Initial Comments:
Based on the findings of an onsite unannounced complaint investigation conducted on April 17, 2023, Waverly 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:
494.140(b)(1) STANDARD
PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS
Name - Component - 00
(1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must-
(i) Be a full time employee of the facility;
(ii) Be a registered nurse; and
(iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis.
Observations:
Based on a review of facility documents, an interview with the Manager of Clinical Services and the Facility Administrator, the agency failed to ensure that a full-time nurse manager, who is responsible for nursing services, is employed by the facility.
Finding include:
A review of the employee roster was conducted on 04/17/2023 at approximately 11:00 AM. The list of employees did not include a nurse manager.
A review of the staffing schedules for the months of March and April, 2023 was conducted on 04/17/2023 starting at approximately 11:10 AM. There was no nurse manager listed on the schedule.
An interview was conducted with INT#2 on 04/17/2023 at approximately 11:30 AM. The surveyor asked about the role of the nurse manager as there was no nurse manager present throughout the investigation. INT#2 responded that on 3/29/2023, a new "Nurse in Charge of Nursing Services" (NICNS) was appointed by the Governing Board. The NICNS is intended to fulfill the role of the nurse manager. The surveyor asked if the NICNS was on site for the surveyor to speak to. INT#2 stated that the NICNS is only on site about once per week and as needed to participate in facility meetings. INT#2 stated that the NICNS has management responsibilities at other DaVita facilities. The surveyor asked for a copy of the Job Description for the NICNS. INT#2 stated that the job description titled, "Registered Nurse In-Center Hemodialysis (ICHD) Expert," which had already been provided to the surveyor, was the job description for the NICNS position.
There was no evidence provided that the NICNS was a full time employee of the facility, nor was there any other evidence that the facility employed a full-time nurse manager.
An interview conducted with the Manager of Clinical Services and the Facility Administrator on April 17, 2023 starting at 1:00 PM confirmed the above findings.
Plan of Correction:Revised V684
Members of Governing Body met to review the Statement of Deficiencies resulting from survey conducted 4/17/2023 and developed a plan of correction. Members of the Governing Body including the Medical Director, Facility Administrator and Regional Operations Director reviewed the requirements for Nurse Manager which includes being a full-time employee of the facility; be a registered nurse, and have at least twelve (12) months of experience in clinical nursing, and an addition six (6) months of experience in providing nursing care to patients on maintenance dialysis. On 3/30/23, a qualified nurse was appointed interim Nurse Manager. This Interim Nurse Manager will be resigning effective on 5/26/2023. The facility has secured a Registered Nurse that will assume Nurse in Charge of Nursing Services for Waverly Dialysis, effective on 5/22/2023. This nurse meets the Conditions of Coverage: 1) being a full time employee of the facility, 2) being a Registered Nurse, 3) have at least 12 months of experience in clinical nursing and 6 months of experience in providing nursing care to patients on maintenance dialysis. The Facility Administrator will review the job description and have an orientation to the facility on the first day of employment and the evidence will be maintained in the teammate file. The Governing Body is responsible to ensure a qualified Nurse Manager is present in the facility to be able to complete all duties described in the job description. The plan of corrections will be monitored during Governing Body meetings until the transition is completed. This plan of correction will also be reviewed during Quality Assurance and Performance Improvement meetings known as Facility Health Meetings and the Facility Administrator will report progress, as well as any barriers to maintaining compliance, with supporting documentation included in meeting minutes. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.
494.180(b)(1) STANDARD
GOV-STAFF # & RATIO MEET PT NEEDS
Name - Component - 00
The governing body or designated person responsible must ensure that-
(1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients;
Observations:
Based on a review of staffing schedules, employee roster, hemodialysis seating schedule, facility policy, hemodialysis treatment records, an interview with the Facility Administrator and Manager of Clinical Services, the agency failed to assure that there was a sufficient number of qualified and trained staff on duty while patients are on dialysis in-center to include lunch breaks, and to deliver routine care, patient assessment and monitoring per facility policy, and to promptly respond to and address patient needs for one (1) of one (1) MR reviewed: MR#1.
