QA Investigation Results

Pennsylvania Department of Health
DIALYSIS CENTER OF NORTH PHILADELPHIA
Health Inspection Results
DIALYSIS CENTER OF NORTH PHILADELPHIA
Health Inspection Results For:


There are  4 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 onsite unannounced Medicare recertification survey conducted on June 27, 2018 through June 29, 2018, Dialysis Center of North Philadelphia was identified to have the following standard level deficiency that was determined to be in substantial 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:




494.62(d)(1) STANDARD
ESRD EP Training Program

Name - Component - 00
(d)(1) Training program. The dialysis facility must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least annually. Staff training must:
(iii) Demonstrate staff knowledge of emergency procedures, including informing patients of-
(A) What to do;
(B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated;
(C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and
(D) How to disconnect themselves from the dialysis machine if an emergency occurs.
(iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and
(v) Properly train its nursing staff in the use of emergency equipment and emergency drugs.
(vi) Maintain documentation of the training.

Observations:

Based on a review of facility documentation, review of clinical records, and an interview with the Charge Nurse, the facility failed to follow its policy regarding fire and evacuation training and drills for two (2) of nine (9) active in-center hemodialysis patients. (Clinical record #'s 1, & 6)

Findings include:

Review of facility policy titled, "Disaster Policy" on June 29, 2018 at approximately 11:30 AM states, "American Renal Associates has developed written procedures for the different types of disasters that could occur such as fire, natural disasters and others. All patients are inserviced on what to do if a disaster occurs and how to evacuate the facility. This is done when the patient is admitted to the facility and on a quarterly basis thereafter. The staff will review emergency procedures with the patients, . . . On a quarterly basis, all staff will participate in fire/disaster drills that will be conducted on each patient and staff shift. . . "


1. Review of clinical record #1 on June 28, 2018 at approximately 1:00 PM revealed there was no written documentation to confirm that the fire and evacuation training and drills had been reviewed with the patient for the first quarter of 2018.

2. Review of clinical record #6 on June 29, 2018 at approximately 9:15 AM revealed there was no written documentation to confirm that the fire and evacuation training and drills had been reviewed with the patient for the first quarter of 2018.


Interview with Charge Nurse on June 29, 2018 at approximately 11:20 AM, confirmed the above findings.
















Plan of Correction:

An in-service was given to the clinic manager on 07/06/18 by the Corporate Manager of Clinical and Regulatory Services regarding patient disaster preparedness training. Per Policy: "All patients are in-serviced on what to do if a disaster occurs and how to evacuate the facility. This is done when the patient is admitted to the facility and on a quarterly basis thereafter. The staff will review emergency procedures with the patients, which include: hand cranking the machine, clamp and disconnect of the lines, evacuation routes from the facility and selection of a common meeting area outside the facility. Also, should the unit be rendered inoperable, the ARA Hotline number will be reviewed. This form will be kept in the patient's medical record and will indicate whether the patient is able to help with these procedures or not." Also per policy "On a quarterly basis, all staff will participate in fire/disaster drills that will be conducted on each patient and staff shift. The staff that participates will write their names on the drill sheet and the names of the patients who are on dialysis at the time will be written on the sheet or a patient schedule will be attached. The drill will simulate a real fire/disaster and a narrative of events will be documented. After the drill is finished, the nurse in charge will critique the drill and discuss any deficiencies noted with the staff. Disaster training will be completed on all patients by 07/13/18. The quarterly disaster training has been added to the in-service calendar and moving forward, disaster preparedness will be completed on patient admission to the facility and quarterly thereafter. Additionally, the Medical Record audit, is completed on 1/3 of records monthly so that all records are audited in a quarter. The quarterly patient disaster reviews are included in this audit. The Clinic Manager will ensure compliance by reviewing the findings of these audits and by tracking when the training is due in the Total Quality Management (TQM) minutes. The clinic manager will also review all new admissions and all patient records monthly for the next 6 months to ensure that the emergency preparedness training was completed upon admission and/or quarterly. A CM monitoring tool was developed to monitor this activity. The findings from the CM monitoring (CM monitoring tool) and audits will be brought to the monthly TQM meetings for review to ensure that all patient quarterly disaster reviews are done. All findings will be addressed at TQM meeting where additional action will be taken as deemed appropriate, such as additional training, continuing the monthly audits or if trends are identified, disciplinary action.


