Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 5, 2023, September 7, 2023 through September 8, 2023 and September 11, 2023, Philadelphia 42nd St. Dialysis was identified to have the following standard level deficiency that was determined to be in substantial compliance with 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services-Emergency Preparedness.
Plan of Correction:
494.62(d)(1) STANDARD
ESRD EP Training Program
Name - Component - 00
§494.62(d)(1): Condition for Coverage:
(d)(1) Training program. The dialysis facility must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
Staff training must:
(iii) Demonstrate staff knowledge of emergency procedures, including informing patients of-
(A) What to do;
(B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated;
(C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and
(D) How to disconnect themselves from the dialysis machine if an emergency occurs.
(iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and
(v) Properly train its nursing staff in the use of emergency equipment and emergency drugs.
(vi) Maintain documentation of the training.
(vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures.
Observations:
Based on a review of medical records (MR), facility policy and an interview with the facility administrator and manager of clinical service, the facility did not provide emergency training to patients according to policy for six (6) of seven (7) MR's. (MR# 1, 2, 3, 5, 6 and 7).
Findings include:
A review of facility policy "Facility Emergency Mangement Plan" was conducted on September 11, 2023 at approximately 10:22 am. Policy states, "1. Training: b. Patients: ii. Quarterly 1. Fire Safety Preparedness..."
A review of MR's was conducted on September 8, 2023 from 1:25 pm to 2:00 pm and September 11, 2023 from 9:55 am to 10:15 am.
MR#1, Admission Date: 12/8/2021, did not have a fire drill documented for first quarter of 2023.
MR#2, Admission Date: 9/14/2021, did not have a fire drill documented for first quarter of 2023.
MR#3, Admission Date: 5/23/218, did not have a fire drill documented for first quarter of 2023.
MR#5, Admission Date: 8/31/2021, did not have a fire drill documented for the first quarter of 2023.
MR#6, Admission Date: 11/28/2019, did not have a fire drill documented for first quarter of 2023.
MR#7, Admission Date: 11/14/2014, did not have a fire drill documented for the first quarter of 2023.
An interview with the facility administrator and manager of clinical service conducted on September 11, 2023 at approximately 11:20 am confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting 09/12/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-07-01 "Facility Emergency Management Plan (EMP)" with emphasis on but not limited to: 1) emphasizing the Facility Administrator or Clinical Coordinator, is responsible to: Conduct and review quarterly fire safety and evacuation training and drills for compliance, identify additional training and education needs. 2) Fire safety drills: a. Required on a quarterly basis; one drill to be conducted for each shift of patients; b. Include patient emergency takeoff procedure, policy: Termination of Dialysis in an Emergency; c. Document training for both teammates and patients; d. Complete exercise evaluation and teammate attendance sheet; e. Document in Governing Body and maintain with facility EMP.
Verification of attendance is evidenced by teammate signature on in-service sheet.
Quarterly fire drills have been scheduled for the next two quarters, with fire drill for current quarter scheduled for 09/18/23 and 09/19/23. Patient training will include all shifts.
The Facility Administrator or designee will audit fire drill documentation for three (3) quarters to verify compliance of training for all shifts of patients. 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 audit results with the Medical Director during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 5, 2023 and September 7, 2023 through September 8, 2023 and September 11, 2023, Philadelphia 42nd St. 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:
494.30(a)(1) STANDARD
IC-WEAR GLOVES/HAND HYGIENE
Name - Component - 00
Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.
Observations:
Based on observation of the clinical area, facility policy and an interview with the facility administrator and clinical services manager, the facility did not ensure infection control procedure regarding glove removal and handwashing for two (2) of ten (10) observations (OBS). OBS#1 and 2).
Findings include:
A review of policy 1-05-01 "Infection Control For Dialysis Facilities" on September 5, 2023 at 1:30 PM states: " 1. All teammates...will perform hand hygiene b. prior to gloving and immediately after removal of gloves. c. after contamination with blood or other infectious material. d. after patient and dialysis delivery system contact,,,7a Gloves should be changed when: ii. When going from a "dirty" area or task to a "clean" area or task. iii. When moving from i. contaminated body site to a clean body site of the same patient; and iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient's dialysis delivery system.
Observation of the clinical area was conducted on 9/5/23 9:45 between AM-12:15 PM.
OBS#1 Machine 16 PCT 1, after touching dialysis machine, did not perform hand hygiene and don new gloves prior to initiating AV Fistula.
