Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on June 14, 2022 through June 16, 2022, Cheltenham 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 June 14, 2022 through June 16, 2022, Cheltenham Dialysis, was identified to have the following standard level deficiencies that were 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(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 a review of medical records (MR), policies and procedures and an interview with the Administrator and Nurse Manager, the facility failed to ensure an initial "Comprehensive Interdisciplinary Assessment/Plan of Care" was completed within thirty (30) days or thirteen (13) outpatient hemodialysis treatments of the initial hemodialysis treatment for one (1) of seven (7) hemodialysis patients. (MR # 2)
Findings include:
A review of the Facility Policy 1-14-01 titled " Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,"was conducted on June 15, 2022 at approximately 11:30 AM. and stated "An initial Plan of Care, based on the findings from the comprehensive assessment will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines."
A review of Medical Records was conducted on June 15, 2022 from approximately 9:30 AM until 12:00 PM and revealed the following:
MR #2. The first hemodialysis treatment at this facility for the patient was 4/27/22. The medical record did not show an initial comprehensive interdisciplinary assessment/ Plan of Care was developed . At the time of review has been forty-nine (49) days after the first outpatient dialysis session.
An interview was conducted with the Administrator and Nurse Manager on 6/16/22 at approximately 1:00 P.M. The Administrator confirmed the above identified findings, and informed the surveyor that the above cited policy is current.
Plan of Correction:Review policy 1-14-01 with all IDT teammates in an in-service. IDT to discuss new patients during weekly Core Team meetings. RD will view new patients in Falcon Application and trigger upcoming Plans of Care. IDT will keep track of this using our CMT Tool. Covering SW, RD, and CNM will collaborate to ensure completion. FA will monitor compliance by auditing Falcon and CMT Tool weekly. Follow-up will be communicated during weekly Core Team and monthly FHM. RD will print POC after completed and will ensure patient meetings are scheduled and all signatures required are obtained at the time of meeting. This process was reviewed with MD and documented in GB.
494.80(d)(2) STANDARD
PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO
Name - Component - 00
In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted-
At least monthly for unstable patients including, but not limited to, patients with the following:
(i) Extended or frequent hospitalizations;
(ii) Marked deterioration in health status;
(iii) Significant change in psychosocial needs; or
(iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis.
Observations:
Based on a review of facility policy, medical record review and interview with the Facility Administrator and the Nurse Manager, it was determined that the facility failed to follow its policy pertaining to completing a monthly comprehensive reassessment/Plan of Care of an unstable patient for four (4) of seven (7) Medical Record (s) reviewed (MR #1, 4, 5 & 7)
Finding include:
A review of the Facility Policy 1-14-01 titled " Interdisciplinary Team (IDT) Patient Assessment and Plan of Care,"was conducted on June 16, 2022 at approximately 11:30 AM. that states "Purpose: To provide guidance for the development of patient assessment and plan of care for IDT teammates. Policy: Assessment: . . . 7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: . . . At least monthly for unstable patients . . . Plan of Care: Monthly (unstable patients) Assessment: Monthly until patient is determined by interdisciplinary team to be stable . . "
A review of Medical Records was conducted on June 15, 2022 from approximately 9:30 AM until 12:00 PM and revealed the following:
MR #1: The patient's starting date at the facility was 6/4/19. The following care plans were in patient's chart as "unstable": 12/21/21, 10/27/21, 8/24/21, 4/6/21, 7/1/20, 3/12/20, 2/11/20. There were missing monthly unstable care plans from 4/2020-6/2020, 8/2020-3/2021, 5/2021-7/2021, 9/2021, 11/2021, and from 1/2022-6/2022 (current). The medical record did not contain any reassessments stating they were stable.
MR #4: The patient's starting date at the facility was 12/24/19. The medical record contained an "unstable" care plan dated 3/30/22. There were missing monthly unstable care plans from 4/2022-6/2022 (current). The medical record did not contain any reassessments stating they were stable.
MR #5: The patient's starting date at the facility was 12/19/18. The medical record contained "unstable" care plans dates 3/15/21 and 6/21/21. There were missing monthly unstable care plans from 4/2021-5/2021, and 7/2021-6/2022 (current). The medical record did not contain any reassessments stating they were stable.
MR#7: The Patient's starting date at the facility was 6/14/18. The medical record contained an "unstable" care plan dated 5/10/21. There were missing monthly unstable care plans from 6/2021-6/2022 (current). The medical record did not contain any reassessments stating they were stable.
An interview was conducted with the Facility Administrator and Nurse Manager on 6/16/22 at approximately 1:00 PM. who confirmed the above identified findings, and informed the surveyor that the above cited policy is current.
