Purpose of the Governing Body at DaVita
Each CMS Certified Facility (CCN) is under the control of an identifiable governing body (GB), or designated person(s), with full legal authority and responsibility for the governance and operation of the facility.
All facilities will use Online Governing Body (OGB) to hold meetings. OGB is a single application to source, complete, and maintain all things Governing Body-related. OGB is a structured meeting process for compliance and standardization and
- Provides overall accountability for the dialysis facility and provide oversight of facility operations, clinical quality, and safety.
- Approves policies and procedures (P&P), clinical practice, and more
- Oversees Facility Health Management (QAPI)
- Is accountable to ESRD, State Health Departments, and CMS
- Other GB Responsibilities
Who are the Members of Governing Body at DaVita?
Clinical Leader
The medical director is responsible for patient care and outcomes, ensuring the quality of medical care in the facility.
Chief Executive Officer
The lead facility administrator manages the facility and all dialysis services under the CCN.
Corporate Representative
The Regional Operations Director oversees the management of multiple facilities, focusing on financial management, compliance, patient care, and teammate relations.
CNM (Nurse in charge of Nursing Services)
If neither the Facility Administrator nor the Regional Operations Director is a licensed nurse, a licensed nurse will oversee nursing services and be a voting member of the Governing Body.
How Often Should the Governing Body Meet?
As per DaVita Governing Body Bylaws section 4.2 (a): The Governing Body shall meet at least annually but as often as necessary to carry out the governance and operation.
This may include, as applicable, but not limited to:
- Daily to resolve or sustain any corrections after a Condition*, Immediate Jeopardy** and/or CLUE call***
- Monthly to consider and act upon Facility Health Meeting (FHM) issues and/or plans of correction
- Biannually to sign off on new, updated or revised policy
Governing Body Responsibilities
Medical Staff Appointments:
- The Governing Body grants privileges to physicians and non-physician practitioners based on qualifications and performance.
- An interim Medical Director must be appointed when the current Medical Director is on leave.
- Inform medical staff about the facility’s QAPI/FHM program, requiring participation in quality improvement efforts.
Grievances:
- Ensure all grievances from patients, families, or staff are addressed and resolved according to policy.
- Review unresolved grievances escalated beyond the facility level.
- Maintain a relationship with the Renal Network.
Involuntary Discharge:
- Ensure involuntary discharge or transfer is rare and follows policies, with efforts made to address issues first.
- Involve the Risk Management department in the discharge process.
Emergency Coverage:
- Provide written emergency instructions and maintain a roster of on-call physicians.
- Approve emergency and disaster plans.
Oversight of QAPI/FHM:
- Review significant issues like infection control and outcomes.
- Discuss CMS survey results, internal audits, and other safety and compliance issues
*Condition: A deficiency in the facility that needs to be corrected within 21 to 45 days and confirmed by a follow-up visit by a CMS surveyor.
**Immediate Jeopardy (IJ): A deficiency in the facility that has caused, or is likely to cause, serious injury, harm, impairment, or death to a patient that must be addressed prior to the survey being completed & resolved within 23 days.
***Corporate-clinical look at unexpected events calls (CLUE): Convened to investigate and address serious regulatory, safety, infection control and operational issues.