Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on July 23, 2021, Fresenius Medical Care of Western Pennsylvania 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 on July 23, 2021, Fresenius Medical Care of Western Pennsylvania was found to have the following standard level deficiency that was 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-ACHIEVE ADEQUATE CLEARANCE
Name - Component - 00
Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.
Observations:
Based on a review of facility policy, medical records (MR) and interviews with staff, the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician for four (4) of eight (8) patient medical records reviewed (MR3, MR4, MR5, MR6).
Findings included:
Review of facility policy on 7/23/2021 at approximately 2:30 PM revealed: "...Patient Assessment and Monitoring...During Treatment...The Registered Nurse (RN) will assess/re-assess any findings addressed pre and during treatment as needed...Post Treatment...An abnormal finding confirmed by the RN will be reported to the attending physician if necessary as determined by the clinical judgement of the registered nurse for assessment and intervention...Monitoring During Treatment...Check machine settings and measurements...Check prescribed blood flow is achieved or reason is documented in medical record if unable to meet prescribed flow..."
MR3, reviewed on 7/23/2021 at approximately 10:15 AM, admission date 6/20/2016, ordered treatments 3 times per week. Patient prescription treatment time 3 hours 45 minutes (for period reviewed). Review of hemodialysis treatment records 7/5/2021 to 7/19/2021 revealed:
7/7/2021, Treatment duration completed 3 hours 2 minutes. MR did not contain documentation of why patient treatment was terminated 43 minutes early.
7/12/2021, Treatment duration completed 3 hours 4 minutes. MR did not contain documentation of why patient treatment was terminated 41 minutes early.
7/14/2021, Treatment duration completed 3 hours 29 minutes. MR did not contain documentation of why patient treatment was terminated 16 minutes early.
MR4, reviewed on 7/23/2021 at approximately 11:05 AM, admission date 4/29/2019, ordered treatments 3 times per week. Patient prescription Blood Flow Rate (BFR) 400 ML/min (for period reviewed). Review of hemodialysis treatment records 7/8/2021 to 7/20/2021 revealed:
7/6/2021, From 11:01 AM to 12:04 PM patient BFR at 350. MR did not contain documentation of why BFR was not at rate as ordered (400).
7/8/2021, From 7:30 AM to 9:02 AM patient BFR at 350. MR did not contain documentation of why BFR was not at rate as ordered (400).
7/16/2021, From 8:34 AM to 9:20 AM patient BFR at 350. MR did not contain documentation of why BFR was not at rate as ordered (400).
MR5, reviewed on 7/23/2021 at approximately 11:35 AM, admission date 6/29/2020, ordered treatments 3 times per week. Patient prescription Blood Flow Rate (BFR) 350 ML/min (for period reviewed). Review of hemodialysis treatment records 7/5/2021 to 7/19/2021 revealed:
7/12/2021, From 2:50 PM to 4:30 PM patient BFR at 450. MR did not contain documentation of why BFR was not at rate as ordered (350).
7/14/2021, From 3:03 PM to 6:28 PM patient BFR at 450. MR did not contain documentation of why BFR was not at rate as ordered (350).
MR6, reviewed on 7/23/2021 at approximately 12:00 PM, admission date 1/10/2015, ordered treatments 3 times per week. Patient prescription Blood Flow Rate (BFR) 550 ML/min and prescription treatment time 4 hours (for period reviewed). Review of hemodialysis treatment records 7/6/2021 to 7/16/2021 revealed:
7/8/2021, From 5:41 AM to 9:01 AM patient BFR at 450. MR did not contain documentation of why BFR was not at rate as ordered (550).
7/15/2021, Treatment duration completed 3 hours 34 minutes. MR did not contain documentation of why patient treatment was terminated 26 minutes early.
Exit conference conducted 7/23/2021 approximately 1:30 PM with director of operations via phone and directly with facility charge RN. Above findings were reviewed.
Plan of Correction:V 544
To ensure compliance the Clinic Manager (CM) or designee will educate the direct patient care (DPC) staff on the following:
- Patient Assessment and Monitoring During Treatment
Special emphasis will be placed on ensuring that all machine settings are set per the physician prescription. This includes the treatment time, the blood flow rate (BFR). The in-service will also reinforce the importance of documentation of why the treatment time was terminated early or BFR was not at the prescribed rate. The staff were also re-educated on ensuring that the Registered Nurse is notified when the prescriptions is not being met and when a patient signs of early.
The in-servicing will be completed by August 13, 2021
All training documentation is on file at the facility.
Effective and ongoing, the CM or Designee, will actively monitor staff to ensure compliance, as follows:
- Direct observation of the staff's adherence to the facility's policies and procedures. Immediate intervention, by the assigned nurse, consisting of re-education up to referral to the CM.
- The assigned nurse documents the observations and applied intervention on the plan of correction (POC) monitoring tool.
- The CM will address staff non-compliance with immediate disciplinary action, which will be documented in an employee's personnel file.
- The Clinical Manager/Designee will audit and utilize the POC audit tool daily for two (2) weeks, if compliance is observed the audits will then be conducted weekly for 4 weeks. If compliance is maintained, the audits will be completed following the Quality Assessment Improvement (QAI) program.
- Staff found to be non-compliant will be re-educated and counseled.
The CM will review the audit results and report the findings monthly at the QAI Committee meeting. The QAI committee will provide guidance and ongoing oversight.
Completion Date: August 31, 2021
|