Initial Comments:



Based on the findings of an onsite unannounced Medicare recertification survey conducted on June 27, 2018 through June 29, 2018, Dialysis Center of North Philadelphia 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 for End-Stage Renal Disease Facilities.






Plan of Correction:




494.30(a)(4)(ii) STANDARD
IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL

Name - Component - 00
[The facility must demonstrate that it follows standard infection control precautions by implementing-
(4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-]
(ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment.



Observations:


Based on observation, review of policy and procedures, and interview with the Charge Nurse, it was determined, the facility failed to ensure infection control procedures were followed by cleaning and disinfecting the Hansen connectors for four (4) of twenty-nine (29) hemodialysis machines observed. (Machine #'s 1, 3, 6, & 26).

Findings include:

Observations were made in the in patient treatment area on June 27 and 28, 2018 between the hours of 9:30 AM and 12:30 PM .

A review of policy titled, "Disinfection of the Patient Treatment Area/Station " was conducted on June 29, 2018 at approximately 11:00 A.M states, ". . . Description: To properly clean and disinfect the dialysis machine and chair to prevent cross contamination due to multiple patient uses. The dialysis machine and patient chair will be thoroughly cleaned with 1:100 bleach solution between patients and at the end of the day. . . Procedure: 6. Between each patient treatment, the patient treatment area/station including the external portion of the machine and chair are to be wiped down with the washcloth soaked in 1:100 bleach solution. . ."

1. On June 27, 2018 at approximately 10:28 AM, it was observed that Patient Care Technician #1 did not disinfect the Hansen connectors on dialysis machine # 1, prior to the start of the next dialysis treatment.

2. On June 27, 2018 at approximately 10:38 AM, it was observed that Patient Care Technician #1 did not disinfect the Hansen connectors on dialysis machine # 6, prior to the start of the next dialysis treatment.

3. On June 27, 2018 at approximately 10:45 AM, it was observed that Registered Nurse #1 did not disinfect the Hansen connectors on dialysis machine # 3, prior to the start of the next dialysis treatment.

4. On June 28, 2018 at approximately 10:30 AM, it was observed that Patient Care Technician #2 did not disinfect the Hansen connectors on dialysis machine # 3, prior to the start of the next dialysis treatment.

5. On June 28, 2018 at approximately 11:14 AM, it was observed that Registered Nurse #2 did not disinfect the Hansen connectors on dialysis machine # 26, prior to the start of the next dialysis treatment.

An interview with the Charge Nurse was conducted on June 28, 2018 at approximately 1:25 PM. The Charge Nurse confirmed the above findings and informed the surveyor that the above policy is current.



Based on review of facility documentation, review of facility policy and procedure and interview with the bio-medical manager, the facility failed to properly document the Dialysis Machine Disinfection Log for twenty-eight (28) of thirty-two (32) dialysis machines. (Dialysis Machines #'s 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, & 30 ).
Findings include:
A review of the policy titled "Technical Operations Manual" conducted on June 28, 2018, at approximately 1:30 P.M. states, " . . . IV. Section Four: Disinfection Standards . . . A. Dialysis Machines: 1. All dialysis machines will be disinfected at the end of each operating day in accordance with the specific manufacturer's instructions. . ."1. A review of the Dialysis Machine Disinfection Log was conducted on June 28, 2018, at approximately 12:30 PM. For the date May 24, 2018, the following dialysis machines had no documentation that they had been been disinfected by both heat and acid on this date: Dialysis Machine #'s 20, 21, 22, 24, & 25.

