Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on August 12, 2025 through August 14, 2025, Northeast Philadelphia Dialysis was identified to have the following standard level deficiency that was determined 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:
494.62(d)(1) STANDARD
ESRD EP Training Program
Name - Component - 00
§494.62(d)(1): Condition for Coverage:
(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 every 2 years.
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.
(vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures.
Observations:
Based on a review of the facility Medical Records (MR), facility policy, and an interview with the facility administrator, the facility did not conduct fire safety drills according to facility policy for six (6) of seven (7) MRs. MR# 1, 3, 4, 5, 6, & 7.
Findings include:
A review of facility policy occurred on 8/14/25 at approximately 10:00 AM and revealed the following:
Policy titled, "Facility Emergency Management Plan 4-07-01" stated, "Training and Education...Patients...Quaterly...Fire safety Prepardness and Emergency take-off procedures..."
A review of Medical Records was conducted on 8/13/25 starting at approximately 10:15 AM and revealed the following:
MR#1 Admission date 6/5/23 did not have a fire safety drill conducted for quarter 2 of 2025.
MR#3 Admission date 4/16/21 did not have a fire safety drill conducted for quarter 2 of 2025.
MR#4 Admission date 6/5/21 did not have a fire safety drill conducted for quarter 4 of 2024 and quarter 2 of 2025.
MR#5 Admission date 4/12/16 did not have a fire safety drill conducted for quarter 4 of 2024 and quarter 2 of 2025.
MR#6 Admission date 10/17/21 did not have a fire safety drill conducted for quarter 4 of 2024 and quarter 2 of 2025.
MR#7 Admission date 12/24/24 did not have a fire safety drill conducted for quarter 2 of 2025.
An interview with the facility administrator conducted on 8/14/25 at approximately 3:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/02/25. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-07-01 "Facility Emergency Management Plan (EMP)" with emphasis on but not limited to: 1) The Facility Administrator or designee, is responsible to provide training for patients: i. On admission and annually: Facility specific response procedures; ii quarterly: Fire Safety Preparedness and Emergency take-off procedures. 2) Documentation: Patients use Reggie form "Emergency Evacuation Acknowledgment Form". Training will be kept in the medical record of all patients. Verification of attendance is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will audit one hundred percent (100%) of current patients' medical records for documentation of fire drill training and participation. Any patients needing a quarterly update will be completed by 10/13/25. The Facility Administrator or designee will audit fire drill documentation for three (3) quarters to verify compliance per policy. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed, until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on August 12, 2025 through August 14, 2025, Northeast Philadelphia 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:
494.90(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 policies/procedure, medical records (MR), hemodialysis (HD) treatment records, and interviews with the facility administrator (FA), the facility failed to follow its policy for monitoring vital signs during HD, for four (4) of seven (7) MR reviewed: MR# 2, 3, 5 & 7.
Findings include:
A review of facility policy occurred on 8/14/25 at approximately 10:00 AM and revealed the following:
Policy titled "Pre-Intra-Post-Treatment Data Collection, Monitoring and Nursing Assessment. Policy 1-03-08" stated, "Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes but is not necessarily limited to....measurement of blood pressure (BP).. sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet)..."
A review of Medical Records was conducted on 8/13/25 starting at approximately 10:15 AM and revealed the following:
MR #2. Start of Care at facility: 6/18/25.
HD (hemodialysis) Treatments on 7/30/25, 8/1/25 and 8/4/25 lists mobility status as "Ambulates-No assistance needed". Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals.
HD (hemodialysis) Treatment on 8/11/25 lists mobility status as "Ambulates- No assistance needed". Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals or post-treatment vitals.
MR#3. Start of Care at facility: 4/16/21.
HD (hemodialysis) Treatments on 7/30/25 and 8/1/25 lists mobility status as "Ambulates-No assistance needed". Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals.
HD (hemodialysis) Treatment on 8/6/15 and 8/8/25 lists mobility status as "Ambulates- No assistance needed". Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals or post-treatment vitals.
HD (hemodialysis) Treatment on 8/11/25 lists mobility status as "Ambulates- No assistance needed". Treatment did not include a standing Blood Pressure (BP) in the post-treatment vitals.
MR#5. Start of Care at facility: 4/12/16.
HD (hemodialysis) Treatment on 7/30/25, 8/1/25, 8/4/25, 8/6/25, 8/8/25 and 8/11/25 lists mobility status as "Wheelchair" Ambulatory as "Ambulatory-No assistance needed". Clinical Manager confirmed patient is able to stand. Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals or post-treatment vitals on the dates listed above.
MR#7. Start of Care at facility: 12/24/24.
HD (hemodialysis) Treatment on 8/4/25 lists mobility status as "Ambulates- No assistance needed". Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals or post-treatment vitals.
HD (hemodialysis) Treatments on 7/30/25, 8/6/25, 8/8/25 and 8/11/25 lists mobility status as "Ambulates-No assistance needed". Treatment did not include a standing Blood Pressure (BP) in the pre-treatment vitals.
An interview conducted with Facility Administrator on 8/14/25 at approximatley 3:00PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/02/25. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection Monitoring and Nursing Assessment" emphasizing but not limited to: 1) Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes but is not necessarily limited to....measurement of blood pressure (BP).. sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet. 2) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately ... The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 3) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct flowsheet audits to verify standing and sitting blood pressure readings are documented pre and post treatment, or the reason why standing reading is missing, with a sitting pressure, per policy: on twenty five percent (25%) of the flow sheets daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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