Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on April 16, 2025, BMA of Mount Pleasant, 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 April 16, 2025, BMA of Mount Pleasant, was identified to have the following standard level deficiency that was determined to be in substantial compliance with the 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 policies/procedure, medical records (MR), and employee interviews, the facility failed to follow its policy for monitoring vital signs and safety checks and reporting and/or documenting abnormal findings for seven (7) of seven (7) MR reviewed (MR1-7).
Findings included:
Review of agency Policy on 4/16/25 at approximately 10:30am revealed:
"Patient Assessment and Monitoring...Pre-Treatment...Blood Pressure, Record blood pressure. Verify: Systolic blood pressures greater than 180mm/Hg and/or diastolic blood pressures greater than 100mm/Hg, Blood pressures less than or equal to 100mm/Hg systolic during treatment...During Treatment, Obtain blood pressure and pulse rate every 30 minutes or more as needed but not to exceed 45 minutes per state regulations, Document machine parameters and safety checks every 30 minutes or more often as needed but not to exceed 45 minutes or per state regulations ...Blood Pressure, Record blood pressure., Recheck blood pressures after a drop that requires interventions such as administering normal saline., Reposition electronic cuff or use manual cuff for aberrant blood pressure readings., Report to the nurse: Systolic blood pressures greater than 180mm/Hg, Diastolic blood pressures greater than 100mm/Hg, Blood pressures less than or equal to 100mm/Hg systolic ... "
Review of medical records on 4/15/25 between approximately 12:30pm and 4:00pm revealed the following:
MR 1, Start of Care at facility: 1/31/25, dates reviewed: 3/31/25-4/11/25.
Treatment record dated 3/31/25: included blood pressure reading during treatment at 6:04am of 92/51 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of blood pressure less than 100mm/Hg systolic. The next blood pressure/pulse reading was obtained at 7:02am, 58 minutes later.
Treatment record dated 4/2/25: included safety check documented at 6:02am, the next safety check documented at 7:30am, 1 hour and 28 minutes later. Blood pressure reading during treatment at 6:03am of 98/61 obtained by a PCT. No documentation of recheck or nurse notification of blood pressure less than 100mm/Hg systolic. The next blood pressure/pulse reading was documented at 8:02am, 1 hour and 59 minutes later.
Treatment record dated 4/4/25: included safety check documented at 7:00am, the next safety check documented at 8:00am, 1 hour later. Blood pressure/pulse documented at 7:04am, the next reading documented at 8:05am, 1 hour and 1 minute later.
Treatment record dated 4/9/25: included blood pressure reading during treatment at 7:04am of 98/58, at 8:02am of 94/64, and at 9:02am of 93/63 obtained by a PCT. No documentation of recheck or nurse notification of blood pressure less than 100mm/Hg systolic.
MR 2, Start of Care at facility: 5/3/22, dates reviewed: 4/1/25-4/12/25.
Treatment record dated 4/1/25: included safety check and vitals documented at 6:50am, the next safety check/vitals documented at 7:40am, 50 minutes later. Safety check and vitals documented at 8:02am, the next safety check/vitals documented at 9:07am, 1 hour and 5 minutes later.
Treatment record dated 4/5/25: included blood pressure reading during treatment at 6:31am of 206/59 obtained by a (PCT). No documentation of recheck or nurse notification of blood pressure greater than 180mm/Hg systolic. Safety check documented at 8:30am, the next safety check documented at 9:30am, 1 hour later. Blood pressure/pulse documented at 8:34am, the next reading documented at 9:31am, 57 minutes later.
Treatment record dated 4/12/25: included safety check documented at 8:00am, the next safety check documented at 9:00am, 1 hour later. Blood pressure/pulse documented at 8:02am, the next reading documented at 9:01am, 59 minutes later.
MR 3, Start of Care at facility: 9/27/23, dates reviewed: 3/31/25-4/11/25.
Treatment record dated 3/31/25: included safety check and blood pressure reading during treatment at 1:34pm of 168/102 obtained by a PCT. No documentation of recheck or nurse notification of blood pressure greater than 100mm/Hg diastolic. The next safety check and blood pressure/pulse reading was obtained at 2:32pm, 58 minutes later.
Treatment record dated 4/2/25: included blood pressure reading during treatment at 1:33pm of 156/111 obtained by a PCT. No documentation of recheck or nurse notification of blood pressure greater than 100mm/Hg diastolic.