2. A review of the Dialysis Machine Disinfection Log was conducted on June 28, 2018, at approximately 12:30 PM. The following dialysis machines, on the specified dates, had no documentation that they had been been disinfected by acid: Machine #'s 20, 21, & 25 on January 3, 2018; Machine #'s 13, 14, 19, 20, 21, & 25 on January 5, 2018; Machine #'s 13, 14, 16, 17, 19, 20, & 21 on January 6, 2018; Machine #'s 4, 5, 6, 8, 18, 20, 21, & 25 on January 11, 2018; Machine #'s 5, 6, 18, & 21 on January 18, 2018; Machine #'s 7, 13, 14, 19, 20, 24, & 25 on January 22, 2018; Machine #'s 14, 15, 19, 21, & 23 on January 25, 2018; Machine #'s 3, 7, 14, 19, & 21 on February 15, 2018; Machine #'s 3, 8, 9, 15, 20, 22, 24, & 25 on March 3, 2018; Machine #'s 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 24, & 25 on March 3, 2018; Machine #'s 11, 13, 14, 15, & 16 on April 23 23, 2018; and Machine #'s 26, 27, 28, 29, & 30 on May 11, 2018;
An interview with the bio-medical manager was conducted on June 28, 2018 at approximately 2:10 PM. The bio-medical manager confirmed the above findings and that the above cited policy was current.






.










Plan of Correction:

An in-service will be completed for all Direct Patient Care (DPC) staff by 7/23/18 by the Clinic Manager regarding the cleaning of the dialysis station with 1:100 bleach solution, including the Hanson connectors.
Per Policy: "Machines, chairs (put in trendelenburg), pillows, saline prime buckets, sharps containers, TVs, TV arms, IV poles, BP tubing, BP basket, stethoscopes, Hanson connectors, O2 concentrators, are to be cleaned with 1:100 bleach solution between every patient treatment."
During the in-service it was stressed that special care must be taken when disinfecting the external portion of the machine to clean the entire surface, including the Hanson connectors with a 1:100 bleach solution prior to set up for the next patient and at the end of the day. This is on the monthly infection control audit which will be increased to weekly for 6 weeks by an assigned Direct Patient Care (DPC) staff member and by the Clinic Manger and monthly thereafter by an assigned DPC staff member. All breaks in Infection Control, including not wiping Hanson connectors, will be immediately addressed by the Clinic Manager. The Clinic Manager will ensure compliance through direct observation and through review of the Infection Control Audits at least monthly prior to the Total Quality Management (TQM) meeting. All findings will be addressed at the monthly TQM meeting where additional action will be taken as deemed appropriate by the committee, such as additional training, continuing the weekly audits or if trends are identified, disciplinary action.
An in-service will be completed for all Direct Patient Care (DPC) staff by 07/17/18 by the Facility Technical Manager (FTM) on machine disinfection and proper documentation on the Dialysis Machine Disinfection Log at the end of the day. Per Policy "All dialysis machines will be disinfected at the end of each operating day in accordance with the specific manufacturer's instructions." Also per policy: "to properly clean and disinfect the dialysis machine to prevent cross contamination due to multiple patient uses. The dialysis machine should undergo an acid cleaning daily when using bicarbonate concentrates during dialysis. The dialysis machine will be rinsed with vinegar daily to dissolve the precipitate formed by bicarbonate solution. Acid Cleaning is not a disinfectant agent but only a precipitate removal agent. Dialysis machines that utilize a heat disinfection system will be disinfected with bleach weekly." During the in-service it was stressed that proper documentation of the machine disinfection must be done at the end of each day on the Dialysis Machine Disinfection Log (A description of the log and how to complete the log was reviewed during the in-service). Each DPC staff member is responsible for documenting of the machines which they disinfected. The Clinic Manager will review the Dialysis Machine Disinfection log daily for 2 weeks then weekly for an additional 4 weeks (total 6 weeks) then monthly thereafter by the facility technical manager. A CM monitoring tool was developed to monitor the daily/weekly reviews. The Clinic Manager (CM) is to be notified of any missed documentation on the log and the FTM and CM will address this with the DPC staff responsible for disinfection of the dialysis machine. The CM will ensure compliance through review of the log as indicated above and monthly prior to the Total Quality Meeting (TQM). The log and CM monitoring tool will be brought to the monthly TQM meeting for review. All findings will be addressed at the monthly TQM meeting where additional action will be taken as deemed appropriate, such as additional training, continuing the weekly audits or if trends are identified, disciplinary action.


