Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on July 18, 2023 through July 19, 2023, Memphis Street Renal Center, 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 conducted on July 18, 2023 through July 19, 2023, Memphis Street Renal Center, was identified 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 review of facility policies/procedure, medical records (MR), and an interview with the facility administrator, the facility failed to ensure the blood flow rate (BFR) and/or the dialysate flow rate (DFR) was administered per physician order for five (5) of seven (7) incenter hemodialysis patient MR's reviewed. (MR #2, 4, 5, 6, and 7.
Findings include:
A review of facility policy titled "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" on July 19, 2023 at approximately 11:45 am states, "Policy: 3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment...Prescription components include but are not necessarily limited to: f. Blood flow rate (BFR) g. Dialysate flow rate (DFR)...Intradialytic Date Collection/Assessment: 10. If the dialysis prescription is not being met (including DFR or change to/inability to obtain prescribed BFR) the reason will be documented and the licensed nurse informed..."
A review of patient medical records (MR) was completed on July 18, 2023 from approximately 10:30 am to 2:00 pm.
MR #2: Admission Date: 5/24/16. Dialysis order date: 6/28/2023. Frequency: Tuesday, Thursday, and Saturday; Target Weight: 76 Kg; Dialyzer: Revaclear 300; Dialysate: 2 K, 2.5 CA, 36 HCO3, 136 NA; Treatment Duration: 210 minutes; BFR: 400; DFR: 500.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
7/17/2023, during entire treatment the BFR was administered at 350 ml/hr.
7/14/2023, between 8:03 am and 10:04 am the BFR as administered at 350 ml/min.
7/12/2023, between 6:29 am and 9:34 am the BFR was administered at 300 ml/min and at 10:06 am the BFR was administered at 270 ml/min.
7/5/2023, between 7:34 am and 10:02 am, the BFR was administered at 350 ml/min.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates.
MR #4: Admission Date: 5/29/20206: Dialysis order date: 6/16/2023. Frequency: Monday, Wednesday, and Friday; Target Weight: 57.4 Kg; Dialyzer: Revaclear 300; Dialysate: 2 K, 2.5 CA, 36 HCO3, 136 NA; Treatment Duration: 210 minutes; BFR: 350; DFR: 500.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
7/17/2023, during entire treatment the BFR was administered at 400 ml/hr.
7/14/2023, during entire treatment the BFR was administered at 400 ml/hr.
7/10/2023, during entire treatment the BFR was administered at 400 ml/hr.
7/7/2023, during entire treatment the BFR was administered at 400 ml/hr.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates.
MR #5: Admission Date: 6/13/2023. Dialysis order date: 6/14/2023. Frequency: Monday, Wednesday, and Saturday; Target Weight: 97 Kg; Dialyzer: Revaclear 300; Dialysate: 2 K, 2.5 CA, 36 HCO3, 136 NA; Treatment Duration: 240 minutes; BFR: 450; DFR: 500.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
7/17/2023, during entire treatment the BFR was administered at 400 ml/hr.
7/14/2023, between 7:31 am and 10:01 am, the BFR as administered at 350 ml/min.
7/12/2023, during entire treatment the BFR was administered at 400 ml/hr.
7/7/2023, during entire treatment the BFR was administered at 400 ml/hr.
7/5/2023, during entire treatment the BFR was administered at 400 ml/hr.
7/3/2023, during entire treatment the BFR was administered at 400 ml/hr.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates.
MR #6: Admission Date: 11/4/18. Dialysis order date: 7/12/2023. Frequency: Tuesday, Thursday, and Saturday; Target Weight: 54 Kg; Dialyzer: Revaclear 300; Dialysate: 2 K, 2.5 CA, 36 HCO3, 136 NA; Treatment Duration: 180 minutes; BFR: 400; DFR: 500.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
7/13/2023, during entire treatment BFR was administered at 350 ml/min.
7/8/2023, during entire treatment the BFR was administered at 350 ml/mn.
7/4/2023, between 8:32 am and 9:13 am, the BFR was administered at 350 ml/min.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates.
MR #7: Admission Date: 5/16/12. Dialysis order date: 7/3/2023. Frequency: Monday, Wednesday, and Friday; Target Weight: 89 Kg; Dialyzer: Reaclear 300; Dialysate: 2 K, 2.5 CA, 36 HCO3, 136 NA; Treatment Duration: 195 minutes; BFR: 400; DFR: 800.
Review of Dialysis Treatment Details Reports revealed the BFR/DFR was not administered at prescribed rates on the following dates:
7/17/2023, between 8:02 am and 9:54 am, the BFR was administered at 350 ml/min and during the entire treatment the DFR was administered at 500 ml/mn.
7/14/2023, during the entire treatment, the DFR was administered at 500 ml/mn.
7/12/2023, during the entire treatment, the DFR was administered at 500 ml/mn.
7/10/2023, during the entire treatment, the DFR was administered at 500 ml/mn.
7/7/2023, during the entire treatment, the DFR was administered at 500 ml/mn.
7/5/2023, during the entire treatment, the DFR was administered at 500 ml/mn.
7/3/2023, during the entire treatment, the DFR was administered at 500 ml/mn.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR/DFR to be administered at a rate different from the prescribed amount for the above date and there was no documentation of a reason why the BFR/DFR was administered at a rate different from the prescribed amount for the above date.
An interview with the facility administrator was conducted on July 19, 2023 at approximately 12:00 pm confirmed the above findings.
Plan of Correction:The Facility Administrator held mandatory in-services for all clinical teammates starting on 7/20/23.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" with Emphasis on but not limited to: 1)Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment.2)Prescription components include but are not necessarily limited to : f. Blood flow rates g. Dialysate flow rates... 3)If the dialysis prescription is not being met(including dialysis flow rate or change to/inability to obtain prescribed blood flow rate)the reason will be documented and the licensed nurse informed.4)Abnormal findings or findings outside of any patient specified physician ordered parameters will be reported to the licensed nurse immediately...5)The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary.6)The Licensed nurse notifies the physician(or NPP if applicable)as needed of changes in patient status.7)All findings, interventions and patient response will be documented in patient's medical record. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The facility Administrator or designee will conduct audits to verify teammate documentation of abnormal findings, notification given to licensed nurse , and the appropriate response by the nurse to the findings : on (25%)of the treatment records daily for two weeks ,then weekly for two weeks. Ongoing compliance will be monitored with monthly ten (10%) medical records audits .Instances of non-compliance will be addressed immediately .
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment Performance Improvement meetings know 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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