QA Investigation Results

Pennsylvania Department of Health
CLINICAL NEPHROLOGY ASSOCIATES, LTD.
Health Inspection Results
CLINICAL NEPHROLOGY ASSOCIATES, LTD.
Health Inspection Results For:


There are  17 surveys for this facility. Please select a date to view the survey results.

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



Initial Comments:

This report is the result of a State licensure survey conducted on December 29, 2020, and completed on January 21, 2021, at Clinical Nephrology Associates, Ltd. It was determined the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Ambulatory Care Facilities, Annex A, Title 28, Part IV, Subparts A and F, Chapters 551-573, November 1999.
















Plan of Correction:




553.25 (1-6) LICENSURE
Discharge Criteria

Name - Component - 00
553.25 Discharge Criteria

A patient may only be discharged from an ASF if the following physical status criteria are met:
(1) Vital signs. Blood pressure, heart rate, temperature and respiratory rate are within the normal range for the patient's age or at preoperative levels for that patient.
(2) Activity. The patient has regained preoperative mobility without assistance or syncope, or function at his usual level considering limitations imposed by the surgical procedure.
(3) Mental status. The patient is awake, alert or functions at his preoperative mental status.
(4) Pain. The patient's pain can be effectively controlled with medication.
(5) Bleeding. Bleeding is controlled and consistent with that expected from the surgical procedure.
(6) Nausea/vomiting. Minimal nausea or vomiting is controlled and consistent with that expected from the surgical procedure.

Observations:

Based on review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure patients were evaluated for discharge criteria as per the facility's policy prior to discharge for two of five medical records reviewed (MR3 and MR4).

Findings include:

A review of facility policy "Sedation/Analgesia" last updated September 2020 revealed "4.6.1 Criteria for discharge based on patient's pre-procedure baseline condition and capabilities. 4.6.1.1 Stable vital signs for at least 30 minutes. 4.6.1.2 Able to swallow and cough. 4.6.1.3 No respiratory distress. 4.6.1.4 Minimal nausea, vomiting, dizziness and pain ... 4.6.1.7 No significant bleeding or drainage from procedure site."
A review on December 29, 2020, of MR3 admitted on December 11, 2020, for Catheter Replacement for Fistula revealed no evidence of documentation that bleeding was evaluated prior to discharge.

An interview conducted on December 29, 2020, at 12:01 PM with EMP1 confirmed MR3 did not contain evidence of documentation that bleeding was evaluated prior to discharge. The facility was unable to provide the medical record documentation requested by the survey team.

A review on December 29, 2020, of MR4 admitted on August 18, 2020, for Thrombectomy revealed no evidence of documentation that pain was evaluated prior to discharge.

An interview conducted on December 29, 2020, at 12:30 PM with EMP1 confirmed MR4 did not contain evidence of documentation that pain was evaluated prior to discharge. The facility was unable to provide the medical record documentation requested by the survey team.





























Plan of Correction:


553.25- Discharge criteria has been reviewed.
Policy #2013 Patient Discharge and Recovery and Policy #2026 Sedation/Anesthesia have been re-evaluated and confirmation of policy that Criteria for discharge meets Regulation 553.25.
The Facility Administrator reviewed Policy # 2013-3.3 The procedure site should be examined immediately before discharge to ensure that there is no bleeding or drainage. After review it has been determined the policy is compliant and meet the required criteria within regulation 553.25. The Facility Administrator also reviewed Policy# 2026-4.6.14- Minimal Nausea, vomiting, dizziness and pain. & 4.6.1.7- No significant bleeding or drainage from procedure site. After review it has been determined the policy is compliant and meet the required criteria within regulation 553.25.
All registered nurses will be educated to ensure the proper criteria, including bleeding and pain assessments, are evaluated and met before patient discharge. Discharge Criteria, which include bleeding assessment and pain assessment, are to be checked by Registered Nurses within the Electronic Medical Record (EMR) as part of the nursing assessment. The Registered Nurse will verify and document in the EMR that the discharge criteria has been met.
Registered Nurses and Physicians will acknowledge understanding of the above policies and criteria by signing the In-service attendance sheet after education is provided.
The Center Manager and Director of Nursing will monitor compliance by performing a medical record audit of 100% of the charts for 30 days. After 30 days, if no deficiencies are identified the Director of Nursing will continue auditing 10% of the medical records for 60 days. If no deficiencies, the audit will close.
If there are deficiencies present, the Center Manager will re-evaluate, re-educate and restart the audit with 100% of the charts for 30 days. After 30 days, if no deficiencies are identified the Director of Nursing will continue auditing 10% of the medical records for 60 days. If no deficiencies, the audit will close.
The results of the audit will be reported to the QA Committee Quarterly which reports to the Governing Body. These meetings will be scheduled in April 2021 to report the progress of the EMR Audit. Any continuing deficiencies will be addressed by the QA Committee. Progress will be reported during meetings and documented to reflect in the QA meeting minutes, as well as, the Governing Body Meeting Minutes which will be scheduled in April of 2021.
The Center Manager, Medical Director and Director of Nursing will be responsible for the Implementation and oversight of this Plan of Correction.




