Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey completed on March 24, 2022, DCI Renal Services of Pittsburgh, LLC 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 onsite Medicare recertification survey completed on March 24, 2022, DCI Renal Services of Pittsburgh, LLC 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:
494.90(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 policy, medical records (MR), and staff (EMP) interview the facility failed to assess and/or manage patient's blood pressure for one (3) three of seven (7) hemodialysis patients reviewed (MR16, MR17, MR19).
Findings include:
Review of facility policy titled, "Patient Monitoring" on 3/23/22 at approximately 3:00 p.m. states: MONITORING OF PATIENTS DURING DIALYSIS, Policy: each patient and machine shall be monitored during each dialysis treatment according to clinic policy...DOCUMENTATION ON THE DIALYSIS FLOWSHEET/DARWIN DIRECT, Vital Signs: BP and pulse to be taken and recorded on initiation of treatments, every 30 minutes and prn if patient symptomatic.
Review of medical records (MRs) on 3/23/22 at approximately 9:30 a.m. to 12:00 p.m. and 1:30 p.m. to 2:45 p.m. revealed the following:
MR16, Review of treatment records dated 1/15/22 through 2/26/22. Treatment sheet dated 2/10/22 revealed patient was assessed at 2:04 p.m. Patient was not assessed again until 3:03 p.m. (59 minutes between assessments).
Treatment sheet dated 2/22/22 revealed patient was assessed at 1:43 p.m. Patient was not assessed again until 2:40 p.m. (57 minutes between assessments).
MR17, Review of treatment records dated 1/31/22 through 3/4/22. Treatment sheet dated 2/23/22 revealed patient was assessed at 1:22 p.m. Patient was not assessed again until 2:23 p.m. (61 minutes between assessments).
Treatment sheet dated 2/28/22 revealed patient was assessed at 12:12 p.m. Patient was not assessed again until 12:53 p.m. (41 minutes between assessments).
Treatment sheet dated 3/2/22 revealed patient was assessed at 11:21 a.m. Patient was not assessed again until 12:21 p.m. (60 minutes between assessments).
Treatment sheet dated 3/4/22 revealed patient was assessed at 11:08 a.m. Patient was not assessed again until 12:17 p.m. (69 minutes between assessments).
MR19, Review of treatment records dated 2/7/22 through 3/4/22. Treatment sheet dated 3/4/22 revealed patient was assessed at 7:18 a.m. Patient was not assessed again until 8:03 a.m. (45 minutes between assessments).
Interview on 3/23/22 at 2:40 p.m. with Nurse Educator confirmed the above findings.
Plan of Correction:543
All clinical staff will be retrained on the "Patient Monitoring" policy H32 by the nurse educator or designee. All clinical staff will sign acknowledgment of understanding policy H32 and the requirement to assess each patient's vital signs at least every 30 minutes during their dialysis treatments. A copy of acknowledgment will be placed in the respective employee files. This training was completed and documentation placed in employee files on 4/8/22 for all staff.
The Nurse Educator, or designee, will audit 50% of the daily treatments for 1 week (the week of April 11th) to ensure staff is following the policy with emphasis on documentation of physician orders not being met and notifying the physician per policy. If standards are met, 20% of the weekly treatments will be audited weekly for 4 weeks (The weeks of 4/18/22, 4/25/22, 5/2/22, and 5/9/22). If standards are met, 10% of the monthly treatments will be audited for three (3) months. If standards are met, 10% of one month's treatments will be audited semi-annually. The respective audit results will be reviewed at monthly QAPI/GB meetings. Governing Body will determine frequency of future audits based upon compliance.
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 review of facility policy, medical records (MR) and staff (EMP) interviews, it was determined that the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician for one (1) of four (4) prescription verifications reviewed (MR12) and three (3) of seven (7) hemodialysis patient records reviewed (MR8, MR14, MR16).
Findings include:
Review of facility policy "Patient care pre and post treatment" on 3/23/22 at approximately 3:00 p.m. states: Policy: the patient shall be stable and specific clinical data shall be documented before a patient's treatment will be initiated...ASSESSMENTS: (pre/post treatment)...RN to assess mental status, lung/cardiac sounds, edema and verify dialysis prescription prior to initiation of dialysis.
Prescription verification completed on 3/22/22 at approximately 1:15 p.m. for Patient MR12, Dialysis station 10, Machine Fresenius T09, revealed the following: Bicarbonate: 32, Na: 139 and DFR 500. Physician orders, dated 2/10/22, as follows: Bicarbonate: 35, Na: 137 and DFR 600. Interview with the charge nurse confirmed the findings.
