QA Investigation Results

Pennsylvania Department of Health
DIALYSIS CARE CENTER MECHANICSBURG, LLC
Health Inspection Results
DIALYSIS CARE CENTER MECHANICSBURG, LLC
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced Medicare survey conducted October 24, 2018 for the purpose of expanding services to include home hemodialysis training and support, Dialysis Care Center Mechanicsburg, Llc. was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Subparts A, B, C, and D: Conditions for Coverage for End-Stage Renal Disease Facilities. Approval for home hemodialysis training and support recommended upon approval of an acceptable plan of correction.







Plan of Correction:




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 review of medical records, facility policy, and an interview with the facility administrator, the facility failed to ensure an initial comprehensive assessment was conducted on all new patients (that is, all admissions to a dialysis facility), within the first 30 calendar days, for one (1) of one (1) home hemodialysis patient medical records (MRs) reviewed. (MR#1).

Findings:

A review was conducted of facility policy on October 24, 2018 at approximately 11:00 a.m. Policy HDS-AD-100-007 'Comprehensive Assessment and Plan of Care' 'Frequency of Comprehensive Assessment and Plan of Care' 'New Patients' state "Patients new to dialysis will have a comprehensive assessment completed by the interdisciplinary team and a Plan of Care developed and implemented within later of 30 calendar days or 13 outpatient hemodialysis sessions beginning with the first outpatient dialysis session".


A review of medical records was conducted on October 24, 2018 between approximately 9:00 a.m. - 12:30 p.m. Patients admission date is listed below:

MR#1 Date of admission 8/8/18: Patients initial comprehensive interdisciplinary comprehensive assessment was completed on 9/28/18. Fifty one (51) days after admission.

An interview with the facility administrator on October 24, 2018 at approximately 12:50 p.m. confirmed the above findings.













Plan of Correction:

The Clinical Nurse Manager will in-service and review with all clinical employees on Policy # HDS-AD-100-007: Comprehensive Assessment & Plan of Care, HDS-MR-900-004: Nutrition Monthly Progress Update, and Social Work Responsibilities. This in-service and review will be conducted by 11/30/18 and yearly there after.

Employees were instructed to: 1) Follow frequency of Comprehensive Assessment and Plan of Care as stated per policy. 2)Complete all Care Plans and monthly notes for each discipline as stated per policy. 3) Have all disciplines sign all Care Plans or IDT's as stated per policy. 4) Complete a Medical Record Audit of Care Plans as stated per policy. 5) A tracking tool was developed to track each discipline. Each discipline will be given a copy of the tracking tool monthly by the 3rd of each month by the Center Director I=or their designee.

The Nurse Manager or designee will conduct audits on random charts weekly for 1 week then monthly as needed or as stated per policy.
Results of audits will be reviewed by the Nurse Manager with the Medical Director during the next monthly QAPI and the Governing Body have reviewed approved and discusses all corrections.

The Clinical Area Manager will be responsible for implementing and monitoring of the plan to ensure compliance.


494.100(a)(3) STANDARD
H-TRAIN CONTENT INCLUDES ER PREP HOME PTS

Name - Component - 00
The training must-
(3) Be conducted for each home dialysis patient and address the specific needs of the patient, in the following areas:
(i) The nature and management of ESRD.
(ii) The full range of techniques associated with the treatment modality selected, including effective use of dialysis supplies and equipment in achieving and delivering the physician's prescription of Kt/V or URR, and effective administration of erythropoiesis-stimulating agent(s) (if prescribed) to achieve and maintain a target level hemoglobin or hematocrit as written in patient's plan of care.
(iii) How to detect, report, and manage potential dialysis complications, including water treatment problems.
(iv) Availability of support resources and how to access and use resources.
(v) How to self-monitor health status and record and report health status information.
(vi) How to handle medical and non-medical emergencies.
(vii) Infection control precautions.
(viii) Proper waste storage and disposal procedures.





Observations:


Based on review of medical records, facility policy, and an interview with the facility administrator, the facility failed to ensure the training conducted for a new home dialysis patient included proper waste storage and disposal procedures for one (1) of one (1) home hemodialysis patient medical records (MRs) reviewed. (MR#1).