Plan of Correction:FA review policy 1-14-01 with all IDT teammates in an in-service.IDT to report out at FHM monthly unstable patients and a POC along with reassessment is evaluated for updates and changes and reflected in FHR documentation. RD and MSW will keep a shared list of patients who are unstable and will update accordingly- adding and removing patients as needed- review process with MD and developed a plan of action in GB.
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/procedures, dialysis treatment documentation, medical records (MR), and administrative interview, the facility failed to follow it's policy for post-treatment data assessment and licensed nurse documentation for two (2) of five (5) incenter hemodialysis MR's reviewed, (MR #3 & 5)
Findings include:
Review of policy occurred on 6/15/22 at approximately 11:30 AM which revealed:
Policy 1-03-08 titled, "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" states, "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 patient temperature, measurement of blood pressure (BP)...heart or pulse rate...patient weight, respiration rate, patient's report of well-being..vascular access status. The nursing assessment will be performed and documented by a licensed nurse..includes the following components: review of patient reports, data collection, complaints and response to treatment, verification machine safety checks...prescription, review of documentation for accuracy, completion and patient data, a physical assessment...Intradialytic (during treatment) Data Collection/Assessment...abnormal findings or findings outside of any patient specific physician ordered paramaters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary....The license nurse notifies the physician..as needed of changes in patient status...Post treatment Data Collection/Assessment: The PCT of licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. If an abnormal finding(s) or concern is identifed post treatment, this needs to be reported to the license nurse. The licensed nurse will assess the patient prior to discharge. Licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician is necessary prior to discharge of the patient from the facility...Abnormal findings: Blood Pressure-Intradialytic: difference of 20 mm/Hg increase or decrease from patient's last Intradialytic treatment BP reading..."
A review of MR's was conducted on 6/15/22 from approximately 9:30 am to 12:00 pm.
MR #3, Start of Care: 5/18/20.
Treatment Record for: 6/3/22:
No post treatment data collection is documented.
MR #5, Start of Care: 12/19/18
Treatment Record for: 5/23/22
7:01 AM (Intradialytic): Blood Pressure (BP) 211/124. PCT documentation: "Patient watching television"
7:26 AM: BP 207/117. Documentation by Nurse "Recheck"
No post treatment nursing assessment documented.
Treatment Record for: 6/8/22
6:13 AM (Intradialytic): BP 209/119
6:31 AM: BP 201/117
7:01 AM: BP 193/109
No post treatment nursing assessment documented.
An interview with the facility administrator and nurse manager on 6/16/22 at approximately 1:00 PM confirmed the above findings.
Plan of Correction:FA review policy 1-03-08 with ALL teammates. Training In-Service was completed and signed off on by all in attendance. FA assigned RN team to review daily any patients with abnormal findings to ensure documentation was completed. FA assigned CNM to be responsible for monitoring and auditing Falcon for documentation and compliance. Weekly, CNM will discuss this in facility's weekly core team meeting. We will document patients with abnormal findings and how was it rectified in our CMT tool.
494.110 STANDARD
QAPI-COVERS SCOPE SERV/EFFECTIVE/IDT INVOL
Name - Component - 00
The dialysis facility must develop, implement, maintain, and evaluate an effective, data-driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team. The program must reflect the complexity of the dialysis facility's organization and services (including those services provided under arrangement), and must focus on indicators related to improved health outcomes and the prevention and reduction of medical errors. The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS.
Observations:
Based on a review of the facility's quality assurance and performance improvement (QAPI) program and an interview with the facility administrator and nurse manager, the facility meetings did not include all members of the facility's interdisciplinary team for five (5) of five (5) QAPI meeting minutes/data reviewed and the facility failed to meet every 30 days.
Findings include:
A review of the QAPI meeting minutes/data/documentation and QAPI meeting sign in sheets was reviewed on 6/16/22 at approximately 9:45 AM.
On the following QAPI dates the following individuals are marked as "Did not attend" or there is nothing written next to their name:
1/18/22: No Medical Social Worker (MSW) or Bio-Medical Technician (Bio-Med)
2/25/22: No Registered Dietitian
3/25/22: No Peritoneal Dialysis RN, MSW, Biomed, Dietitian, Hemodialysis RN
5/20/22: No Peritoneal Dialysis RN
5/31/22: No Peritoneal Dialysis RN, MSW
There was no documentation of a meeting held between 3/25/22-5/20/22 (56 days).
An interview with the administrator and nurse manager on 6/16/22 at 1:00 PM confirmed the above findings. The Administrator stated the meeting that was documented on 5/20/22 took place on 4/29/22 but was not able to give any documentation of a meeting sign-in sheet confirming this.
Plan of Correction:FA review policy 1-14-06 with IDT and develop a process of static consistency or completion of FHM and all required IP's, updates, etc. FA to hold IDT members accountable to same. FA held a training in-service for all IDT members. FA to ensure ALL CQI committee members are available and present during meeting as well as printing and signing signature page during FHM. Review process with MD and IDT in GB.
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