Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on August 23, 2021 through August 25, 2021, BMA of Easton 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 August 23, 2021 through August 25, 2021, BMA of Easton 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:
494.90(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, medical records (MR), dialysis treatment documentation, observational tour, and an interview with the facility administrator, medical director, and director of operations, the facility failed to follow it's policy for reporting and documentation of abnormal findings pre, post, and during dialysis for two (2) of five (5) medical records reviewed (MR #3 and MR #4).
Findings include:
A review of policy titled "Patient Assessment and Monitoring" on August 24, 2021 at approximately 12:30 PM states for "During Treatment", "The Registered Nurse will assess/reassess any findings addressed pre or during treatment as needed." Policy states for "Post Treatment", "If any changes or abnormal findings in the patient's condition, vital signs, or vascular access are observed or reported by the patient, the PCT/LPN MUST report the changes in the patient condition to a registered nurse who will further assess the patient prior to discharge after the treatment." Policy states for "Monitoring During Treatment", "Report to the Nurse: systolic blood pressures greater than 180 mm/Hg; diastolic blood pressure greater than 100 mm/Hg; blood pressure less than or equal to 100 mm/Hg systolic."
A review of medical records was conducted on August 24, 2021 between approximately 10:30 AM and 12:30 PM.
A review of dialysis treatment records between August 24, 2021 and August 23, 2021 was conducted on August 24, 2021 between approximately 10:30 AM and 12:30 PM.
MR #3, Start of Care: 3/24/2015, Dialysis treatment orders from 8/13/2021: Estimated Dry Weight (EDW): 112 kg; Frequency: Monday-Wednesday-Friday; Dialyzer: Optiflux 180NRe; Dialysate: 2.0 K, 2.5 Ca, 38 HCO3, 137 Na; Blood Flow Rate (BFR): 450; Dialysate Flow Rate (DFR): Autoflow 1.5; Treatment Duration: 4 hours 15 minutes.
Treatment record for 8/20/2021:
08:02 AM B/P 88/40, "Access visible; green AMP light; denies complaints; patient alert; goal down for 200 due to C profile" documented by PCT.
08:02 AM B/P 78/39, documented by PCT without comments.
08:30 AM B/P 86/38, documented by PCT without comments.
11:01 AM B/P 53/40, "Access visible; green AMP light; denies complaints; UF off; Patient alert; Treatment discontinued without problem; patient wanted to stop treatment" documented by PCT.
No follow-up note addressing blood pressure from RN after PCT documentation or in RN discharge note.
MR #4, Start of Care 6/8/2016, Dialysis treatment orders from 8/4/2021: EDW 54.5 kg; Frequency: Monday-Wednesday-Friday; Dialyzer: Optiflux 160 NRe; Dialysate: 2.0 K, 2.5 Ca, 35 HCO3, 137 Na; BFR: 400; DFR: Autoflow 1.5; Treatment Duration: 4 hours 30 minutes.
Treatment record for 8/9/2021:
10:31 AM B/P 191/74, "Access visible; green AMP light; denies complaints; patient alert" documented by PCT.
11:00 AM B/P 199/80, "Access visible; green AMP light; denies complaints; patient alert" documented by PCT.
11:30 AM B/P 181/68, "Access visible; green AMP light; denies complaints; patient alert" documented by PCT.
12:01 PM B/P 214/80, "Access visible; green AMP light; denies complaints; patient alert" documented by PCT.
12:47 PM 196/79, documented by PCT without comments.
13:03 PM 192/78, "UF on; access visible; green AMP light; denies complaints; patient alert" documented by RN.
No follow-up note addressing blood pressure from RN after PCT documentation or in discharge note.
Treatment record for 8/11/2021:
11:03 AM B/P 206/79, documented by PCT without comments.
11:03 AM B/P 208/79, "UF on; access visible; sleeping; green AMP light; denies complaints" documented by PCT.
11:32 AM B/P 207/79, "UF on; access visible; sleeping; green AMP light; denies complaints" documented by PCT.
No follow-up note addressing blood pressure from RN after PCT documentation or in discharge note.
Treatment record for 8/13/2021:
11:37 AM B/P 206/81, "Green AMP light; denies complaints; access visible" documented by PCT.
12:01 PM B/P 201/71, "Green AMP light; denies complaints; access visible" documented by PCT.
No follow-up note addressing blood pressure from RN after PCT documentation or in discharge note.
Treatment record for 8/18/2021:
10:33 AM B/P 197/63, "UF on; resting comfortably; treatment initiated without problem; access visible; patient alert; green AMP light; denies complaints; br up to 400" documented by PCT.
11:04 AM B/P 199/73, documented by PCT without comments.
11:37 AM B/P 205/71, "Green AMP light; denies complaints; access visible; pt alert uf on. high bp pt denies any c/o" documented by PCT.
12:04 PM B/P 221/75, "Green AMP light; denies complaints; access visible; pt alert uf on" documented by PCT.