Findings include:
A review of the employee roster revealed the following current clinical positions: One (1) contract labor Registered Nurse (RN) who services the facility full-time, One (1) contract labor RN who services the facility part time, 1 Part Time Licensed Practical Nurse (LPN), 7 Patient Care Technicians, and 2 Patient Care Associates. Additional staffing support may be provided by DaVita "float" RN's (RN's who work at multiple DaVita facilities) who are either employed or contracted by DaVita. There are currently no full time or part time RN's employed by the Waverly facility.
A review of the staffing schedule for the month of April 2023 was conducted on April 17, 2023 at approximately 11:15 AM. On 04/12/2023 and 04/13/2023, one nurse was scheduled for the shift.
An interview was conducted with the Facility Administrator (INT#1) on 04/17/2023 at approximately 12:00 PM to discuss staffing. The surveyor noted that on 04/12/2023 and 04/13/2023, there was only one nurse scheduled. On 04/12/2023, nineteen (19) patients received In Center Hemodialysis (ICHD) during the early morning shift, and sixteen (16) patients received ICHD during the mid morning shift. On 04/13/2023, nineteen (19) patients received ICHD during the early morning shift, and fifteen (15) patients received ICHD during the mid morning shift. The surveyor asked INT#1 how the nurse takes rest breaks in situations where s/he is the only nurse on the unit. INT#1 responded that "she doesn't."
A review of facility policy Policy 1-03-08 CWOW-Pre-Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment, conducted on April 17, 2023 at approximatley 10:15 AM states in part, "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);" and, "The nurse will assess the patient pre-treatment as warranted by the patient's condition;" and "The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation;" and, "Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately (refer to "abnormal findings" section in this policy). The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary;" and "All findings, interventions, and patient response will be documented in the patient's medical record;" and "The PCT or 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 identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge;" and, "The following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record .....patient report/complaints and/or teammate observation of ....cramping."
A review of the Medical Record and Hemodialysis Treatment Records was conducted on April 17, 2023 starting at approximately 11:45 AM. The start of care is indicated below.
MR#1: SOC 12/05/2018. Hemodialysis (HD) Treatment Records for 03/27/2023, 03/29/2023, 03/31/2023, 04/03/2023, 04/05/2023, 04/07/2023, 04/10/2023, 04/12/2023, and 04/14/2023 were reviewed and the following was found:
03/27/2023: On the Intradialytic Section of the HD Treatment Record, the Patient Care Technician (PCT) documented at 1033 that the treatment was terminated, the patient reported cramping, 200 milliliters (ml) saline was given, RN was made aware, and the patient's blood pressure (BP) was 128/77. Twenty minutes later at 1053, the PCT documented on the Intradialytic Section of the HD Treatment Record that the patient was (still) reporting cramping, BP dropped to 96/43, 300 ml was saline given, RN was made aware, oxygen was given at 2 liters/minute. There were no further notes or data on the Intradialytic Section of the HD Treatment Record after 1053. On the Treatment Nurse Assessment Section of the HD Treatment Record, the post assessment is untimed. There is a post assessment note which states, "Patient's BP dropped after treatment. Patient cramping. PCT gave 300 ml and 2l of oxygen. Patient's pressure increased and patient felt better and felt ok to leave." The submission status date/time for the Post Treatment Assessment completed by the RN was timed 2:23 PM. There is no evidence on the HD Treatment Record or in the Electronic Medical Record Nursing Notes to support that the RN assessed the patient at 10:33 AM or anytime thereafter.
03/31/2023: There is no Post-Treatment Nurse Assessment documented on the HD Treatment Record..
