Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on March 4, 2025 through March 6, 2025, PDI -Lancaster 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 March 4, 2025 through March 6, 2025, PDI -Lancaster PDI- Lancaster, 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:
494.180(e) STANDARD
GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED
Name - Component - 00
The facility's internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services.
The grievance process must include-
(1) A clearly explained procedure for the submission of grievances.
(2) Timeframes for reviewing the grievance.
(3) A description of how the patient or the patient's designated representative will be informed of steps taken to resolve the grievance.
Observations:
Based on reviews of policies/procedures, patient grievance log complaint filings (CF) and interview with the acting Facility Administrator (FA) the clinic failed to ensure all patient grievances were documented for one (1) of two (2) complaint filings reviewed. (CF #2)
Findings include:
Review of policy: 3-01-06A completed 3/5/25 at approximately 1:00PM revealed: Title: Addressing Patient Grievances: Davita Teammates Policy: 1. "Patient grievances may be verbal or written. They may be submitted directly to a facility teammate or submitted to the DaVita Guest Services department". 2. "All complaints/grievances should be documented on the facility Patient Grievance Log". 5. "Based on the nature of the complaint, the appropriate member of the interdisciplinary team (IDT) will discuss the grievance with the patient and take appropriate action towards a solution, if possible". 6. If the patient grievance cannot be resolved, the FA will be notified, The FA will meet with the patient to discuss the grievance and take appropriate action toward a solution...".
Review of the patient grievance log completed on 3/4/25 between approximately 2:30 PM and 3:30 PM revealed the following:
CF#2 contained completed sections: individuals filing, complaint, investigators, and details of the complaint. Sections for the investigation, plan of resolution and resolution description were left blank.
An interview with acting facility administrator completed 3/6/25 at approximately 2:00PM confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-service(s) for all clinical teammates starting on 3/24/25. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-01-06A "Addressing Patient Grievances: DaVita Teammates" with emphasis on but not limited to: 1) Patient grievances may be verbal or written. They may be submitted directly to a facility teammate or submitted to the DaVita Guest Services department. 2) All complaints / grievances should be documented on the facility Patient Grievance Log. 3) Based on the nature of the complaint, the appropriate member of the interdisciplinary team will discuss the grievance with the patient and take appropriate action towards a solution, if possible. 4) If the patient grievance cannot be resolved, the FA will be notified. The FA will meet with the patient to discuss the grievance and take appropriate action towards a solution... Verification of attendance at the in-service is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will perform audits of the Patient Grievance Log to verify all grievances are addressed with documented resolution: monthly for three (3) months. Ongoing compliance will be monitored with a monthly review of grievances in preparation for Facility Health Meeting. 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 Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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