12:31 PM B/P 93/62, "Green AMP light; denies complaints; access visible" documented by PCT.
13:02 PM B/P 186/126, documented by RN without comments.
13:16 PM B/P 209/76, "Access visible; RN notified; green AMP light; patient alert; increased goal 3.5, a profile" documented by PCT.
13:41 PM B/P 106/80, documented by PCT without comments.
13:48 PM B/P 188/78, documented by PCT without comments.
14:13 PM B/P 196/74, "Access visible; green AMP light; denies complaints; UF off; treatment discontinued without problem; cleared well" documented by PCT.
14:13 PM Post B/P sitting 202/82, post B/P standing 179/66" documented by PCT.
No follow-up note addressing blood pressure from RN after PCT documentation or in discharge note.
An interview with the facility administrator, medical director, and director of operations on August 25, 2021 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:To ensure compliance the clinic manager (CM) or designee will in-service all the direct patient care (DPC) staff on policy:
- Patient Assessment and Monitoring
Emphasis will be placed on ensuring that a follow up note for any treatment interventions and/or abnormal blood pressures (BP) are documented by the Registered Nurse (RN) either in the clinical notes or in the discharge note.
Inservicing will be completed by September 8, 2021. All training documentation is on file at the facility.
The CM or designee will perform daily flowsheet audits for two (2) weeks. At that time if compliance is observed the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly Quality Assessment Improvement (QAI) schedule. A plan of correction (POC) specific audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audits and report the findings to the QAI Committee at the monthly meeting. The QAI committee will be responsible for further guidance and ongoing oversight.
494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P
Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;
Observations:
Based on policy and procedure review, medical record review, and an interview with the facility administrator, it was determined the Medical Director failed to ensure the registered nurse adhered to the facility policy of assessment on patients new to dialysis facility before initiation of their first treatment for one (1) out of five (5) medical records (MR) reviewed (MR #5).
Findings include:
Review of policy "Comprehensive Interdisciplinary Assessment and Plan of Care states, "A registered nurse must perform an assessment on patients new to dialysis before initiation of their first treatment to determine immediate needs. The RN must document the assessment. The assessment may be documented on the CIA in eCC, evaluation cascade in Chairside or multidisciplinary notes and should include at a minimum: neurologic: level of alertness/mental status, orientation, identification of sensory deficits; subjective complaints; rest and comfort: pain status; activity: ambulation status, support needs, fall risk; access: assessment; respiratory: respirations description, lung sounds; cardiovascular: heart rate and rhythm; presence and location of edema; fluid gains, blood pressure and temperature pre-treatment; integumentary: skin color, temperature and as needed, type/location of wounds."
A review of medical records conducted on August 24, 2021 between approximately 10:30 AM and 12:30 PM revealed the following:
MR #5, Start of Care 6/29/2021: A hemodialysis flow sheet dated 6/29/2021 (initial treatment): Hemodialysis treatment initiated at 6:21 AM. RN assessment time of 6:25 AM stated: "Fluid Assessment symptoms: None; Lungs: Decreased breath sounds; Ankle - Severity: 1+: 2 mm or less, disappears rapidly; Lungs - Sound Location: Bilateral; Edema Ankle - Location: Bilateral; Pulse - Rhythm: Regular; Note: RN Evaluation - No Unusual findings noted; denies any covid-19 symptoms." No evidence of neurological status, subjective complaints, pain status, ambulation status, support needs, fall risk, access assessment, integumentary assessment.
An interview with the facility administrator on 8/25/2021 at approximately 11:00 AM confirmed the above findings.
Plan of Correction:By September 3, 2021, the Director of Operations (DO) and the CM will meet with the Medical Director to review the Medical Director Responsibilities as defined in the Conditions for Coverage. The meeting also reviewed the Medical Staff Bylaws and policies:
- Comprehensive Interdisciplinary Assessment and Plan of Care
The meeting will focus on the importance of the staff always following Fresenius Medical Care (FMC) policies. The meeting reviewed that a nursing assessment must be completed by an RN on a patient new to dialysis. The assessment must be completed prior to the initiation of the treatment to determine immediate needs.
Minutes of the meeting with the Medical Director will be on file at the facility for review.
The Medical Director was informed at the meeting that the CM and the staff will receive education on the above policies by the CM or designee by September 10, 2021. The staff meeting will emphasize that an assessment must be completed by an RN on a patient new to dialysis. The assessment must be completed prior to the initiation of the treatment to determine immediate needs.
All training documentation will be on file at the facility.
The Medical Director was informed that the CM or designee will perform audits on all newly admitted patients for three (3) months. At that time, if compliance is maintained, the audits will then follow the monthly QAI schedule. A POC specific audit tool will be used for the audits.
The Medical Director was informed that staff found to be non-compliant will be re-educated and counseled.
To ensure ongoing compliance the CM will review the audit findings with the Medical Director at the QAI Committee monthly meeting. Sustained compliance will be monitored by the QAI committee with oversight by the GB.
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