Review of medical records (MRs) on 3/23/22 at approximately 9:30 a.m. to 12:00 p.m. and 1:30 p.m. to 2:45 p.m. revealed the following:
MR8, admission date 2/22/22. Treatment sheets reviewed dated between 2/22/22 and 3/19/22. Physician orders dated 2/21/22- dialysate flow rate (DFR) 800, blood flow rate (BFR) 400.
-3/1/22 Start time 11:16 a.m. 1:54 p.m. BFR 0, From 2:51 p.m. to 3:23 p.m BFR ran at 350. Treatment end time 3:27 p.m.
-3/17/22 Start time 11:03 a.m. From 11:35 a.m. through 3:14 p.m. BFR ran at 375. Treatment end time 3:19 p.m.
-3/19/22 Start time 11:16 a.m. From 11:16 a.m. through 3:20 p.m. DFR ran at 500. Treatment end time 3:30 p.m.
Medical record did not contain documentation regarding the changes in the DFR or BFR.
MR14, admission date 6/30/2020. Treatment sheets reviewed dated between 2/26/22 and 3/19/22. Physican orders dated 2/11/22- dialysate flow rate (DFR) 800, blood flow rate (BFR) 500.
-2/26/22 Start time 11:02 a.m. From 11:31 a.m. to 2:24 p.m BFR ran at 415. Treatment end time 2:29 p.m.
-3/1/22 Start time 11:03 a.m. BFR 310, From 11:23 a.m. through 2:30 p.m. BFR ran at 400. Treatment end time 2:34 p.m.
-3/8/22 Start time 11:39 a.m. BFR 200, From 12:10 p.m. through 2:46 p.m. DFR ran at 440. Treatment end time 2:52 p.m.
Medical record did not contain documentation regarding the changes in the DFR or BFR.
MR16, admission date 11/13/21. Treatment sheets reviewed dated between 1/15/22 and 2/26/22. Physican orders dated 11/13/21- dialysate flow rate (DFR) 800, blood flow rate (BFR) 450.
-1/15/22 Start time 11:55 a.m. 12:11 p.m. to 12:28 p.m. BFR ran at 440 and DFR ran at 500. 12:59 p.m. BFR 0 and DFR 500. 1:29 p.m. BFR 400 and DFR 500. 1:47 p.m. BFR 0. Treatment end time 1:49 p.m.
-2/8//22 Start time 12:43 p.m. From 12:47 p.m. through 2:51 p.m. BFR ran at 285. At 3:02 p.m. BFR 0. Treatment end time 3:04 p.m.
-2/26/22 Start time 11:37 a.m. From 11:54 a.m. through 2:39 p.m. BFR ran at 400. From 11:44 a.m. through 2:39 p.m. DFR ran at 500. Treatment end time 2:42 p.m.
Medical record did not contain documentation regarding the changes in the DFR or BFR.
Interview on 3/23/22 at 2:40 p.m. with Nurse Educator confirmed the above findings.
Plan of Correction:544
All clinical staff will be retrained on the "Patient Monitoring" policy H32 and "Patient Care Pre and Post Treatment" policy H-32A by the nurse educator or designee. Training will include the responsibility to document the reason when unable to achieve the prescribed DFR or BFR and notification to the charge nurse. The charge nurse will be responsible for notifying the physician if the prescribed BFR cannot be prescribed for 3 consecutive treatments. RN will verify goal and all parts of patient's dialysis prescription are being met during pre-treatment assessment. Charge nurse will verify all patient's prescriptions are followed every treatment. This training was completed and documentation placed in the employee files on 4/8/22 for all staff.
The "In-Center Hemodialysis Standing Orders" will be reviewed with all clinical staff with particular emphasis on physician orders for machine settings to include "blood flow rate (BFR)" and "dialysis flow rate (DFR)". All clinical staff will review and sign acknowledgement of understanding of policy and standing orders. A copy of the acknowledgement will be placed into the respective employee education file. This will be completed by the nurse educator or designee and in employee files by 4/15/22.
The Nurse Educator or designee will audit 50% of the daily treatments for 1 week (the week of April 11th) to ensure staff is following the policy with emphasis on documentation of physician orders not being met and notifying the physician per policy. If standards are met, 20% of the weekly treatments will be audited weekly for 4 weeks (the week of 4/18/22, 4/25/22, 5/2/22, and 5/9/22). If standards are met, 10% of the monthly treatments will be audited for three (3) months. If standards are met, 10% of the treatments will be audited semi-annually. The audit results will be reported and reviewed at monthly QAPI and Governing Body meetings.
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