QA Investigation Results

Pennsylvania Department of Health
FRESENIUS/TEMPLE DIALYSIS - ONTARIO
Health Inspection Results
FRESENIUS/TEMPLE DIALYSIS - ONTARIO
Health Inspection Results For:


There are  13 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:


Based on the findings of an unannounced onsite incident investigation survey conducted on March 9, 2018, Fresenius/Temple Dialysis-Ontario was found not to be in 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:




494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P

Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;



Observations:



Based on a review of the medical record (MR), facility policy, federal regulation, and interviews with staff the facility did not follow its policy regarding involuntary discharge for one (1) of one (1) MR. MR#1.

Findings include:

A review of policy on 3/8/18 at 1400 FMS-CS-IC-103-011C1, "Routine and Involuntary Patient Discharge" states: " When discharge is necessary because...4. The patient's behavior is deemed disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate is seriously impaired and The Interdicsiplinary team has complied with the procedures outlined in the Disruptive Patient Behavior and behavioral Agreement policy , all intervention efforts have been documented but the behavior has continued or worsened..Then 1. Notify the Director of Operations/Area Manager (DO/AM). 2. Notify and obtain a written order from the Medical Director and attending physician for the discharge. If the Medical Director and/or attending physician disagree with the decision, notify the DO/AM and/or RVP (Regional Vice President) immediately. 3. Once all necessary approvals and orders are obtained, prepare a 30-day notice of discharge to provide to the patient outlining the behavioral issues that are prompting the discharge. Note: The 30 days are counted from the date the patient is expected to receive the notice, not from the date the letter is written. 4. Provide the patient and his/her representative with a list of alternative treatment facilities in the area, assist with transferring care of the patient to another facility and document this in the medical record."
A review of MR#1 was conducted on March 9, 2018 at 0930. The patient was admitted to the facility on 7/12/13. A consent for treatment and the receipt of patient rights and responsibilities was signed on 7/12/13.
The patient was given the discharge letter with 30 day notice with an attached list of nearby dialysis facilities dated 1/17/18 with the last date of treatment, to be 2/16/18. The patient was given these documents during the dialysis treatment at the facility on 1/17/18.
Per administrator note dated 1/3/18 where the FA informed the attending physician that the facility will be moving forward to discharge and asked for his help. The attending physician stated that the attending physician is not the medical director and that although the patient has outbursts and is disruptive, the patient is not violent.
Per interview with the operations director on March 9, 2018 at 11:50 informed the regional vice president of the discharge on 2/20/18.
The medical record did not contain an order for discharge written by the attending physician. The order for discharge was written by the Medical Director on 2/16/18. A review of facility policy states that the discharge letter is sent once all approvals and orders are obtained. The facility obtained the Medical Director order for discharge and informed the regional vice president after the discharge letter was written and given to the patient.
An interview with the Operations Director and Facility Administrator on March 9, 2018 at 1230 confirmed the above findings.








Plan of Correction:

V715 494.150(c)(2)(i) MD RESP- ENSURE ALL ADHERE TO P&P

On March 19, 2018, the Director of Operations (DO) and the Facility Administrator (FA) met with the Medical Director to review the Medical Director responsibilities as defined in the Conditions for Coverage. Emphasis of the meeting focused on the Medical Director responsibility to ensure the implementation of Fresenius policies and procedures. The meeting also reviewed the role of the Medical Director to ensure that all attending physicians also adhere to the policies and procedures. The meeting will focus on review of the following policy and procedure:
- FMS-CS-IC-I-103-011A Routine and Involuntary Patient Discharge Policy
- FMS-CS-IC-I-103-011C1 Routine and Involuntary Patient Discharge Procedure
The meeting will be completed by INSERT DATE. Documentation of the meeting will be on file at the facility.
By April 6, 2018, the Education Coordinator (EC) will in-service the Interdisciplinary Team (IDT) members on:
- FMS-CS-IC-I-103-011A Routine and Involuntary Patient Discharge Policy
- FMS-CS-IC-I-103-011C1 Routine and Involuntary Patient Discharge Procedure
The focus of the in-service will be on ensuring that the Involuntary Discharge (IVD) policy is implemented in its entirety with all IVD, including ensuring that the discharge orders are written by both the attending physician and the Medical Director in the event they ae not the same physician caring for the patient. The meeting will also review that the patient may not be given the notice of discharge until all approvals and orders are obtained.
All training documentation will be on file at the facility.
To ensure ongoing compliance, the DO will review the process of any future IVD to verify the entry of all needed discharge order, documentation of attempts to place the patient at other facilities and verification of the patient's 30-day discharge letter delivered after all approvals and the orders for discharge obtained.
Staff found to be non-compliant will be re-educated and counseled.
The DO will report any IVD with the Quality Assessment Improvement (QAI) committee meetings for sustained compliance. The QAI committee will report any IVD to the Governing Body (GB) for ongoing oversight.