494.80(a)(2) STANDARD
PA-APPROPRIATENESS OF DIALYSIS RX

Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:

(2) Evaluation of the appropriateness of the dialysis prescription,




Observations:

Based on review of clinical records, review of policies and procedures and interview with the Charge Nurse, it was determined the facility failed to ensure the physician's orders for duration of treatment were followed for three (3) of nine (9) in-center hemodialysis clinical records reviewed. (Clinical record #'s 3, 5, & 6).

Findings include:

1. A review of policy titled, "Patient Treatment Information " on June 29, 2018 at approximately 11:15 AM states, " a. Early termination of Treatment. It is highly discouraged by the staff of this facility to have a patient reduce his prescribed dialysis treatment time. In order for a patient to receive an adequate dialysis treatment, the dialysis time must be adhered to by the patient. . . if the patient chooses to do this he/she must take full responsibility for any consequences that may occur. An Against medical Advice (AMA) form must be completed and signed by the patient each time that the patient requests that the prescribed treatment be shortened. . . The patient's attending physician must be informed, if the request exceeds 10 minutes. . ."

1. Review of medical record #3 on June 28, 2018 at approximately 1:35 PM revealed a physician order, dated 05/05/18, for the patient to be dialyzed for three (3) hours per day, three (3) days per week ( Tuesday, Thursday, & Saturday).

Review of the dialysis flow sheets revealed on 05/05/18, the patient was dialyzed for a total of two (2) hours and thirty-eight (38) minutes.

There was no documentation on these dates the physician was notified of these findings, and no record of an Against Medical Advice (AMA) form signed by the patient.

2. Review of medical record #5 on June 29, 2018 at approximately 9:10 AM revealed a physician order, dated 02/16/18, for the patient to be dialyzed for four (4) hours per day, three (3) days per week ( Monday, Wednesday, & Friday).

Review of the dialysis flow sheets revealed on 05/07/18, the patient was dialyzed for a total of three (3) hours and ten (10) minutes; on 05/11/2018, the patient was dialyzed for a total of three (3) hours and nine (9) minutes; on 05/16/2018, the patient was dialyzed for a total of three (3) hours and twenty-seven (27) minutes; on 05/18/2018, the patient was dialyzed for a total of three (3) hours and fifteen (15) minutes; and on 05/25/2018, the patient was dialyzed for a total of three (3) hours and thirty (30) minutes.

There was no documentation on these dates the physician was notified of these findings, and no record of an Against Medical Advice (AMA) form signed by the patient.

3. Review of medical record #6 on June 29, 2018 at approximately 9:15 AM revealed a physician order, dated 04/23/18, for the patient to be dialyzed for four (4) hours per day, three (3) days per week ( Monday, Wednesday, & Friday).

Review of the dialysis flow sheets revealed on 05/04/18, the patient was dialyzed for a total of three (3) hours and twenty (20) minutes; on 05/09/2018, the patient was dialyzed for a total of two (2) hours and twenty (20) minutes; on 05/18/2018, the patient was dialyzed for a total of two (2) hours and twenty (20) minutes; on 05/25/2018, the patient was dialyzed for a total of two (2) hours and forty-five (45) minutes; on 05/28/2018, the patient was dialyzed for a total of three (3) hours; and on 05/30/2018, the patient was dialyzed for a total of three (3) hours and fifteen (15) minutes.

There was no documentation on these dates the physician was notified of these findings, and no record of an Against Medical Advice (AMA) form signed by the patient.




An interview conducted with the Charge Nurse on June 29, 2018 at approximately 11:40 AM confirmed the above findings, and the Charge Nurse informed the surveyor that the above cited policy is current.



























Plan of Correction:

