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12/5/2007 Survey Tag 0188 Detail for:
Tuesday, May 26, 2020 12:41 AM

Survey Date: 12/5/2007

Regulation Number:0188


Regulation Description: There is a written long-term program representing the selection of a suitable treatment modality (i.e., dialysis or transplantation) and dialysis setting (i.e., home, self-care) for each patient that is developed by a professional team which includes but is not limited to the physician director of the dialysis facility or center where the patient is currently being treated, a physician director of a center or facility which offers self-care dialysis training (if not available at the location where the patient is being treated), a transplant surgeon, a qualified nurse responsible for nursing services, a qualified dietitian and a qualified social worker.

Surveyor Findings:

Based on patient medical record review and staff interview, the facility failed to assure that written long-term programs in five (#1, #2, #3, #4 and #5) of 5 medical records reviewed were developed by a complete professional team. The findings were:

All five of the medical records were reviewed on 12/5/07. All the medical records contained a written long-term program; however, only the registered nurse and attending physician participated in the program as implied by their signatures.

There was no evidence that a transplant surgeon, qualified dietitian or a qualified social worker were members of the professional team responsible for developing the long-term program for each patient.

The clinical supervisor was made aware of the lack of participation of the transplant surgeon, dietitian and social worker on 12/5/07 at 3:30 p.m. The supervisor stated that s/he had done her part as the registered nurse with the long-term program and the nursing portion for all the patients was up-to-date.

Facility Plan of Correction:

All patient's lont-term care plans will be reviewed for all necessary professional team's signatures to be completed by 12/31/07.

Patient #1,#2,#3,#4 and #5 were reviewed and the proper signatures were obtained. See attachments.

The policy of Summit Kidney Centers is that all Long term care plans, physicians Standing Orders, Nursing History and Physical, Treatment options, Psycosocial Assessments, Dietiary Assessments and Consent to dialyze forms are to be monitored by the Director of Nursing. This responsiblity may be delegated to the appropriate personnel.

QA at this time states that all charts will be reviewed quarterly. A data base that monitors and flag dates and requirments has been started in the computer, a designated person will monitor and update files. The results will be reported to the DON and upward to the Medical Director.

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Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
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Denver CO 80246-1530
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