Go to the State of Colorado Web
5/24/2010 Survey Tag 0750 Detail for:
PIKES PEAK DIALYSIS CENTER
Wednesday, October 23, 2019 12:19 AM

Survey Date: 5/24/2010

Regulation Number:0750

Regulation Title: CFC-GOVERNANCE

Regulation Description:

Surveyor Findings:


Based on the number and nature of the deficiencies cited, staff interviews, and review of patient records, policies/procedures, personnel/credential files, meeting minutes and other facility documents, the governing body (as the entity ultimately responsible for the governance and operation of the facility and responsible for the health care and safety of patients) failed to ensure that the facility maintained complete medical records, and that facility staff followed facility policies/procedures, and that the Medical Director was involved in the oversight of providers adherence to facility policies/procedures and with the quality improvement process for ensuring that medical errors were not repeated. The Governing Body failed to provide a comprehensive and proactive leadership to ensure the facility met the requirements for the health and safety of the patients.

The findings were:

1. Cross Reference to the QAPI Standard tags V626 and V634 for findings related to the facility's failure to "identify and correct deficiencies in the completeness of medical records as part of the QAPI program" and "implement process changes to ensure that a wrong patient's dialyzer would be used on another patient."

2. Cross Reference to the Medical Director Condition Tag V710 and Standard Tags V711 and V715 for findings related to the Medical Director's failure to "ensure that providers practicing in the facility were adhering to facility policies in regards to security, completeness, and centralization of medical records" as well as the Medical Director's failure to "be involved in the quality improvement process in ensuring that medical errors were not repeated."
3. Cross Reference to the Medical Record Condition Tag V725 and Standard Tags V726, V727, V729, and V730 for findings related to the facility's failure to "maintain complete and accurate records and protect them against loss and unauthorized use".

Facility Plan of Correction:

V750
The Governing Body will provide comprehensive and proactive leadership to ensure the facility meets the requirements for the health and safety of the patients. An in-service on the Governing Body process and documentation of said meeting was conducted by the
Regional Operations Director (ROD) on 06/15/2010. The Governing Body will ensure the facility maintains an effective, data driven, quality assessment and performance improvement program (QIFMM) that that is led by the Medical Director and ensures the security of medical records, includes the evaluation and prevention of medical errors, to include but not be limited to dialyzers being used by the wrong patients, and ensures teammates adhere to policies and procedures.
Policy #3-02-01Medical Record Maintenance has been reviewed with the facility team with emphasis on the need for a monthly review of 10% of the medical records and that medical records are to remain in the facility at all times, until such time they are archived in an approved medical records storage company. Policy #3-02-02 Medical Record Preparation Charting Guidelines has been reviewed with the teammates with the emphasis on that all entries are to be timed, dated and signed at the time of entry. A letter was written to XXX Nephrology Associates on May 20, 2010 by the Medical Director, stating that no documents are to be removed from the facility from that date forward. FA and Medical Director are responsible for ongoing compliance with POC. AA’s are to complete all filing and audit 100% of the patient charts by 6/21/10, followed by monthly audits of 10% of the charts. In addition compliance will be evidenced by random audits conducted by the FA of monthly physician Rounding Reports X 3 months. Results of audits will be reported in QIFMM and addressed as necessary. FA and Medical Director are responsible for ongoing compliance with POC.

Adverse occurrences will be reviewed in QIFMM meeting with action plans developed and implemented as needed. Policy changes will be made if indicated. After internal review of cited incidents a plan of action was put in place that required that the teammate not sign off dialyzer until the patient is in their chair. Policy # 01-03-02 “Prescription Verification and Safety Checks” was revised to include written verification on the dialyzer while the patient is present, by 2 teammates. A governing body meeting which included the Medical Director was held on 05/20/2010 approving the new policy. Documentation of this meeting is on file in the facility. All teammates were in-serviced on this policy on 05/21/2010 and 05/22/2010. The Charge Nurse/Clinical Coordinator is observing the PCT's for compliance with verification while the patient is in the chair. In addition, audits will be conducted on 100% of reuse dialyzers X 1 month followed by auditing of 50% of reuse dialyzers X 1 month, to ensure compliance. The dialyzer audits were implemented on 06/08/2010. These audits are being conducted by the reuse technician and given to the FA for review daily. Results of audits will be reported in QIFMM and addressed as necessary. FA is responsible for ongoing compliance with POC.

The Governing Body will meet monthly x 3 to ensure compliance with POC. Further compliance to the POC will be reviewed during monthly QA meetings and reported to the Governing Body no less than semi- annually. The Facility administrator (FA) representing the GB will be responsible for ensuring implementation and ongoing compliance with this POC.

Back to Survey Tag Summary for:PIKES PEAK DIALYSIS CENTER

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

Return to Health Facilities Main Page