555.22 (c)(1-5) LICENSURE
Surgical Services - Preoperative Care

Name - Component - 00
555.22 Pre-operative Care

(c) Written instruction for preoperative procedures, which have been approved by the medical
staff, shall be given to the patient or responsible person, and shall include:
(1) Applicable restrictions upon food and drink before surgery
(2) Special preparations to be made by the patient
(3) The required proximity of the patient to the ASF for a specific time following surgery if applicable.
(4) An understanding that the patient may require admission to the hospital in the event of medical need.
(5) The requirement that, upon discharge of a patient who has received sedation or general anesthesia, a responsible person shall be available to escort patient home. With respect to patients who receive local or regional anesthesia, a medical decision shall be made regarding whether such patients require a responsible person to escort them home.


Observations:

Based on review of facility Bylaws, medical records (MR) and interview with staff (EMP1), it was determined the facility failed to provide evidence of documentation that written preoperative instructions, approved by the medical staff, were provided to patients for five of five medical records reviewed (MR1, MR2, MR3, MR4 and MR5).

Findings include:

Review of the facility's ByLaws, revealed "... . The Governing Body of the Medical Staff shall be the Body of Managers of the Company. The Body of Managers oversees the business and governance of the Center."

A review on December 29, 2020, of MR1 admitted on December 8, 2020, for Vascular Mapping revealed no evidence of documentation that written preoperative instructions, approved by the medical staff, were provided to the patient or patient representative.

A review on December 29, 2020, of MR2 admitted on July 7, 2020, for Vein and Vascular Mapping revealed no evidence of documentation that written preoperative instructions, approved by the medical staff, were provided to the patient or patient representative.

A review on December 29, 2020, of MR3 admitted on December 11, 2020, for Catheter Placement for Fistula revealed no evidence of documentation that written preoperative instructions, approved by the medical staff, were provided to the patient or patient representative.

A review on December 29, 2020, of MR4 admitted on October 18, 2020, for Thrombectomy revealed no evidence of documentation that written preoperative instructions, approved by the medical staff, were provided to the patient or patient representative.

A review on December 29, 2020, of MR5 admitted on November 17, 2020, for Vessel Mapping revealed no evidence of documentation that written preoperative instructions, approved by the medical staff, were provided to the patient or patient representative.

An interview conducted on December 29, 2020, at 12:44 PM with EMP1 confirmed MR1, MR2, MR3, MR4 and MR5 did not contain evidence of documentation that written preoperative instructions, approved by the medical staff, were provided to the patient or patient representative. EMP1 stated "There appears to be no preoperative instructions documented in the medical records and we do not have a facility policy to address the provision of written preoperative instructions for patients prior to procedures."