An in-service will be completed on all Direct Patient Care (DPC) staff by 7/23/18 by the Clinic Manager (CM) to reinforce that the duration of the dialysis treatment must be followed per physician order. Per policy: "It is highly discouraged by the staff of this facility to have a patient reduce his prescribed dialysis treatment time. In order for a patient to receive an adequate dialysis treatment, the dialysis time must be adhered to by the patient. If the patient wants to come off of dialysis early, the patient must be informed of the risks associated with doing this, which could include death. If the patient chooses to do this he/she must take full responsibility for any consequences that may occur. An Against Medical Advice (AMA) form must be completed and signed by the patient each time that the patient requests that the prescribed treatment time be shortened. Documentation must also be made on the patient's treatment sheet. If this is a repeated request, it becomes a problem that must be discussed at the monthly care plan meetings. The patient's attending physician must be informed, if the request exceeds 10 minutes. If a patient knows ahead of time that his treatment time will have to be shortened for one particular day, every effort will be made by the staff to have the patient dialyze at another time or on a different day. If the patient informs the staff at the beginning of the treatment, adjustments will be made to the treatment to accommodate the shortened time." All patients will be educated in the month of July on risks associated with shortened treatment time. The patient will receive a copy of the education, sign an acknowledgement of the education, and the signed acknowledgement will be filed in the patient's medical record. During the in-service the DPC staff was instructed that each time a patient chooses to shorten their treatment time, and Early Termination of Treatment (a.k.a. AMA) form must be signed by the patient and the charge nurse (CN) must be notified. The CN must inform the patient of the risks associated with doing this and document the education on the treatment sheet or in the nurse progress notes. The CN will review the treatment sheets at the end of the day to ensure that all treatment times are completed per physician order and that an Early Termination of Treatment (a.k.a. AMA) is signed each time the treatment is shortened. The CN will document all AMA's on the AMA Report in the clinical portal and notify the physician of the shortened treatment. A CN monitoring tool has been developed to monitor this activity and will be utilized for the next 3 months. The CM will ensure compliance through review of the CN monitoring tool, and will spot check treatment sheets one day a week for the next 3 months to ensure all patients complete their treatment times as ordered and that an AMA form is completed when indicated and the physician notified. A CM monitoring tool was developed to monitor this activity. The CM will review the CN rounding tool and the AMA Report monthly prior to the Total Quality Meeting (TQM). Any patient noted to have excessive AMA's will be referred to the Interdisciplinary Team (IDT) forassessment through the Comprehensive Assessment/Plan of Care (CA/POC). All findings above will be reviewed in the monthly TQM meeting where additional action will be taken as deemed appropriate by the committee such as continuation of the monitoring tools, further education or disciplinary action.


494.80(b)(1) STANDARD
PA-FREQUENCY-INITIAL-30 DAYS/13 TX

Name - Component - 00
An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session.



Observations:


Based on a review of clinical records, policies and procedures and an interview with the Charge Nurse, the facility failed to ensure an initial "Comprehensive Interdisciplinary Assessment " was completed within thirty (30) days or thirteen (13) outpatient hemodialysis treatments of the initial hemodialysis treatment for two (2) of nine (9) hemodialysis patients. (Clinical record # 4 & 5)

Findings include:

A review of facility policy titled, " Patient Assessment" on June 29, 2018 at approximately 11:25 AM states, " Each new admission to the dialysis facility is to have an individualized and comprehensive assessment completed by the interdisciplinary team within 30 days or 13 treatments after their first outpatient dialysis treatment at the facility. . . The purpose of the assessment is to gather criteria to develop the patient's treatment plan and expectations of care. . ."

1. A review of the clinical record #4 was conducted on June 28, 2018, at approximately 1:45 P.M. The first hemodialysis treatment at this facility for the patient was March 29, 2018. The documentation showed an initial comprehensive interdisciplinary assessment was developed and implemented on May 25, 2018, fifty-seven (57) days after the first outpatient dialysis session.

2. A review of the clinical record #5 was conducted on June 29, 2018, at approximately 9:10 A.M. The first hemodialysis treatment at this facility for the patient was February 16, 2018. The documentation showed an initial comprehensive interdisciplinary assessment was developed and implemented on April 8, 2018, fifty-one (51) days after the first outpatient dialysis session.



An interview was conducted with the Charge Nurse on June 29, 2018 at approximately 11:30 A.M. The Charge Nurse confirmed the above identified findings, and informed the surveyor that the above cited policy is current.






























