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3/31/2009 Survey Tag 0626 Detail for:
Tuesday, March 31, 2020 2:55 AM

Survey Date: 3/31/2009

Regulation Number:0626


Regulation Description: The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility's organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS.

Surveyor Findings:

Based on staff interview, medical record review and review of the facility's QAPI (Quality Assessment and Performance Improvement) program, the facility failed to implement and maintain an effective, data-driven assessment and performance improvement program. This failure created the potential for lack of improvement in patient care and outcomes.

The findings were:

A review of the QAPI program was performed on 3/30/09. There was no evidence the facility was monitoring any of the ten (nine are pertinent to this facility) areas that are specifically required to be continuously assessed, trended and reviewed.

According to the 2008 (DFR) Dialysis Facility Report for this facility, the statistics for anemia management and high catheter rate far exceeded the national average. The facility's hemoglobin rate was 43% between 10-12 g/dL compared to 54% nationally. The catheter rate for prevalent patients receiving hemodialysis treatment in the facility was at 47% compared to 12% nationally.

Three medical records of hemodialysis patients were reviewed on 3/30/09. Two of the three patients had a catheter in place for their vascular access. One of the three patients had a fistula. According to the laboratory results of 3/2/09, two of three patients had low hemoglobins. One patient had a hemoglobin of 8.9 g/dL and another patient was at 10.1 g/dL.

The clinical manager was interviewed, on 3/30/09 at approximately 11:45 a.m. The manager stated that he/she was aware of the regulations pertaining to the QAPI program and was in the process of establishing the criteria. However, it was not implemented at this time.

Facility Plan of Correction:

The Children’s Hospital acknowledges that our Quality Assessment and Performance Improvement processes needed to be more formalized and leadership-driven; however, it is important to note that our pediatric patient population is unique; specifically, the rate of catheter placement in pediatric patients is significantly different from adults.

How the Facility will CORRECT the deficient practice:

The Kidney Center has developed a Quality Assessment/Performance Improvement program and policy that outlines the purpose, scope, personnel, responsibilities, organization, and procedures for monitoring and evaluating the key indicators related to assessing and improving health outcomes and decreasing or preventing medical errors as outlined on the Measures Assessment Tool (MAT).

How the facility will IDENTIFY areas of deficient practice:

The Clinical Manager in conjunction with the Medical Director and members of the Quality and Patient Safety Department have developed a quality scorecard to enable timely tracking of these key indicators for further analysis, prioritization of improvements, reviewing adverse events, and developing, implementing, evaluating, and revising plans to improve patient care.

What will the facility do to PREVENT the same deficiency from recurring?

These quality indicators will be reviewed MONTHLY by the Kidney Center Quality Assurance interdisciplinary team that consists of the Medical Director, other physicians as indicated, the Clinic Manager (RN), a masters-prepared social worker, a registered dietician, a quality improvement specialist, and other team members, as applicable.

How will the facility MONITOR the implementation of the plan of correction to ensure the problems remain corrected?

In addition to the monthly monitoring, the Kidney Center quality indicators will be reviewed twice each year by the Clinical Effectiveness and Improvement Committee (a multi-disciplinary hospital-wide quality improvement committee that is primarily focused on patient outcomes).


Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

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