Cross Reference:
555.24(f)(1-7) Surgical Services - Postoperative care

























Plan of Correction:

555.22- PreOp Care:
Policy #2066 Pre Operative Instructions Policy
The Facility Administrator reviewed current policies for preoperative instructions. It has been identified that the Preoperative Instructions were within Policy# 2002- Eligibility Criteria.
Pre Operative Instructions have been reviewed with the Medical Director. The Center Manager and Medical Director identified a need for a Pre Operative Instruction Policy. Policy# 2066 has been created for Pre Operative Instructions. Written documentation will be generated and reflect documentation in the Patient Medical Record.
All Preoperative instructions have been re-evaluated, policy created, and an upgrade to the Electronic Medical Record ensuring Pre Operative Instructions are compliant with Regulation 552C. Receipt by patient will be generated in the Electronic Medical Record.
All Access Coordinators and Registered Nurses will be educated to ensure that proper preoperative instructions are given to the patient prior to the procedure. All Access Coordinators and/or Registered Nurses will review preoperative instructions with patient/responsible adult and confirm understanding.
Access Coordinators and Registered Nurses will acknowledge understanding Policy# 2066 and confirm education on understanding the preoperative instructions review with the patient/responsible adult by signing the In-service attendance sheet after education is provided.
The Center Manager and Director of Nursing will monitor compliance by performing a medical record audit of 100% of the charts for 30 days. After 30 days, if no deficiencies are identified the Director of Nursing will continue auditing 10% of the medical records for 60 days. If no deficiencies, the audit will close.
If there are deficiencies present, the Center Manager will re-evaluate, re-educate and restart the audit of 100% of the charts for 30 days. After 30 days, if no deficiencies are identified the Director of Nursing will continue auditing 10% of the medical records for 60 days. If no deficiencies, the audit will close.
The Center Manager and Director of Nursing will be responsible for the Implementation and oversight of this Plan of Correction.
Policy# 2066 has been created, reviewed, and approved by the Medical Director. It has been confirmed to meet Regulation 555.22. The policy will be reviewed and approved by the QA Committee and the Governing Body during the April 2021 meetings.



555.24 (f)(1-7) LICENSURE
Surgical Services - Postoperative Care

Name - Component - 00
555.24 Post Operative Care

(f) Protocols approved by the medical staff shall be established for instructing patients in self-care after surgery, including written instructions which, at a minimum shall include the following:

(1) The symptoms of complications associated with procedures performed
(2) An explanation of prescribed drug regime, including directions for use of any medications.
(3) Limitations and restrictions on activities of the patient, if necessary.
(4) Specific phone number to be used by the patient, if a complication or question arises.
(5) Date for follow-up or return visit
(6) Instructions on the care of dressing and wounds
(7) Instructions on dietary restrictions

Observations:

Based on a review of facility policy, medical records (MR) and interview with staff (EMP), it was determined the facility failed to ensure written discharge instructions were given to the patients or patient's representative for one of five medical records reviewed (MR2).

Findings include:

A review of facility policy "Discharge Instructions" last updated March 12, 2019, revealed "2. Policy: All patients being discharged from the center shall receive written instructions that have been explained to the patient and his/her care partner (responsible adult). The patient and his/her care partner shall sign receipt of the instructions once they understand them... 4.3 Discharge instructions must be signed by the patient or family to acknowledge understanding of said instructions. A copy of the discharge instructions is placed in the patient's medical record and a copy is given to the patient/family."

A review on December 29, 2020, of MR2 admitted on July 7, 2020, for Vein and Vascular Mapping revealed no evidence of documentation that written discharge instructions were given to the patient or patient's representative.

An interview conducted on December 29, 2020, at 12:44 PM with EMP1 confirmed MR2 did not contain evidence of documentation that written discharge instructions were given to the patient or patient's representative.


Cross Reference:
555.22(c)(1-5) Surgical Services - preoperative
















Plan of Correction:

