Initial Comments:
Based on the findings of an onsite unannounced complaint investigation conducted on site on September 26, 2022 and off site on September 28, 2022, Philadelphia PMC 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:
494.170 STANDARD
MR-COMPLETE, ACCURATE, ACCESSIBLE
Name - Component - 00
The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.
Observations:
Based on a review of medical records (MR), hemodialysis treatment records, electronic progress notes, and an interview with the clinical coordinator, the facility failed to maintain complete and accurate records on all patients for one (1) of one (1) clinical record reviewed: CR#1.
Findings include:
On September 26, 2022 at 12:30 PM, a review of Policies 1-04-01, "Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Access Care #19" was conducted and states, "Document findings and interventions in patient's medical record;" Policy 7-05-02, "Pre and Post Treatment Assessment and Data Collection" under the Pre-Treatment Assessment section states, "The assessment by the licensed nurse teammate will include the following: Vascular Access ....Skin Assessment" and under Post-Treatment Assessment Section states, "Assessment of the following systems includes but is not limited to: Vascular Access, Skin."
On September 28, 2022 at 6:00 PM, a review of Policy 1-03-08, "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" was conducted and states, "The nursing assessment will include ....review of documentation for accuracy, completion, and patient data."
An interview was conducted with PF#1 on September 26, 2022 at 1:30 PM. PF#1 stated that on 08/23/2022, the arteriovenous graft (AVG) was cannulated and hemodialysis treatment initiated by PF#3 for CR#1.
A review of the medical record, electronic progress notes, and twenty-six hemodialysis treatment records between 07/02/2022 and 08/30/2022 was conducted on September 26, 2022 starting at approximately 11:00 AM. The start of care is indicated below.
CR#1 SOC 07/02/2015 found that on 08/18/2022, the Pre-Treatment Vitals section of the hemodialysis treatment record contained documentation that cannulation of the AVG was performed by PF#2. The Intradialytic Section of the Treatment record contained contrary documentation that cannulation of the AVG was performed by PF#4. On 08/23/2022, the Pre-Treatment Vitals section of the treatment record contained documentation that cannulation of the AVG was performed by PF#2. The Intradialytic Section of the Treatment Record contained documentation that PF#2 initiated the hemodialysis treatment. There is no documentation to support that on 08/23/2022, cannulation of the AVG and initiation of the hemodialysis treatment was performed by PF#3 per the interview that was conducted with the clinical coordinator. A review of the medical record found a copy of a Hospital After Visit Summary related to an Emergency Department visit that occurred on 08/24/2022 for "vascular access problems, hemorrhage due to vascular prosthetic devices, implants and grafts sequela (complication)," and "laceration repair" with instructions to follow-up in 5 days for suture removal. There was no documentation on the treatment records, electronic progress notes, nor the medical record by the hemodialysis treatment team of the ED Visit that occurred on 08/24/2022, nor was there any documentation by the hemodialysis treatment team to support the recognition or assessment of the suture site at the time of hemodialysis treatments occurring on 08/25/2022 and/or 08/30/2022.
An interview conducted with the Group Facility Administrator and Clinical Coordinator on September 26, 2022 starting at 2:45 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-service(s) for all Clinical Teammates starting on 10/4/2022. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" and Policy 1-04-01 "Arteriovenous Fistula (AVF) and Arteriovenous Graft (AVG) Vascular Access Care" with emphasis on but not limited to: 1. Data collection and nurse assessment: 1) Patient data will be obtained and documented by the patient care technician or a licensed nurse. Data collection includes but is not necessarily limited to... Patient's report of well-being, level of pain or discomfort, complaints, hospitalization; vascular access status. 2) The Nursing assessment will be performed and documented by a licensed nurse. The assessment includes the following components: i. Review of patient reports, data collection, complaints and response to treatment... v. Review of documentation for accuracy, completion, and patient data. 3) Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: h) all accesses evaluated. Education also included a review of Policy # 1-04-01 AVF and AVG Vascular Access Care. 2. Vascular access care: PURPOSE: To reduce the risk of infection in the patient, to reduce trauma to the fistula or graft while minimizing blood loss and to maximize the lifetime of each access. 1) Inspection of the AVF or AVG access includes the following... Condition of previous cannulation sites... Bruising and/or bleeding... Checking of skin for trauma or skin tears... Verification of attendance at in-service is evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct audits to verify vascular access observations are documented accurately on treatment records: on twenty five percent (25%) of the flow sheets daily for two (2) weeks, then weekly for two (2) weeks. 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 the audit results with teammates during homeroom meetings, and with the 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.