04/03/2023: The HD treatment was initiated at 0638. The Pre-Treatment Nurse Assessment was not documented until 1:39 PM/1:41 PM
04/12/2023: The HD treatment was started at 6:51 AM. The Pre-Treatment Nurse Assessment was not documented until 5:57 PM/6:01 PM. The RN noted "late entry: assessments and medications done at start of treatment but not documented." Treatment ended at 11:05 AM. The Post-Treatment Nurse Assessment was documented at 6:03 PM. The RN noted "late entry: patient stable at time of discharge unable to chart until now due to needs of the facility with other patients and responsibilities." A review of the staffing schedule for 04/12/2023 found that only one nurse was scheduled for the shift and therefore, the nurse was unable to perform a timely assessment of the patient given that the nurse was covering nineteen (19) pateints on the early morning shift, and sixteen (16) patients on the mid morning shift.
An interview with the Manager of Clinical Services and the Facility Administrator conducted on April 17, 2023 starting at 1:00 PM confirmed the above findings.
Plan of Correction:V757
The challenges faced by the entire dialysis community - especially from a nurse/staffing perspective - is well known to both CMS and the local survey offices. At all times the facility does its best to ensure that patient treatment days and times are not disrupted by these staffing shortages. A Governing Body was held to develop a staffing contingency plan to ensure permanent adequate clinical coverage. The Governing body agreed to hire and train additional staffing to meet the standards expected to achieve safe dialysis.
The current staffing consists of one (1) full-time contracted RN, one (1) full-time LPN, and seven (7) full-time CCHT. There are two (2) RN's and one (1) PCT in training.
The Facility Administrator is working closely with Medical Director, Regional Operational Divisional Manager and sister clinics to get help with additional staffing needs. The Facility Administrator is also in the process trying to hired additional staffing for the unit. Staffing schedules will be reviewed for any day facility is out of compliance and will be discussed with the Medical Director at monthly Facility Health Meetings with supporting documentation included in the meeting minutes.
The facility will continue to post requests for experienced and non-experienced positions in addition, the Facility Administrator will counsel any teammate for excessive absenteeism and tardiness in accordance to DaVita's attendance policy. This plan of correction will be reviewed during Facility Health Meetings and the Facility Administrator will report progress, as well as any barriers to maintaining compliance, with supporting documentation included in meeting minutes. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.
494.180(e) STANDARD
GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED
Name - Component - 00
The facility's internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services.
The grievance process must include-
(1) A clearly explained procedure for the submission of grievances.
(2) Timeframes for reviewing the grievance.
(3) A description of how the patient or the patient's designated representative will be informed of steps taken to resolve the grievance.
Observations:
Based on a review of facility policies, grievance log, medical record, an interview with MR#1, and an interview with the Facility Administrator (FA) and Manager of Clinical Services, the agency failed to provide the patient with steps taken to resolve a grievance, and failed to follow the agency's grievance policy.
Findings include:
A review of Policy 3-01-06 Patient Grievance; Policy 3-10-06A Addressing Patient Grievances, DaVita Teammates; and the Patient Grievance Procedure that is provided to and signed by patients was reviewed on April 17, 2023 starting at approximately 10:45 AM.
Policy: 3-01-06 Patient Grievance states in part, "If the patient's grievance cannot be resolved by the FA, the Regional Operations Director (ROD) and the Medical Director will be notified, and a formal grievance conference will be coordinated. This grievance conference should occur within 10 days of receipt of the grievance. If the patient grievance cannot be resolved by the ROD and /or Medical Director, the Divisional Vice President will be notified. The Divisional Vice President will discuss the grievance with the patient and take appropriate action towards a solution, if possible. The Divisional Vice President along with the Group General Counsel will take the necessary steps to review and, if necessary, investigate the grievance. The Divisional Vice President will issue a written, final decision to the patient within 10 days of the grievance conference."
Policy: 3-01-06A Addressing Patient Grievances: DaVita Teammates reads in part, "The DaVita teammate receiving the grievance should report the grievance to the charge nurse, facility administrator or social worker. Based on the nature of the complaint, the appropriate member of the interdisciplinary team will discuss the grievance with the patient and take appropriate action towards a solution, if possible; "the FA will meet with the patient to discuss the grievance and take appropriate action towards a solution, if possible. If the grievance is not resolved, the patient should be invited to a grievance conference. The grievance conference should be coordinated to occur within 10 days of receipt of the complaint;" and "The patient will be invited to participate in a formal grievance meeting attended by the facility administrator, social worker, medical director, and regional operations director."