555.24- Post Operative Care:
Policy #2011- Discharge Instructions
The Facility Administrator reviewed, re-evaluated, and confirmed Policy #2011 to reflect compliance with Regulation 555.24.
The Facility Administrator and the Medical Director identified a need for additional Discharge Instructions for patients who do not undergo an invasive procedure. Non-Invasive Procedure Discharge Instructions have been created to ensure compliance for all patients to receive discharge instructions. The Non-Invasive Discharge Instructions address continuing with the patient's regular diet, medications should be discussed with patient's healthcare provider should there be changes, patients should continue their regular dialysis treatment as scheduled. Patients are also instructed to follow up with their Nephrologist should there be any questions or issues. Patients that have a vein mapping will be discharged with Vein Mapping Discharge Instructions. Patients who do not undergo any procedure will also be given Non-Invasive Discharge Instructions to inform patients to continue with dialysis.
Registered Nurses and Physicians will acknowledge understanding of Policy# 2011 and also understanding that every patient will receive discharge instructions by signing the In-service attendance sheet after education is provided.
The Center Manager and Director of Nursing will monitor compliance by performing a medical record audit of 100% of the charts for 30 days. After 30 days, if no deficiencies are identified the Director of Nursing will continue auditing 10% of the medical records for 60 days. If no deficiencies, the audit will close.
If there are deficiencies present, the Center Manager will re-evaluate, re-educate and restart the audit by performing a medical record audit of 100% of the charts for 30 days. After 30 days, if no deficiencies are identified the Director of Nursing will continue auditing 10% of the medical records for 60 days. If no deficiencies, the audit will close.
The results of the audit will be reported to the QA Committee Quarterly which reports to the Governing Body. These meetings will be held in April 2021. Any continuing deficiencies will be addressed by the QA Committee. Progress of the audit will be reported during meetings and documented to reflect in the QA meeting minutes, as well as, the Governing Body Meeting Minutes which will be scheduled to meet in April 2021. The Medical Director approved the Non-Procedure Discharge Instruction document.
The Non-Invasive Procedure Discharge Instructions have been presented to the Medical Staff, QA Committee and Governing Body for Review/Approval. QA Committee and Governing Body meetings will be scheduled in April 2021.
The Medical Director, Center Manager and Director of Nursing will be responsible for the Implementation and oversight of this Plan of Correction.




555.24 (g) LICENSURE
Surgical Services - Postoperative

Name - Component - 00
555.24 Post Operative Care

(g) Patients shall be discharged only upon the written signed order of a practitioner.


Observations:

Based on review of facility policy, medical record (MR), and interview with staff (EMP), it was determined the facility failed to ensure a patient was discharged from the facility based upon a physician's written discharge order for one of one medical record reviewed (MR2).

Findings include:

A review of facility policy "Discharge Instructions" last updated March 12, 2019, revealed "3.1 The discharge order must be written by the surgeon, attending physician and/or attending anesthesiologist... 3.7.2 The nurse will verify the discharge order with the physician's order sheet."

A review on December 29, 2020, of MR2 admitted on July 7, 2020, for a Vein and Vascular Mapping procedure revealed no written discharge order by the physician.

An interview conducted on December 29, 2020, at 12:44 PM with EMP1 confirmed there was no evidence of documentation in MR2 of a written discharge order.















Plan of Correction:

555.24- Post Operative Care:
Policy #2011- Discharge Instructions
The Facility Administrator reviewed, re-evaluated, and confirmed Policy #2011 to reflect compliance with Regulation 555.24.
All Medical staff and Registered Nurses will be educated to ensure the proper physician's order is evaluated and signed before patient discharge. The Registered Nurse will verify the signed discharge order is in place before patient is discharged. This will be documented and will reflect in the patient's medical record.
Registered Nurses and Physicians will acknowledge understanding of Policy# 2011 and discharge criteria of a written discharge order signed by a physician for every patient. Participation and understanding will be verified by Physicians and Registered Nurses signing the attendance sheet after education is provided.
The Center Manager and Director of Nursing will monitor compliance by performing a medical record audit of 100% of the charts for 30 days. After 30 days, if no deficiencies are identified the Director of Nursing will continue auditing 10% of the medical records for 60 days. If no deficiencies, the audit will close.
If there are deficiencies present, the Center Manager will re-evaluate, re-educate and restart the audit of 100% of the charts for 30 days. After 30 days, if no deficiencies are identified the Director of Nursing will continue auditing 10% of the medical records for 60 days. If no deficiencies, the audit will close.
The results of the audit will be reported to the QA Committee Quarterly which reports to the Governing Body. These meetings will be scheduled in April 2021. Any continuing deficiencies will be addressed by the QA Committee. Progress of the audit will be reported during meetings and documented to reflect in the QA meeting minutes, as well as, the Governing Body Meeting Minutes. These meetings will be scheduled in April 2021.
The Medical Director and Center Manager will be responsible for the Implementation and oversight of this Plan of Correction.