494.180(f)(4) STANDARD
GOV-INVOL DISCHARGE PROCESS REQUIREMENTS

Name - Component - 00
The medical director ensures that no patient is discharged or transferred from the facility unless -
(4) The facility has reassessed the patient and determined that the patient's behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired, in which case the medical director ensures that the patient's interdisciplinary team-
(i) Documents the reassessments, ongoing problems(s), and efforts made to resolve the problem(s), and enters this documentation into the patient's medical record;
(ii) Provides the patient and the local ESRD Network with a 30-day notice of the planned discharge;
(iii) Obtains a written physician's order that must be signed by both the medical director and the patient's attending physician concurring with the patient's discharge or transfer from the facility;
(iv) Contacts another facility, attempts to place the patient there, and documents that effort; and
(v) Notifies the State survey agency of the involuntary transfer or discharge.
(5) In the case of immediate severe threats to the health and safety of others, the facility may utilize an abbreviated involuntary discharge procedure.




Observations:



Based on a review of the medical record (MR), facility policy, federal regulation, and interviews with staff the facility did not follow its policy regarding involuntary discharge for one (1) of one (1) MR. MR#1.

Findings include:

A review of policy on 3/8/18 at 1400 FMS-CS-IC-103-011C1, "Routine and Involuntary Patient Discharge" states: " When discharge is necessary because...4. The patient's behavior is deemed disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate is seriously impaired and The Interdicsiplinary team has complied with the procedures outlined in the Disruptive Patient Behavior and behavioral Agreement policy , all intervention efforts have been documented but the behavior has continued or worsened..Then 1. Notify the Director of Operations/Area Manager (DO/AM). 2. Notify and obtain a written order from the Medical Director and attending physician for the discharge. If the Medical Director and/or attending physician disagree with the decision, notify the DO/AM and/or RVP (Regional Vice President) immediately. 3. Once all necessary approvals and orders are obtained, prepare a 30-day notice of discharge to provide to the patient outlining the behavioral issues that are prompting the discharge. Note: The 30 days are counted from the date the patient is expected to receive the notice, not from the date the letter is written. 4. Provide the patient and his/her representative with a list of alternative treatment facilities in the area, assist with transferring care of the patient to another facility and document this in the medical record."
A review of MR#1 was conducted on March 9, 2018 at 0930. The patient was admitted to the facility on 7/12/13. A consent for treatment and the receipt of patient rights and responsibilities was signed on 7/12/13.
The patient was given the discharge letter with 30 day notice with an attached list of nearby dialysis facilities dated 1/17/18 with the last date of treatment, to be 2/16/18. The patient was given these documents during the dialysis treatment at the facility on 1/17/18.
Per administrator note dated 1/3/18 where the FA informed the attending physician that the facility will be moving forward to discharge and asked for his help. The attending physician stated that the attending physician is not the medical director and that although the patient has outbursts and is disruptive, the patient is not violent.
Per interview with the operations director on March 9, 2018 at 11:50 informed the regional vice president of the discharge on 2/20/18.
The medical record did not contain an order for discharge written by the attending physician. The order for discharge was written by the Medical Director on 2/16/18. A review of facility policy states that the discharge letter is sent once all approvals and orders are obtained. The facility obtained the Medical Director order for discharge and informed the regional vice president after the discharge letter was written and given to the patient.
An interview with the Operations Director and Facility Administrator on March 9, 2018 at 1230 confirmed the above findings.










Plan of Correction:

V 767 494.180(F)(4) GOV-INVOL DISCHARGE PROCESS REQUIREMENTS

On March 19, 2018, the DO had a GB call to review the IVD process and the responsibilities of the GB with the discharge of a disruptive patient. Emphasis of the meeting focused on the facility's responsibility to ensure the implementation of the policy for any future IVD. The meeting will focus on review of the following policy and procedure:
- FMS-CS-IC-I-103-011A Routine and Involuntary Patient Discharge Policy
- FMS-CS-IC-I-103-011C1 Routine and Involuntary Patient Discharge Procedure
The meeting will be completed by INSERT DATE. Documentation of the meeting will be on file at the facility.
By April 6, 2018, the EC will in-service the IDT members and the FA on:
- FMS-CS-IC-I-103-011A Routine and Involuntary Patient Discharge Policy
- FMS-CS-IC-I-103-011C1 Routine and Involuntary Patient Discharge Procedure
The focus of the in-service will be on ensuring that the IVD policy is implemented in its entirety with all potential IVD, including ensuring that the discharge orders are written by both the attending physician and the Medical Director, in the event they are not the same physician caring for the patient. The meeting will also review that the patient may not be given the notice of discharge until all approvals and orders are obtained.
All training documentation will be on file at the facility.
To ensure ongoing compliance, the DO will review the process of any future IVD to verify the entry of all needed discharge order, documentation of attempts to place the patient at other facilities and verification of the patient's 30-day discharge letter delivered after all approvals and the orders for discharge obtained.
Staff found to be non-compliant will be re-educated and counseled.
The DO will report any IVD with the QAI committee meetings for sustained compliance. The QAI committee will report any IVD to the GB for ongoing oversight.