Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on July 27, 2022 through July 29, 2022, U S Renal Care Hanover 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 survey conducted on July 27, 2022 through July 29, 2022, U. S. Renal Care Hanover Dialysis was identified to have the following standard level deficiency that was 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:
494.150(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 policy/procedure, medical records (MR), and interview with clinic administrator the clinic failed to ensure staff had patients complete and sign an against medical advice (AMA) form when terminating treatments early for one (1) of two (2) records reviewed. MR #1.
Findings include:
Review of policy: # C-AD-0530, completed 7/27/22 between approximately 1:30PM and 3:00PM revealed: Against Medical Advice; Purpose: "To provide a means of tracking patients that make decisions against medical advice (AMA)". PROCEDURE: "1. The following step will be followed for any patients who decides to act against medical advice: a. the AMA form will be used for patients who: i. Refuse to complete prescribed treatment;... DOCUMENTATION: 3. the AMA form will be maintained in the patient's medical record".
Review of medical records completed on 7/27/22 between approximately 10:00AM and 2:00PM revealed the following:
MR #1; Admit date: 4-27-22; Dialysis orders as of 6-13-22: M-W-F, Optiflux 180NRE, 3K 2.5 Ca BFR 300 DFR 500 EDW 51 kg 3 hour duration.
Treatment note dated 7/22/22, showed a treatment length of 1: 45, starting at 12:43PM and ending at 2:40PM. Post-dialysis comments, "patient requested sign-off". No AMA form signed by the patient was noted in the record.
Treatment note dated 7/15/22, showed a treatment length of 2:47, starting at 11:14AM and ending at 2:01PM. Post-dialysis comments, "Arrived late for treatment and requested off early for another appointment... patient requested sign-off". No AMA form signed by the patient was noted in the record.
Treatment note dated 7/13/22, showed a treatment length of 1: 45, starting at 8:13AM and ending at 8:59AM. Post-dialysis comments, "Patient arrived 30 minutes late for treatment. Became disruptive, yelling at someone on the telephone and then at staff when asked to lower her voice. Demanded to be taken off early... patient requested sign-off". No AMA form signed by the patient was noted in the record.
Treatment note dated 6/17/22, showed a treatment length of 1: 45, starting at 11:00AM and ending at 1:34PM. Post-dialysis comments, "patient requested sign-off". No AMA form signed by the patient was noted in the record.
Interview with the clinic administrator completed on 7/29/22 at approximately 1:00PM confirmed the above findings.
Plan of Correction:FA or designee to educate clinical staff regarding policy "C-AD-0530 Against Medical Advice". Education emphasized that an AMA form is to be completed and filed for every treatment that a patient makes the decision to not complete full treatment. Staff to notify the CN if the patient reports that they will not be completing their full treatment. CN is to ensure that AMA is printed and completed. FA or designee will complete audits on all treatments to ensure that an AMA is signed if needed. The audit will be completed 3 times per week for 4 weeks. If the Governing Body deems that substantial improvement has occurred, audits will continue weekly x 4 and then monthly x 2. Audit results will be reviewed with staff and during monthly QAPI meetings. The Governing Body will review QAPI meeting minutes to ensure continued compliance. Identified non-compliance will result in additional staff in-servicing and increased frequency of auditing.
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