Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 8/29/2025, PDI-Ebensburg 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 completed 8/29/2025, PDI-Ebensburg was found 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:
494.80(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 a review of facility policies and procedures, medical record (MR) and staff (EMP) interviews, the facility failed to confirm the dialysis prescription treatment time for one (1) of five (5) in-center hemodialysis medical records (MR) reviewed (MR4).
Findings included:
Review of the agency policy and procedures on 8/29/2025 at approximately 2:00 PM revealed, " TITLE: PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT ...POLICY: 1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse ...2. The Nursing assessment will be performed and documented by a licensed nurse: specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN). a. The assessment includes the following components: i. Review of patient reports, data collection, complaints and response to treatment ii. Verification that machine safety checks have been completed and documented iii. Verification of prescription including machine parameters ...3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not limited to: a. Dialyzer make and model b. Treatment time ...10. If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed ... "
MR4 start of care 2/24/2025, was reviewed on 8/29/2025 at approximately 10:10 AM. A review of the patient's hemodialysis flowsheet dated 8/8/2025 through 8/25/2025 revealed the physician ordered dated 3/20/2025. The order treatment duration is listed at 3 hour and 15 minutes. The review of treatment sheet dated 8/11/2025 list the start of treatment 5:51 AM and the end treatment time at 8:52 AM. EMP1 confirmed no documentation was available to confirm the treatment time was altered per physician order.
An exit interview was conducted with the manager clinical services and group facility administrator on 8/29/2025 at approximately 2:30 PM that confirmed the above findings.
Plan of Correction:01656 PDI-Ebensburg PA CMS Core 082925
FA Joseph Kuzilla
POC Completion Date: 10/06/20256
POC Submission Date: 09/10/2025
V 503 The Facility Administrator or Clinical Coordinator held mandatory in-services for all clinical teammates starting on 09/10/2025. 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" with emphasis on but not limited to: 1) Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse ... 2) The Nursing assessment will be performed and documented by a licensed nurse: specifically, a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN). a. The assessment includes the following components: i. Review of patient reports, data collection, complaints and response to treatment; ii. Verification that machine safety checks have been completed and documented; iii. Verification of prescription including machine parameters ... 3) Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not limited to: a. Dialyzer make and model b. Treatment time ... 4) If the dialysis prescription is not being met (including dialysis flow rate or change to/inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed ... 5) All finding interventions and patient response will be documented in the patient's medical record. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will conduct flow sheet audits to verify when teammates document abnormal findings, [including but not limited to incorrect treatment time] the nurse is notified and appropriate interventions are taken as needed, and actions are documented, per policy: on twenty five percent (25%) of flowsheets 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 the 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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