Plan of Correction:

The Corporate Clinical and Regulatory Manager met with the Interdisciplinary Team (IDT) on 07/06/18 to review the time frame for completing the Initial Comprehensive Assessment and Plan of Care (CA/POC). Per Policy: "Each new admission to the dialysis facility is to have an individualized and comprehensive assessment completed by the interdisciplinary team within 30 days or 13 treatments after their first outpatient dialysis treatment at the facility and a comprehensive reassessment must occur within 3 months after the completion of the initial assessment. The purpose of the assessment is to gather criteria to develop the patient's treatment plan and expectations of care. The team must allow sufficient time following the patient's admission for each discipline to fully assess the patient, including collecting appropriate data, interviewing the patient, and evaluating the patient's response to dialysis treatment." During the in-service it was stressed that it is never acceptable to go beyond the 30 day/13 treatment required time frame for completion of the initial assessment. A tracking tool is in place to monitor when CA/POCs are due. The Clinic Manager is responsible for completing this tool, placing new admissions on the tool and making sure that CA/POCs are completed within 30 days after admission. All recent admission records have been reviewed and added to the CA/POC tracking tool. The CM will monitor all new patient admissions weekly for the next 3 months to ensure the IDT completes the CA/POC within 30 days or 13 treatments, whichever comes first. A CM monitoring tool has been developed to monitor this activity. The Clinic Manager will ensure compliance through completion and review of this tool monthly prior to the Total Quality Management Meeting (TQM). The CM monitoring tool and the CA/POC tracking tool will be reviewed at the monthly TQM meeting where additional action will be taken as deemed appropriate by the committee such as continuation of the monitoring tools, further education or disciplinary action.


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 review of clinical records, review of facility policy and procedure, and interview with the Charge Nurse, the medical director did not ensure that staff followed the correct policy and procedure regarding permanent discharge from the facility for two (2) of two (2) clinical records reviewed. (Clinical record #'s 10 & 11)

Findings include:

Review of policy titled, "Admission, Transfer and Discharge Policy" on June 29, 2018 at approximately 11:20 AM states, ". . . e. Discharge or Transfer. a patient would be permanently discharged from the facility for the following reasons: transplantation, transfer, withdrawal from dialysis or death. In any of these events, a Discharge Summary form must be completed which must include, if applicable, a Prognosis and Final Diagnosis. The Discharge Summary must be completed and signed by the physician within 30 days of the patient's discharge from the facility. . . "


1. A review of the clinical record #10 was conducted on June 29, 2018, at approximately 10:45 A.M. The first hemodialysis treatment at this facility for the patient was November 14, 2017 and the patient expired on January 1, 2018. The documentation showed the Discharge Summary wasn't completed and signed by the physician within 30 days of the patient's discharge from the facility. The Discharge Summary was completed and signed by the physician on May 31, 2018.

2. A review of the clinical record #11 was conducted on June 29, 2018, at approximately 10:55 A.M. The first hemodialysis treatment at this facility for the patient was October 22, 2015 and the patient expired on January 4, 2018. The documentation showed the Discharge Summary wasn't completed and signed by the physician within 30 days of the patient's discharge from the facility. The Discharge Summary was completed and signed by the physician on May 31, 2018.

An interview was conducted with the Charge Nurse on June 29, 2018 at approximately 11:45 A.M. The Charge Nurse confirmed the above identified findings.







Plan of Correction:

An in-service was given to the Clinic Manager, Charge Nurse and Medical Director on 7/6/18 by the Regional Vice President of Operations to review the responsibilities of the medical director with emphasis on the policy for completing the Discharge Summary. Per Policy "A patient would be permanently discharged from the facility for the following reasons; transplantation, transfer, withdrawal from dialysis or death. In any of these events, a Discharge Summary form must be completed which must include, if applicable, a Prognosis and Final Diagnosis. The Discharge Summary must be completed and signed by the physician within 30 days of the patient's discharge from the facility. This form should be the top sheet on the patient's discharged record." During the in-service it was emphasized that the Discharge Summary must be completed by the Charge Nurse and Medical Director and must be signed by the Medical Director within 30 days of discharge. All discharge records have been reviewed to ensure a Discharge Summary was completed and signed by the medical director. The Clinic Manager (CM) will review all medical records of discharged patients weekly for 3 months to ensure the discharge summaries are complete and signed by the physician within 30 days. A CM monitoring tool has been developed to monitor this activity. The CM monitoring tool will be reviewed at the monthly Total Quality Meeting (TQM) where additional action will be taken as deemed appropriate by the committee such as continuation of the monitoring, further education or disciplinary action.