Initial Comments:
Based on the findings of an unannounced Medicare recertification survey completed on 8/16/2018, DCI Renal Services of Pittsburgh was found to be in compliance with the following 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 8/13/2018 through 8/16/2018, DCI Renal Services of Pittsburgh 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:
494.30(b)(2) STANDARD
IC-ASEPTIC TECHNIQUES FOR IV MEDS
Name - Component - 00
[The facility must-]
(2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and
Observations:
Based on review of the facility policies and procedures, observations and staff (EMP) interviews, the facility failed to ensure staff labeled multi-dose medication vials and medication bottles with the initials of the person opening the vial and the expiration date of the medication for three (3) of three (3) medications observed.
Findings include:
A review was conducted of facility policy on 8/16/2018 at approximately 2:00 PM revealed, Policy "Medication Administration PURPOSE: This policy is to eliminate opportunities for staff-to-patient and patient to-staff transmission of infectious agents by complying with Federal and State Laws/Regulations...POLICY: Medication will be drawn and administered per the following guidelines. Medications are to be drawn in a clean area away from the patient station and brought to the station for that patient only...Multi-dose vials are to be dated and initialed immediately after opening. Multi-dose vials are only good for 21 days after opening..."
During an observation of the facility on 8/14/2018 at approximately 10:15 AM revealed, one (1) opened multi-dose vial, Epogen [medication] 20000 U/ml [units per milliliter]. Also two medication bottles Calcitriol Capsules 0.5, none of the medication containers had a written date or initials of the staff member that confirmed when the medications were opened.
An exit interview with the administrator, nurse manager, medical director, social worker, dietitian, technical, regional technical manager and home manager on 8/16/2018 at approximately 3:20 PM confirmed the findings.
Plan of Correction:The Governing Body, at the 9/14/2018 monthly quality meeting will review and approve an inservice outline covering Policy "Medication Administration PURPOSE: This policy is to eliminate opportunities for staff-to-patient and patient to-staff transmission of infectious agents by complying with Federal and State Laws/Regulations...POLICY: Medication will be drawn and administered per the following guidelines. Medications are to be drawn in a clean area away from the patient station and brought to the station for that patient only...Multi-dose vials are to be dated and initialed immediately after opening. Multi-dose vials are only good for 21 days after opening..."
The Nurse Manager and/or designee will complete an inservice for all RN staff by 9/21/2018 that ensures explicit points concerning the dating and initialing of multi-dose vials immediately after they are opened. An inservice sign in-sheet will demonstrate compliance of this portion of the POC.
Beginning the week of 9/24/2018 the Nurse Manager/Nurse Educator or designee will audit (and document on an audit form) all medication multi-dose vials for dates/signatures at least weekly until 100% compliance is demonstrated for at least 2 consecutive weeks. At that time the same auditing will continue at least 2 times per month until 100% compliance is demonstrated for at least 2 months. Auditing from that point will continue once each quarter for an additional six month period.
All audit findings will be reviewed by the Governing Body at the monthly quality meeting that follows that audit. The Governing Body will access accuracy, compliance, and review process and procedure as indicated by findings. The Governing Body may suggest and require such procedural changes as may be evident during the auditing period for this issue. Evidence of Governing Body participation throughout will be noted in meeting minutes of that Body throughout the auditing period.
494.40(a) STANDARD
DIALYS PROPORT-MONITOR PH/CONDUCTIVITY
Name - Component - 00
5.6 Dialysate proportioning: monitor pH/conductivity
It is necessary for the operator to follow the manufacturer's instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient.
Observations:
Based on observations, facility policy, and staff interview, the facility failed to ensure the staff followed independent testing protocol for use of the phoenix meter for one (1) of two (2) observations of the Preparation of the Hemodialysis Machine/Extracorporeal Circuit.
Findings include:
A review was conducted of facility policy on 8/16/2018 at approximately 2:00 PM revealed, Policy "Dialysis Machine Testing (Conductivity, pH and Temperature, using the pHoenix Meter POLICY: To ensure accuracy of dialysate concentrations prior to the initiation of each dialysis treatment and any time a dialysate bath is changed during a dialysis treatment. Dialysis machine conductivity, pH, and temperature must be checked externally using the pHoenix Meter prior each treatment..."
Observations conducted in patient treatment area on 8/15/2018 at approximately 10:35 AM revealed the following: During observation of patient 10 located at station 25, Observation #2 "Preparation of the Hemodialysis Machine/Extracorporeal Circuit" EMP 6 did not test dialysate ph and conductivity with a phoenix meter prior to initiation of the dialysis treatments.
