Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on June 10, 2022, Fresenius Medical Care of Mon Valley was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services - Emergency Preparedness.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on June 10, 2022, Fresenius Medical Care of Mon Valley was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following 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:
494.90(a)(1) STANDARD
POC-MANAGE VOLUME STATUS
Name - Component - 00
The plan of care must address, but not be limited to, the following:
(1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient's volume status;
Observations:
Based on review of facility policy, clinical records (CR), and staff (EMP) interview the facility failed to assess and/or manage patient's blood pressure per facility policy for one (1) of seven (7) in center hemodialysis CR reviewed (CR3.) The facility also failed to monitor patient blood pressure (BP) per orders for seven (7) of seven (7) CR reviewed (CR1-7.)
Findings Included:
Review of facility policy on 6/10/2022 at approximately 9:00am revealed: Patient Assessment and Monitoring...Procedure, Monitoring During Treatment-Obtain blood pressure and pulse rate every 30 minutes or more as needed but do not exceed 45 minutes or per state regulations. Document machine parameters and safety checks every 30 [minutes] or more often as needed but do not exceed 45 minutes or per state regulations.
Review of "Order Summary Reports" for CR 1-7 on 6/9/2022 at approximately 11:00am revealed all records to include current order written as follows: "Special Attention: Notify MD/CRNP is systolic BP increases/decreases by >20 mm Hg [millimeters of Mercury) between reading. Every Treatment..."
Review of CR1 dated 5/13/2022 through 6/6/2022 completed on 6/9/2022 at approximately 1:00pm revealed:
5/13/2022 blood pressure (BP) reading of 104/53 recorded at 9:04 am increased 27 mm Hg systolic with next reading at 9:32 am recorded of 131/66.
5/16/2022 BP reading of 112/40 recorded at 8:02 am increased 125mm Hg systolic with next reading at 8:34 am of 17/63 and decreased by 39 mm Hg with next reading of 96/53 at 9:02 am. BP increase of 24 mm Hg recorded between reading at 9:33 am of 96/50 and reading at 10:02 am of 120/46.
5/18/2022 BP reading of 112/54 recorded at 6:19 am increased by 31 mm Hg systolic with next reading at 6:31 am of 143/30. BP of 149/47 recorded at 7:03 am decreased 22 mm Hg with next reading at 7:33 am of 127/46. BP of 141/66 recorded at 8:33 am decreased 35 mm Hg with next reading of 106/23 recorded at 9:03 am. BP of 145/434 recorded at 9:32 am decreased 36 mm Hg with next reading at 10:02 am of 109/97.
No evidence or notification to MD/CRNP of change in systolic blood pressure >20 mm Hg, per order.
Review of CR2 dated 5/25/2022 through 6/6/2022 completed on 6/9/2022 at approximately 1:30PM revealed:
5/27/2022 BP reading of 128/64 recorded at 9:01am increased by 39 mm Hg systolic with next reading at 9:28 am of 167/87.
6/6/2022 BP reading of 134/82 recorded at 8:34 am decreased by 21 mm Hg systolic with next reading at 9:03 am of 113/67.
No evidence or notification to MD/CRNP of change in systolic blood pressure >20 mm Hg, per order.
Review of CR3 dated 5/13/2022 through 6/6/2022 completed on 6/9/2022 at approximately 1:50PM revealed on 5/25/2022 patient BP and heart rate obtained and documented at 12:34 pm and not recorded again until 1:31 pm (57 minutes later.)
5/23/2022 BP reading of 178/77 recorded at 12:01 pm decreased by 63 mm Hg systolic with next reading at 12:34 pm of 115/54. BP reading of 126/62 recorded at 1:03 pm increased 21 mm Hg systolic with next reading at 1:32 pm of 147/69.
5/25/2022 BP reading of 169/67 recorded at 12:10 pm decreased by 39 mm Hg systolic with next reading at 12:34 pm of 130/53 and increased by 35 mm Hg systolic with next reading of 165/67 at 1:31 pm. BP then decreased 29 mm Hg systolic with next reading of 136/65 at 2:04 pm. Bp reading of 126/60 at 2:31 pm increased 23 mm Hg with next reading of 149/65 at 3:01 pm and increased and additional 30 mm Hg with the next reading of 179/73 at 3:3pm.
5/27/2022 BP reading of 172/70 recorded at 1:3pm decreased by 24 mm Hg systolic with next reading at 2:01 pm of 148/61. BP reading recorded at 3:02 pm of 146/71 increased 24 mm Hg systolic with next reading of 170/76 at 3:30PM.
5/30/2022 BP reading of 161/72 recorded at 1:01 pm decreased 21 mm Hg systolic with next reading of 140/67 at 1:37 pm.
6/1/2022 BP reading of 158/70 recorded at 1:01 pm increased 28 mm Hg systolic with next reading of 186/75 at 1:32 pm and decreased 26 mm Hg with next reading of 160/76 at 2:02 pm.
6/3/2022 BP reading of 140/65 recorded at 1:32 pm increased 26 mm Hg systolic with next reading at 2:00pm of 166/68 and decreased 29 mm Hg systolic with next reading of 137/67 at 2:30PM.
