QA Investigation Results

Pennsylvania Department of Health
DIALYSIS CLINIC, INC. - NEW KENSINGTON
Health Inspection Results
DIALYSIS CLINIC, INC. - NEW KENSINGTON
Health Inspection Results For:


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Initial Comments:

Based on the findings of an onsite unannounced Medicare recertification survey completed on 12/13/2019, Dialysis Clinic, Inc. - New Kensington 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 completed 12/13/2019, Dialysis Clinic, Inc. - New Kensington was found to have the following standard level deficiency that was determined to be in substantial compliance with the following requirement(s) 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 "PARAMETER REPORTING GUIDELINES" and medical records (MR) and staff (EMP) interview the facility failed to assess and/or manage patient's blood pressure for two (2) of four (4) incenter hemodialysis MR reviewed (MR2 & MR4).

Findings Included:

Review of facility "PARAMETER REPORTING GUIDELINES" completed on 12/12/2019 at approximately 11:00 a.m. revealed: "PARAMETER REPORTING GUIDELINES...Blood Pressure Pre...Systolic > 200 Diastolic > 105...Blood Pressure Intra...> or equal to 20 mmHg decrease from prior BP check at anytime during tx or increase to >=180-100...Blood Pressure Post...Systolic > 180 Diastolic > 100."

Review of MR2 completed on 12/11/2019 at approximately 8:15 a.m. revealed admission date 2/21/2019. Treatment sheets reviewed dated 11/01/2019 through 11/29/2019.
11/01/2019 1:20 p.m. BP 170/106, 1:50 p.m. BP 149/99 taken by PCT, treatment sheet did not contain evidence that RN was notified of decrease in BP.
11/11/2019 11:50 a.m. BP 197/133, 12:20 p.m. BP 167/116 taken by PCT, treatment sheet did not contain evidence that RN was notified of decrease in BP.
11/15/2019 11:19 a.m. BP 155/101, 11:50 a.m. BP 135/94 taken by PCT, treatment sheet did not contain evidence that RN was notified of decrease in BP.
11/27/2019 11:50 a.m. BP 163/108, 12:20 p.m. BP 108/98 taken by PCT, treatment sheet did not contain evidence that RN was notified of decrease in BP.

Review of MR4 completed on 12/12/2019 at approximately 10:00 a.m. revealed admission date 5/22/2015. Treatment sheets reviewed dated 11/13/2019 through 12/04/2019.
11/20/2019 1:20 p.m. BP 189/113, 1:50 p.m. BP 161/94, 2:20 BP 139/62, 2:50 BP 113/60, 3:20 p.m. BP 158/102 and 3:50 BP 138/93 taken by PCT, treatment sheet did not contain evidence that RN was notified of decreases in BP.

Interview completed on 12/13/2019 at approximation 1:30 p.m. with EMP1, EMP2 & EMP3. EMP1 stated "they should be documenting that they notified the RN of these changes."











Plan of Correction:

Nurse Manager and/or Designee will educate all patient care staff responsible for assessing and/or managing patient's blood pressure as outlined in the facility's "Parameter Reporting Guidelines" on or before December 30, 2019.
Nurse Manager and/or Designee will perform a flowsheet audit of all flowsheets for two (2) weeks, weekly for two (2) weeks and then monthly for three (3) months. All audit findings will be reported in Governing Body Meetings to be held weekly, for two (2) weeks, then monthly thereafter.