OBS#2 Machine 17 PCT 2 after touching the machine screen, did not discard gloves, perform hand hygiene and don new gloves prior to inserting the fistula needle into the patient's vascular access.
An interview with the clinical services manager conducted on September 5, 2023 at 1:00 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/12/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 1) All teammates ... will perform hand hygiene ...prior to gloving and immediately after removal of gloves; after contamination with blood or other infectious material; after patient and dialysis delivery system contact... 2) Gloves should be changed when... ii. When going from a "dirty" area or task to a "clean" area or task; iii. When moving from a contaminated body site to a clean body site of the same patient; iv. After touching one patient or their dialysis delivery system and before arriving to care for another patient or touch another patient's dialysis delivery system. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Clinical Coordinator or designee will conduct infection control audits to verify teammates are wearing gloves and performing hand hygiene per policy: daily for two (2) weeks, then weekly for two (2) week. Ongoing compliance will be monitored with monthly infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results of the audits with teammates during homeroom meetings and with Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this 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/procedure, medical records (MR), and an interview with the facility administrator and manager of clinical service, the facility failed to ensure the blood flow rate (BFR) and/or the dialysate flow rate (DFR) was administered per physician order for three (3) of seven (7) incenter hemodialysis patient medical records (MR) reviewed.
(MR #1, 4 and 5); and the facility failed to provide documentation that a patient requested early treatment termination for two (2) of seven (7) incenter hemodialysis patient medical records (MR) reviewed, (MR #1 and 2).
Findings include:
A review of facility policy titled "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" on September 7, 2023 at approximately 2:18 pm states, "Policy: 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment...Prescription components include but are not necessarily limited to: f. Blood flow rate (BFR) g. Dialysate flow rate (DFR)...Intradialytic Date Collection/Assessment: 10. If the dialysis prescription is not being met (including DFR or change to/inability to obtain prescribed BFR) the reason will be documented and the licensed nurse informed..."
A review of facility policy titled "CWOW-Prescribed Treatment Time Not Met" on September 7, 2023 at approximately 2:10 p.m states, "Policy: A. Completion of the Early Termination of Treatment Against Medical Advice Form: 1. The RN will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time...3. The RN will obtain the patient ' s signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient ' s signature prior to rinse-back, the RN will obtain the patient ' s signature on the form prior to the patient ' s departure from the facility. 4. A RN must countersign all Early Termination of Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 5. If a patient refuses to sign the Early Termination of Treatment Against Medical Advice form, the RN will document the patient ' s refusal with the words " patient refused " in the patient signature box along with the date. Under such circumstances, the RN will sign the form and will also obtain a witness ' signature on the form... B. Prescribed Treatment Time Not Met: 1. If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient ' s attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient ' s specific needs..."
A review of medical records was conducted on September 7, 2023 approximately 12:30 p.m.- 2:20 p.m., and September 8, 2023 approximately 9:14 a.m.- 10:20 a.m.
MR #1: Admission Date: 12/8/2021. Dialysis order date: 8/22/2023. Frequency: Monday, Wednesday, and Friday; Target Weight: 76.5 Kg; Dialyzer: Gambro, Revaclear ; Dialysate: 2 K, 3 CA, 35 HCO3, 136 NA; Treatment Duration: 240 minutes; BFR: 450; DFR: 800.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
8/28/2023 1:18 pm BFR 420 ml/min, 1:48 pm BFR 400 ml/min; 2:18 pm BFR 360 ml/min, 2:48 pm BFR 340 ml/min and 3:18 pm BFR 320 ml/min. PCT did not inform the licensed nurse.
9/2/2023 between 1:29 pm and 2:29 pm, BFR was administered at 400 ml/min. PCT did not inform the licensed nurse.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates.
Review of Dialysis Treatment Details Reports revealed the patient requested early termination of treatment on the following dates:
8/28/2023 Treatment time 240 minutes, 62 minutes short.
There is no documentation of an Early Termination of Treatment Against Medical Advice form in the MR.
MR #2: Admission Date: 9/14/2023. Dialysis order date: 8/23/2023. Frequency: Tuesday, Thursday, and Saturday; Target Weight: 97.5 Kg; Dialyzer: Gambro, Revaclear ; Dialysate: 2 K, 2.5 CA, 35 HCO3, 137 NA; Treatment Duration: 240 minutes; BFR: 400; DFR: 800.
