QA Investigation Results

Pennsylvania Department of Health
CLEARFIELD DIALYSIS
Health Inspection Results
CLEARFIELD DIALYSIS
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced recertification survey completed on 12/21/18, Clearfield Dialysis 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 and expansion of services to include peritoneal dialysis home training and support survey was completed on 12/21/18, Clearfield Dialysis 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. Approval for peritoneal dialysis home training and support recommended.













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 and medical records (MR) and staff (EMP) interview the facility failed to monitor intradialytic treatments and assess and/or manage patient's blood pressure for two (2) of five (5) incenter hemodialysis MR reviewed (MR4 & MR5)

Findings Included:

Review of facility policy completed on December 20, 2018 at approximately 10:00 a.m. revealed: "PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT...Policy: 1-03-08...Revision Date: April 2017...1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse...4. Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse...ABNORMAL FINDINGS:...Blood Pressure - Intradialytic Difference of 20 mm/Hg increase or decrease from patient's last intradialytic treatment BP reading...Blood Pressure Post Treatment...Sitting systolic BP greater than 140 mm/Hg...9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring i. For non-nocturnal treatments is completed at least every thirty (30) minutes."

Review of MR4 completed on December 21, 2018 at approximately 9:00 a.m. revealed admission date 5/17/2017. Treatment sheets reviewed dated 12/06/2018 through 12/18/2018.
12/06/2018 10:12 a.m. BP 132/64, 10:42 a.m. BP 160/78 taken by PCT, 11:12 a.m. BP 137/67, 11:42 a.m. BP 161/78 taken by PCT, 12:12 p.m. BP 141/72 taken by PCT, treatment sheet did not contain evidence that licensed nurse was notified of fluctuations in BP in accordance with facility policy.
12/08/2018 12:14 p.m. BP 144/73, 12:44 p.m. BP 164/86 taken by PCT, treatment sheet did not contain evidence that licensed nurse was notified of increase in BP in accordance with facility policy
12/11/2018 9:37 a.m. BP 149/73, 10:05 a.m. BP 172/83 taken by PCT, treatment sheet did not contain evidence that licensed nurse was notified of increase in BP in accordance with facility policy.
12/13/2018 treatment sheet did not contain evidence that a "INTRADIALYTIC DATA COLLECTION/ASSESSMENT" was completed at 11:05 a.m. in accordance with facility policy. "Every 30 minutes". The treatment sheet indicated and assessment was completed at 10:35 a.m. and 11:32 a.m.

Review of MR5 completed on December 21, 2018 at approximately 10: 30 a.m. revealed admission date 10/05/2017. Treatment sheets reviewed dated 12/04/2018 through 12/18/2018.
12/11/2018 7:52 a.m. BP 176/88, 8:22 a.m. BP 198/98 taken by PCT, treatment sheet did not contain evidence that licensed nurse was notified of increase in BP in accordance with facility policy.
12/13/2018 treatment sheet did not contain evidence that a "INTRADIALYTIC DATA COLLECTION/ASSESSMENT" was completed at 9:42 a.m. in accordance with facility policy. "Every 30 minutes". The treatment sheet indicated and assessment was completed at 9:12 a.m. and 10:12 a.m.

Interview completed on December 20, 2018 at approximation 11:30 a.m. with EMP1 confirmed the findings.












Plan of Correction:

V543
The Facility Administrator (FA) held a mandatory in-service for all clinical Teammates (TMs) on 01/04/19 and 01/07/19. In-service included a review of Policy #1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment emphasizing: 1) Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse a minimum of every thirty (30) minutes; 2) A difference of 20mm/Hg increase or decrease from patients last intradialytic treatment BP reading will be documented and immediately reported to the licensed nurse. The licensed nurse must take appropriate action, contact physician if warranted, and follow physician orders. All findings, interventions and patient response will be documented in patient's medical record. Verification of attendance at in-service is evidenced by TMs signature on in-service sheet. The FA or designee will conduct daily audits on twenty five percent (25%) of patient treatment flow sheets for two (2) weeks, then weekly for four (4) weeks, and then monthly on ten (10%) of treatment sheets for two (2) months to verify compliance. Instances of non-compliance will be addressed immediately. The FA will review results of the audits with the Medical Director during monthly Facility Health Meeting (FHM-QAPI) with documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.