Findings:

A review was conducted of facility policy on October 24, 2018 at approximately 11:00 a.m. Policy 'Home Dialysis Patient Education and Training Policy' 'Home Program Education and Training' section M states "The following topics will be included in the Home Training Program: ........... Proper waste storage and disposal procedures".

A review of medical records was conducted on October 24, 2018 between approximately 9:00 a.m. - 12:30 p.m. Patients admission date is listed below:

MR#1 Date of admission 8/8/18: Patients 'Home Dialysis Training Checklist' was provided with date range of 8/15/18 - 9/27/18. This checklist did not include 'Proper waste storage and disposal procedures" in the "Skills" column.
No other documentation was provided to show this area of training was completed. Received email from facility administrator on 10/25/18 at approximately 12:07 a.m. with an attachment containing a blank 'Independent HHD Skills Checklist'. The 'Operation of the NxStage Cycler' section #15 of this blank form does contain a section which contains "Properly Disposal of Medical Waste".

An interview with the facility administrator on October 24, 2018 at approximately 12:50 p.m. confirmed the above findings.









Plan of Correction:

The Clinical Nurse Manager will in-service and review with all clinical employees on Policy #HDSIC-650-020: Needles and Sharps Safety by 10/31/18.

Nurse Manager or designees will conduct a 100% audit for patient's medical waste training. The Nurse Manager to complete monthly checklist to ensure that all items, audits and reports are completed monthly on proper handling of medical waste by 10/31/18 and by the end of the last week of each month.

Results of audits will be reviewed by the Nurse Manager with the Medial Director during the next monthly QAPI and the Governing Body have reviewed approved and discussed all corrections.

The Clinical Are Manager will be responsible for implementing and monitoring of the plan to ensure compliance.


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 facility policy, review of medical records, and an interview with facility administrator, the facility failed to ensure newly admitted patients had a minimal evaluation completed by a registered nurse (RN), prior to initiating treatment for immediate needs which contained the minimal elements of nursing standards of care for new hemodialysis patients for one (1) of one (1) medical records (MR) reviewed (MR#1).

Findings include:

A review was conducted of facility policy on October 24, 2018 at approximately 11:00 a.m. Policy HDS-AD-100-008 'Admission Policy' 'Policy' section E states "The registered nurse will meet with the patient new to dialysis to perform an initial nursing assessment prior to initiation of treatment".

A review of medical records was conducted on October 24, 2018 between approximately 9:00 a.m. - 12:30 p.m. Patients admission date is listed below:

MR#1 Date of admission 8/8/18: Patient treatment flow sheet dated 8/8/18 reveals patients initial dialysis treatment. Patient treatment began at "08:45" hours. An untitled form with no date/time listed was provided to show an initial assessment was conducted by a registered nurse prior to first treatment. A separate form (not pertaining to this patient) labled 'Initial Assessment' was provided by the administrator as an example of "another" form used for the initial registered nurse evaluation. This form has a column which lists the date/time when completed.

An interview with the facility administrator on October 24, 2018 at approximately 12:50 p.m. confirmed the above findings.















Plan of Correction:

The Clinical Nurse Manager will in-service and review with all employees on the Policy #HDS-AD-100-008: Admissions Policy, and #HDS-MR-900-010 Home Program Medical Record Audit Policy by 10/31/18 and then yearly with competencies in October or as needed.

Employees were instructed to:
1)Complete all appropriate paperwork prior to admission as stated per policy.
2) Complete all consent forms prior to initiation of dialysis as stated per policy.
3)Complete Initial Assessment as stated per policy.
4)Complete annual H&P as stated per policy.
5)Complete chart audit reviews if 10% or a minimum of five medical records quarterly as stated per policy.


The Nurse Manager or designee will conduct audits on random charts daily for 1 week then 3 per week for 3 weeks then monthly thereafter.

Results of audits will be reviewed by the Nurse Manager with the Medical Director during monthly QAPI meetings and the Governing Body has reviewed approved and discusses all corrections.

The Clinical Area Manager will be responsible for implementing and monitoring of the plan to ensure compliance.