Review of Dialysis Treatment Details Reports revealed the patient requested early termination of treatment on the following date:
9/1/2023 Treatment time 240 minutes, 78 minutes short.
There is no documentation of an Early Termination of Treatment Against Medical Advice form in the MR.
MR #4: Admission Date: 7/13/2023. Dialysis order date: 8/22/2023. Frequency: Tuesday, Thursday, and Saturday; Target Weight: 72.5 Kg; Dialyzer: Gambro, Revaclear ; Dialysate: 2 K, 2.5 CA, 30 HCO3, 138 NA; Treatment Duration: 240 minutes; BFR: 400; DFR: 600.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
8/29/2023 between 6:39 to 6:58 am BFR 350 ml/min and 10:03 am BFR 360 ml/min. PCT did not inform the licensed nurse.
8/31/2023 7:40 am BFR was administered at 350 ml/min, between 8:00 am to 8:30 am BFR was administered at 360 ml/min. between 8:59 am to 9:39 am BFR was administered at 350 ml/min, and 10:00 am BFR was administered at 310 ml/min. PCT did not inform the licensed nurse.
9/5/2023 6:53 am BFR was administered at 350 ml/min, between 8:28 am to 10:15 am BFR 350 ml/min. PCT did not inform the licensed nurse.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates.
MR #5: Admission Date: 8/31/2021. Dialysis order date: 8/29/2023. Frequency: Tuesday, Thursday, and Saturday; Target Weight: 104.1 Kg; Dialyzer: Gambro, Revaclear ; Dialysate: 2 K, 2.5 CA, 35 HCO3, 137 NA; Treatment Duration: 240 minutes; BFR: 400; DFR: 800.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
8/31/2023 11:16 am to 2:01 pm BFR was administered at 370 ml/min. PCT did not inform the licensed nurse.
9/2/2023 between 12:32 pm to 2:02 pm BFR 350 ml/min. PCT did not inform the licensed nurse.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates.
An interview with the facility facility administrator and manager of clinical service on September 8, 2023 at approximately 2:25 p.m. confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/12/23. Surveyor observations were reviewed. Education included but was not limited to a review of A. Policy 1-03-08 "Pre- Intra- Post treatment Data Collection, Monitoring and Nursing Assessment" and Policy 1-01-09 "CWOW-Prescribed Treatment Time Not Met" with emphasis on but not limited to:
A. Policy 1-03-08 "Pre- Intra- Post Treatment...": 1) Patient identity, prescription and machine settings are verified by teammates prior to initiation of treatment with the exception of blood flow rate (BFR) which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription component are confirmed by a licensed nurse by 1 hour of treatment initiation along with the nursing assessment. Prescription components include but are not necessarily limited to: Blood flow rate (BFR); Dialysate flow rate (DFR). 2) 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. 3) All findings, interventions and patient response will be documented in the patient's medical record.
B. Policy 1-01-09 "CWOC- Prescribed Treatment Time": 1. Completion of the early termination of treatment against medical advice form: 1) The RN will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. 2) The RN will obtain the patient's signature on the Early Termination of Treatment against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient's signature prior to rinse-back, the RN will obtain the patient's signature on the form prior to the patient's departure from the facility. 3) A RN must countersign all Early Termination of Treatment against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 4) If a patient refuses to sign the Early Termination of Treatment against Medical Advice form, the RN will document the patient's refusal with the words "patient refused" in the patient signature box along with the date. Under such circumstances, the RN will sign the form and will also obtain a witness' signature on the form. 2. Prescribed Treatment Time Not Met: 1) If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient's attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient's specific needs.
Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
For Policy 1-03-08 Pre-Intra-Post treatment Data Collection Monitoring and Nursing Assessment the Facility Administrator and nurses will conduct audits on twenty five percent (25%) of the flow sheets daily for two (2) weeks then weekly for two (2) weeks then on ten percent (10%) monthly medical records audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will audit treatment records to verify presence of complete documentation and notification to and response by the Registered Nurse regarding blood flow rate, and dialysis flow rate if not meeting treatment prescription: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be addressed with monthly ten percent (10%) medical records audit.
The Facility Administrator or designee will audit the AMA form binder to verify completion of the "Early Termination of Treatment against Medical Advice" form is signed by the patient and Registered Nurse when treatment times are not met on the treatment record as prescribed on twenty five percent (25%) of treatment records: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored monthly with ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with the teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment Performance Improvement meeting known as Facility Health Meeting, with supporting documentation in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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