. Education included but was not limited to Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: 1) The Nursing assessment will be performed and documented by a licensed nurse; specifically a Registered Nurse (RN) ... 2) The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation. Verification of attendance is evidenced by teammate signatures on the in-service sheet.
The Facility Administrator or designee will conduct flowsheet audits to verify the nursing assessment is completed and documented for each patient within one (1) hour of treatment initiation, per policy: on twenty five percent (25%) of flowsheets daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.
The Medical Director will review progress of teammate education, results of all audits, and adherence to this plan of correction during monthly Quality Assessment Performance Improvement meetings known as the Facility Health Meeting. The Facility Administrator will report progress, as well as any barriers to maintaining compliance, with supporting documentation included in the meeting minutes. Action plans will be evaluated for effectiveness, new plans developed as applicable to achieve compliance with teammate adherence to policy and procedure. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.
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