An exit interview with the administrator, nurse manager, medical director, social worker, dietitian, technical, regional technical manager and home manager on 8/16/2018 at approximately 3:20 PM confirmed the findings.
Plan of Correction:The Governing Body, at the 9/14/2018 monthly quality meeting will review and approve an inservice outline covering: Policy "Dialysis Machine Testing (Conductivity, pH and Temperature, using the pHoenix Meter POLICY: To ensure accuracy of dialysate concentrations prior to the initiation of each dialysis treatment and any time a dialysate bath is changed during a dialysis treatment. Dialysis machine conductivity, pH, and temperature must be checked externally using the pHoenix Meter prior each treatment..."
The Nurse Manager and/or designee will complete an inservice for all patient care staff by 9/21/2018 that ensures explicit points concerning the completion of required check of machine conductivity, pH and temperature prior to initiation of each dialysis treatment. An inservice sign in-sheet will demonstrate compliance of this portion of the POC.
Beginning the week of 9/24/2018 the Nurse Manager/Nurse Educator or designee will audit (and document on an audit form) at least 20 treatment initiations weekly until 100% compliance is demonstrated for at least 2 consecutive weeks. At that time the same auditing will continue at least 2 times per month until 100% compliance is demonstrated for at least 2 months. Auditing from that point will continue once each quarter for an additional six month period.
All audit findings will be reviewed by the Governing Body at the monthly quality meeting that follows that audit. The Governing Body will access accuracy, compliance, and review process and procedure as indicated by findings. The Governing Body may suggest and require such procedural changes as may be evident during the auditing period for this issue. Evidence of Governing Body participation throughout will be noted in meeting minutes of that Body throughout the auditing period.
494.90(a)(6) STANDARD
POC-P/S COUNSELING/REFERRALS/HRQOL TOOL
Name - Component - 00
The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis.
Observations:
Based on a review of agency policy, medical records (MR) and staff (EMP) interview, the facility failed to ensure that a standardized mental and physical assessment tool was administered by the time of the first reassessment and/or repeated at least annually for one (1) of four (4) MR's reviewed (MR#9).
Findings:
A review was conducted of facility policy on 8/16/2018 at approximately 2:00 PM revealed, Policy "SOCIAL SERVICE...POLICY: The services of a full time qualified social worker shall be retained under a standard employment agreement. The social worker shall meet federal requirements. The social worker shall be responsible for conducting psychosocial evaluations; providing casework care for the patient and patient's family; identifying helpful community resources and assisting patients and their families to use them. The social worker shall complete an ESRD Social Evaluation on each patient within 30 days from the date of admission to this facility. The social worker shall record progress notes whenever necessary, but at least quarterly. Entries in the record by the social worker shall comply with all regulations regarding writing of progress notes, etc. The social worker shall participate on the professional team for the planning of patient care."
A review of MR#9 was conducted on 8/15/2018 at approximately 2:10 PM. Admission date was 4/25/2016. No documentation was provided to confirm the administration of an initial standardized mental and physical assessment tool (KDQOL). No documentation was provided for the administration of an annual standardized mental and physical assessment during 2016, 2017 and 2018. No documentation was provided by the agency of patient refusing to complete an initial/annual standardized mental and physical assessment.
An exit interview with the administrator, nurse manager, medical director, social worker, dietitian, technical, regional technical manager and home manager on 8/16/2018 at approximately 3:20 PM confirmed the findings.
Plan of Correction:An audit of all required KDQOL surveys, as indicated in the DCI Medical Information System will be completed monthly for six months beginning no later than September 24,2018.
This audit will verify that there is documentation in the progress note of the electronic chart each time a survey is distributed to a patient, that there is documentation of the date it was returned for scoring, and in the instance when a patient may refuse to complete/return a survey that a specific note is entered in the electronic chart inthose cases.
When the audit demonstrates 100% at six months, the auditing may be done once a quarter for an additional six months.
All audit findings will be reviewed by the Governing Body at the monthly quality meeting that follows that audit. The Governing Body will access accuracy, compliance, and review process and procedure as indicated by findings. The Governing Body may suggest and require such procedural changes as may be evident during the auditing period for this issue. Evidence of Governing Body participation throughout will be noted in meeting minutes of that Body throughout the auditing period.
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