QA Investigation Results

Pennsylvania Department of Health
COMPASS HOME DIALYSIS
Health Inspection Results
COMPASS HOME DIALYSIS
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite initial Medicare certification survey conducted on May 3, 2018, Freedom Dialysis LLC 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 May 3, 2018, Freedom Dialysis LLC was identified to have the following standard level deficiencies, 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:




494.130 STANDARD
LAB-CLIA LABS/MEET NEEDS OF PTS

Name - Component - 00
The dialysis facility must provide or make available, laboratory services (other than tissue pathology and histocompatibility) to meet the needs of the ESRD patient. Any laboratory services, including tissue pathology and histocompatibility must be furnished by or obtained from, a facility that meets the requirements for laboratory services specified in part 493 of this chapter.


Observations:


Based on a review of the facility's compliance manual and an interview with the chief operating officer and administrator, the facility did not make laboratory services available by not obtaining a stat lab agreement.

Findings include:

A review of the facility compliance manual was conducted on May 4, 2018 at 11:30 AM.
The manual did not contain a stat lab agreement.

An interview with the chief operating officer on May 3, 2018, at 11:40 AM stated that the stat lab agreement was to be added as an addendum to the hospital agreement and that it is in progress with the Bryn Mawr Hospital out reach manager.





Plan of Correction:

CMS PLAN OF CORRECTION
ID PREFIX TAG Provider's Plan of Correction
Date of Completion 5/16/2018
V-0676 A stat Lab amendment to the Mainline Hospital dba Mainline Health Laboratory was requested on 4/19/18. This was reviewed in the Governing Body Meeting held on April 19, 2018. (See GB meeting minutes dated 4/20/2018).


The Plan of Correction for the statement of deficiencies was reviewed in Freedom's Governing Body Meeting. THE GB was updated on the status of the stat Lab Agreement. Date of Completion 5/15/2018


The facility received the signed stat lab agreement from Mainline Hospital dba Mainline Health Laboratory 5/16/2018. The Director of Operations will be responsible for any additional follow-up. (See copy of Stat Lab Agreement attached to this Plan of Correction). Date of Completion: 5/16/2016



494.180 STANDARD
GOV-ID GOV BODY W/FULL AUTHORITY/RESPONS

Name - Component - 00
The ESRD facility is under the control of an identifiable governing body, or designated person(s) with full legal authority and responsibility for the governance and operation of the facility. The governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patients ' personal and property rights, and to the general operation of the facility.


Observations:


Based on a review of the facility compliance manual and an interview with the administrator and chief operating officer, the governing body did not enforce rules relative to the general operation of the facility by not obtaining a back up dialysis agreement with another area dialysis facility.

Findings include:

A review of the facility compliance manual was conducted on May 4, 2018 at 11:30 AM.
The manual did not contain a an agreement with another area dialysis facility whereby patients of the back up facility could treat the facility's patients if the facility were unable to provide services for a period of time.

An interview with the administrator and chief operating officer on May 4, 2018 at 1:30 PM confirmed that the facility had not obtained a backup dialysis agreement.






Plan of Correction:

V-0751 The Plan of Correction for the statement of deficiencies was reviewed in Freedom's Governing Body Meeting on May 15, 2018. (See Governing Body Meeting Minutes 5/15/2018).

The Freedom Director of Operations in conjunction with the Chief Nursing Officer was assigned responsibility for obtaining the chronic dialysis facility back-up agreement.

A chronic dialysis facility back-up agreement has now been established with Dialysis Care, Inc. (DCI), located at 3300 Henry Avenue, Philadelphia, PA. (See copy of the agreement attached to this Statement of Deficiencies/Plan of Correction). 5/15/2018