Treatment record dated 4/9/25: included blood pressure reading during treatment at 11:06am of 144/119 obtained by a PCT. No documentation of recheck or nurse notification of blood pressure greater than 100mm/Hg diastolic. Safety check and blood pressure of 98/78 documented at 1:32pm by a PCT. No documentation of recheck or nurse notification of blood pressure less than 100mm/Hg systolic. Next safety check and blood pressure/pulse documented at 2:33pm, 1 hour and 1 minute later.
MR 4, Start of Care at facility: 6/3/24, dates reviewed: 3/31/25-4/11/25.
Treatment record dated 4/7/25: included safety check and blood pressure/pulse check documented at 10:41am, the next safety check and blood pressure/pulse check documented at 11:32am, 1 hour later.
Treatment record dated 4/9/25: included blood pressure/pulse check documented at 10:47am, the next blood pressure/pulse check documented at 12:05pm, 1 hour and 18 minutes later.
MR 5, Start of Care at facility: 2/15/25, dates reviewed: 3/25/25-4/12/25.
Treatment record dated 4/12/25: included blood pressure reading during treatment at 10:18zm of 173/104, at 1:32pm of 157/101, and at 1:36pm of 155/105 obtained by a PCT. No documentation of recheck or nurse notification of blood pressure greater than 100mm/Hg diastolic.
MR 6, Start of Care at facility: 1/15/24, dates reviewed: 3/31/25-4/11/25.
Treatment record dated 3/31/25: included safety check documented at 9:00am, the next safety check documented at 9:58am, 58 minutes later. Blood pressure/pulse documented at 9:01am, the next reading documented at 9:58am, 57 minutes later.
Treatment record dated 4/4/25: included safety check and blood pressure/pulse documented at 9:04am, the next safety check documented at 10:00am, 56 minutes later. Next blood pressure/pulse documented at 9:58am, 54 minutes later.
Treatment record dated 4/9/25: included blood pressure reading during treatment at 6:28am of 187/103, at 6:31am of 206/109, at 7:04am of 202/109, and at 9:31am of 194/105 obtained by a PCT. No documentation of recheck or nurse notification of blood pressure greater than 180mm/Hg systolic and 100mm/Hg diastolic.
MR 7, Start of Care at facility: 1/13/25, dates reviewed: 3/31/25-4/11/25.
Treatment record dated 3/31/25: included blood pressure reading during treatment at 7:01am of 97/73 obtained by a PCT. No documentation of recheck or nurse notification of blood pressure less than 100mm/Hg systolic.
Treatment record dated 4/7/25: included blood pressure reading during treatment at 7:04am of 95/50, at 9:04am of 99/65, at 10:33am of 94/58, and at 10:40am of 94/58 obtained by a PCT. No documentation of recheck or nurse notification of blood pressure less than 100mm/Hg systolic.
An interview conducted with Clinic Manager and Director of Operations on 4/16/25 at approximately 3:00pm confirmed the above findings.
Plan of Correction:To ensure compliance the Clinic Manager (CM) or designee will in-service all the direct patient care (DPC) staff on policy:
- Patient Assessment and Monitoring
The in-service will focus on the staff ensuring that the registered nurse (RN) is informed of any vital signs (VS) outside of parameters per policy and/or physician orders. This includes blood pressures which are not in the acceptable range at any time pre, post or during treatment. This includes any issues of hypertension or hypotension. The staff will also be re-educated to verify the BP by repositioning electronic cuff or to use a manual cuff to take the BP. The meeting will reinforce the need to document the RN notification of the out-of-range BP. The meeting will re-educate the RNs that an assessment of the patient needs to be completed with documentation of the evaluation and any interventions taken along with a follow-up assessment after the intervention. The RN staff will also be instructed to document physician notification as indicated. The meeting will also re-educate the staff on the importance of ensuring that patient monitoring and VS are completed and documented every thirty (30) to forty-five (45) minutes during the patient treatment.
Inservicing will be completed by May 2, 2025. All training documentation will be on file at the facility.
The CM or designee will perform daily audits for two (2) weeks. At that time if one hundred percent (100%) compliance is observed the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A plan of correction (POC) specific audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audits and report the findings to the QAPI Committee at the monthly meeting. The QAPI committee will be responsible for further guidance and ongoing oversight.
Completion date: May 30, 2025
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