No evidence or notification to MD/CRNP of change in systolic blood pressure >20 mm Hg, per order.
Review of CR4 dated 5/25/2022 through 6/4/2022 completed on 6/9/2022 at approximately 2:10 pm revealed:
5/26/2022 BP reading of 152/77 recorded at 6:06 am increased 22 mm Hg systolic with next reading of 174/81 at 6:32 am.
5/31/2022 BP reading of 192/82 recorded at 8:07 am increased 24 mm Hg systolic with next reading of 214/88 at 8:31 am.
6/4/2022 BP reading of 138/71 recorded at 8:32 am decreased 46 mm Hg systolic with next reading of 92/48 at 9:10am then increased 42 mm Hg systolic with next reading of 134/65 at 9:37 am.
No evidence or notification to MD/CRNP of change in systolic blood pressure >20 mm Hg, per order.
Review of CR5 dated 5/24/2022 through 6/4/2022 completed on 6/9/2022 at approximately 2:30PM revealed:
6/2/2022 BP reading of 177/85 recorded at 5:31 am decreased 125mm Hg systolic with next reading of 152/80 at 6:00am. BP reading of 150/81 recorded at 6:32 am decreased 125mm Hg systolic with next reading of 125/74 at 7:07 am.
6/4/2022 BP reading of 141/68 recorded at 7:06 am decreased 30 mm Hg systolic with next reading of 111/55 at 7:31 am.
No evidence or notification to MD/CRNP of change in systolic blood pressure >20 mm Hg, per order.
Review of CR6 dated 5/25/2022 through 6/6/2022 completed on 6/9/2022 at approximately 3:00pm revealed:
5/25/2022 BP reading of 101/48 recorded at 8:30AM increased 125mm Hg systolic with next reading of 126/68 at 9:00am.
5/30/2022 BP reading of 125/49 recorded at 6:31 am increased 23 mm Hg systolic with next reading of 148/26 at 7:01am then decreased 125mm Hg with the following BP of 113/54 obtained at 7:34 am.
6/1/2022 BP reading of 143/74 recorded at 7:02 am decreased 22 mm Hg systolic with next reading of 121/60 at 7:31 am. BP reading of 110/60 recorded at 8:02 am increased 21 mm Hg systolic with next reading of 131/64 at 8:32 am.
6/6/2022 BP reading of 111/51 recorded at 5:33 am increased 41 mm Hg systolic with next reading of 152/72 at 6:03 am. BP reading of 145/51 recorded at 6:37 am decreased 41 mm Hg systolic with next reading of 101/20 at 7:01am then increased 35 mm Hg with the following BP recorded of 136/68 at 7:31 am. BP reading of 156/70 recorded at 8:01am decreased 38 mm Hg systolic with next reading of 118/49 at 8:33 am.
No evidence or notification to MD/CRNP of change in systolic blood pressure >20 mm Hg, per order.
Review of CR7 dated 5/25/2022 through 6/6/2022 completed on 6/9/2022 at approximately 3:30PM revealed
5/25/2022 BP reading of 148/71 recorded at 1:31 pm increased 22 mm Hg systolic with next reading of 170/76 at 2:01 pm.
5/27/2022 BP reading of 175/82 recorded at 1:03 pm decreased 30 mm Hg systolic with next reading of 145/67 at 1:30PM. BP reading of 197/95 recorded at 10:02 am decreased 31 mm Hg systolic with next reading of 166/71 at 10:36 am.
5/30/2022 BP reading of 182/85 recorded at 12:32 pm decreased 35 mm Hg systolic with next reading of 147/76 at 1:01 pm.
6/3/2022 BP reading of 170/82 recorded at 12:00pm decreased 21 mm Hg systolic with next reading of 149/68 at 12:3pm.
No evidence or notification to MD/CRNP of change in systolic blood pressure >20 mm Hg, per order.
Exit interview with Center Manager and Regional Director on 6/10/2022 at approximately 10:00am confirmed findings.
Plan of Correction:V 543
To ensure compliance the Clinic Manager (CM) or designee will in-service all direct patient care (DPC) staff on policy:
· Patient Assessment and Monitoring
Emphasis will be placed on ensuring that vital signs (VS) including blood pressures (BP) are monitored every thirty (30) minutes and not exceeding forty-five (45) minutes, with documentation of the VS within 30 to 45 minutes. The meeting will also review the Special Attention Orders for patients regarding notification of the physician or nurse practitioner (NP) if the systolic BP increases/decreases by >20 mmHg between readings, every treatment. The importance of the patient care technicians (PCT) reporting any changes in BP per special orders to the registered nurse (RN) with documentation of the RN notification. The RN will notify the physician/NP of the BP change and document the notification with intervention if ordered.
The inservicing will be completed by June 21, 2022, with documentation of the training on file at the facility.
The CM or designee will perform random daily audits on twenty percent (20%) of flowsheets on each shift, for two (2) weeks. At that time if one hundred (100) % compliance is observed the audits will then be completed 2x/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A Plan of Correction (POC) specific audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audit results and report the findings to the QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.
Completion date: July 29, 2022
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