The "Patient Grievance Procedure" document that is provided to and intended to be signed by patients at the time of admission was generated from the facility's system on 04/17/2023 for the purpose of reviewing the Pennsylvania (PA) Department of Health (DOH) complaint phone number/hotline number that is currently being provided to patients. It was found that the document contains a generic phone number to the PA DOH. The PA DOH complaint hotline phone number is not contained on the form.
An interview was conducted with MR#1 on 04/17/2023 at approximately 9:15 AM. MR#1 stated that he had concerns about safety and staffing. MR#1 stated that s/he had concerns about the competency of a particular nurse. MR#1 also stated that s/he had concerns about safety as it relates to the facility's staffing, specifically when only one nurse is scheduled for the shift. MR#1 stated that the concerns were relayed to INT#1,
An interview was conducted with INT#2 on 04/17/2023 at approximately 09:45 AM. INT#2 stated that s/he is familiar with the concerns of MR#1.
A review of the grievance log was conducted on 04/17/2023 at approximately 11:40 AM. A grievance from MR#1 was documented on 03/27/2023, pertaining to a concern about the competency of a nurse. After discussion between MR#1 and INT#1, the documentation stated that MR#1 seemed satisfied with the discussion. A resolution to the complaint was documented on 3/28/2023. On 04/03/2023, a second grievance was voiced by MR#1 regarding the same issue. There was no documented resolution to the complaint. It was also documented that MR#1 did not seem satisfied with the response. Additionally, there was no documentation in the grievance log on 03/27/2023 or 04/03/2023 of MR#1's concern regarding safety, i.e., when only one nurse is scheduled for the shift.
An interview was conducted with the INT#1 and INT#2 on 04/17/2023 at approximately 12:00 PM. The surveyor asked INT#1 about MR#1 ' s concerns regarding safety due to staffing, i.e., having only 1 RN scheduled on the unit periodically. The surveyor asked if, per the facility's grievance policy, the social worker had been involved in the situation, or if the issue had been escalated to the ROD, or if there had been a grievance conference to address MR#1 ' s concern. INT#2 stated that none of those measures had yet occurred.
A review of the hardcopy and electronic medical records was conducted on 04/17/2023 starting at 11:45 AM. There was no documentation in either of the medical record formats concerning the MR#1's grievance.
An interview conducted with the Facility Administrator and the Manager of Clinical Services on April 17 2023 starting at 1:00 PM confirmed the above findings.
Plan of Correction:V765
The Facility Administrator or designee held mandatory in-services for all clinical and support teammates beginning on DATE. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-01-06A "Addressing Patient Grievances: DaVita Teammates" and Policy 3-01-06 "Patient Grievance" with emphasis on, but not limited to:
1. Addressing Patient Grievances: 1) Patient grievances may be verbal or written. They may be submitted directly to a facility teammate or submitted to the DaVita Guest Services department. 2) All complaints/grievances should be documented on the facility Patient Grievance Log.
2. Patient Grievance: 1) all patients of this facility have the right to have their grievances handled promptly and courteously. 2) Grievances may be reported to a DaVita teammate either verbally or in writing. Grievances should be submitted to a DaVita teammate within 30 days of the date of the incident or when the person filing the grievance on behalf of the patient became aware of the issue. 3) The Facility Administrator (or her/his designee) is to discuss the grievance with the patient, investigate and take appropriate action towards a solution, if possible. This discussion should occur within 10 days of receipt of the grievance. If the patient's grievance cannot be resolved by the FA, the ROD and Medical Director will be notified and a formal grievance conference will be coordinated. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee will audit the Patient Grievance Log to verify adequate documentation and timing of grievance resolution is being met: weekly for two (2) weeks with expected compliance rate of ninety five percent (95%), and monthly for two (2) months with expected compliance rate of one hundred percent (100%). Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation in the meeting minutes. The Facility Administrator is responsible for ongoing compliance with this plan of correction.
|