QA Investigation Results

Pennsylvania Department of Health
BELMONT COURT DIALYSIS
Health Inspection Results
BELMONT COURT DIALYSIS
Health Inspection Results For:


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Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey conducted on April 30th, May 1st and 3rd, 2019, Belmont Court Dialysis (Doylestown) 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 unannounced Medicare recertification survey conducted April 30th, and May 1st and 3rd, 2019, Belmont Court Dialysis (Doylestown) was identified to have the following standard level deficiency 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:




494.80(b)(1) STANDARD
PA-FREQUENCY-INITIAL-30 DAYS/13 TX

Name - Component - 00
An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session.



Observations:

Based on a review of clinical records, policies and procedures and an interview with the Administrator, the facility failed to ensure an initial "Comprehensive Multi-interdisciplinary Assessment/Plan of Care" was completed within thirty (30) days or thirteen (13) outpatient hemodialysis treatments of the initial hemodialysis treatment for two (2) of three (3) hemodialysis patients. (Clinical record # 1 and 2)

Findings include:

1. A review of the Facility Policy entitled "Comprehensive Multi-interdisciplinary Assessment/Plan of Care" was conducted on May 3, 2019 at approximately 10:30 AM. Page 1, paragraph 1 reads: "An initial assessment must be conducted on all new patients and a Plan of Care developed and implemented within the latter of thirty (30) calendar days or thirteen (13) outpatient hemodialysis sessions".

2. A review of the Clinical record #1 was conducted on May 1, 2019, at approximately 10:00 A.M. The first hemodialysis treatment at this facility for the patient was January 21, 2019. The documentation showed an initial comprehensive interdisciplinary assessment/ Plan of Care was developed and implemented on March 11, 2019, forty-nine (49) days after the first outpatient dialysis session.

A review of the Clinical record # 2 was conducted on May 1, 2019, at approximately 10:40 A.M. The first hemodialysis treatment at this facility for the patient was February 22, 2019. The documentation showed an initial comprehensive interdisciplinary assessment/Plan of Care was developed and implemented on April 8, 2019, forty-five (45) days after the first outpatient dialysis session.


3. An interview was conducted with the Administrator on May 1, 2019 at approximately 12:30 P.M. The Administrator confirmed the above identified findings, and informed the surveyor that the above cited policy is current.


























Plan of Correction:

A review of Belmont Dialysis policy titled: Comprehensive Multidisciplinary Assessment and Plan of Care (CMPA)

1. A review of the policy Section VI, Number 10 paragraph 1. reads:

An initial assessment must be conducted on all NEW patients and a Plan of Care developed and implemented within thirty day (30) calendar days or thirteen (13) outpatient hemodialysis sessions beginning with the first outpatient session. This
requirement applies to all patients NEW to dialysis, without regard to the modality of treatment. Patients changing modality are classified as NEW patients and must have comprehensive assessments and plans of care completed with the same frequency as patients NEW to dialysis

2. A review of the policy Section VI, Number 10 paragraph 2, reads : A follow-up
comprehensive Reassessment must occur on all NEW patients within three (3) months after the completion of the initial assessment to adjust the patient's Plan of Care as appropriate or if necessary. "The Plan of Care must be updated and implemented within
fifteen (15) days of reassessment. The patients care plan is an synopsis of the patient's current treatment plan... It is an interdisciplinary care plan which includes input from the Patient's Nephrologist, primary nurse, social worker, and dietician."


The plan of correction care plan in-service was presented on 5/10/2019 by the Nurse Manager to the interdisciplinary team. The nurse Manager laid out the Plan of Correction and the tracking table concerning our initial and ninety day care plan going forward for timelyness and completeness no later than Monday 05/20/2019. Quality Assurance staff meeting will finalize completeness of the care plans by the Medical Director on Wednesday 05/22/2019. The nurse manager and Medical Director at Belmont Court Dialysis monthly QA meeting on 5/22/2019 will analyze and review for and completeness. The signature of the medical director showing that the care plan
is finalized and may return to the patient chart for audit by the Administrative Secretary.