494.180(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 medical records (MR), electronic progress notes, hemodialysis treatment records, facility policy, facility complaint log, and staff interview, the facility failed to implement the patient internal grievance process for one (1) of one (1) clinical record reviewed: CR#1.
Findings include:
An interview was conducted with the Social Worker (MSW) on 09/26/2022 at 12:10 PM. The MSW stated that on 08/25/2022, CR#1 voiced a complaint about bleeding that occurred from CR#1's access site, an arteriovenous graft, which necessitated an Emergency Department Visit on 08/24/2022 for suture placement, and that CR#1 complained about and attributed the bleeding incident to PF#1 who CR#1 stated had inserted the cannulation needles on 08/23/2022. The MSW stated that she referred the complaint to the Facility Administrator (FA) and scheduled a meeting between the patient and the FA to occur on 08/30/2022.
On 09/26/2022 at approximately 12:45 PM, a review of Policy 3-01-36 "Patient Grievance" was conducted and states, "The FA (or his/her 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."
On 09/26/2022 at approximately 11:00 AM, a review of the Facility Complaint Log was conducted and revealed that there were no complaints entered into the complaint log from CR#1 in August or September for the above complaint, nor was there any other documentation to support an investigation of the complaint.
A review of the clinical record was conducted on September 26, 2022 at approximately 11:00 AM. The start of care is indicted below.
CR#1 SOC 07/02/2015 contained a document in the medical record titled, "Grievance Procedure" signed by the patient on 12/15/2020. The document states, "I may report a grievance to a DaVita teammate either verbally or in writing. The teammate should report the grievance to the charge nurse. If a solution to the grievance is not reached through this discussion, the charge nurse is to notify the Facility Administrator. Grievances submitted will be communicated to the Facility Administrator/designee within one (1) business day for follow-up. The Facility Administrator will discuss the grievance with me and take appropriate action towards a solution, if possible. This discussion should occur within 10 days of the Facility Administrator's receipt of the grievance."
An interview conducted with the Group Facility Administrator and Clinical Coordinator conducted on September 26, 2022 starting at 2:45 PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all teammates starting on 10/4/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-01-06 "Patient Grievance" and Policy 3-01-06A "Addressing Patient Grievances: DaVita Teammates" with emphasis on but not limited to: 1. Patient grievance: 1) All patients of this facility have the right to have their grievances handled promptly and courteously. 2. Addressing 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) Complaints/Grievances should be documented on the facility Patient Grievance Log. 3) All details of patient grievances and discussions will be documented. This documentation will be maintained in a separate file and kept in a secure and locked location. The Grievance Investigation Document may be used for this purpose. This form is not for patient use. 4) The DaVita teammate receiving the grievance should report the grievance to the charge nurse. Grievances submitted to Guest Services will be communicated to the FA or designee and ROD within one (1) business day for follow-up. 5) The charge nurse will discuss the grievance with the patient and take appropriate action towards a solution, if possible. 6) If the patient grievance cannot be resolved by the charge nurse, the Facility Administrator will be notified. The Facility Administrator will discuss the grievance with the patient and take appropriate action towards a solution, if possible. This discussion should occur within ten (10) days of receipt of the grievance. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Social Worker and Facility Administrator completed the missing grievance log entry on 09/27/22 regarding the meeting held on 08/30/22 between the Facility Administrator and patient. Meeting details included findings of an investigation which had been conducted by the Facility Administrator and the follow-up with the patient. The Facility Administrator or designee will conduct audits on the Grievance Log weekly for two (2) weeks then monthly for two (2) months, to verify all reported patient grievances are documented and that follow-up with the patient is timely and appropriate. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review the audit results with the Social Worker during weekly core team meetings, and with the 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.
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