Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on May 10, 2022 through May 12, 2022, Abington Dialysis 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 May 10, 2022 through May 12, 2022, Abington Dialysis, 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-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/procedures, dialysis treatment documentation, medical records (MR), and administrative interview, the facility failed to follow it's policy for post-treatment data assessment and licensed nurse documentation for two (2) of six (6) incenter hemodialysis MR's reviewed, (MR #2 & 5) and failed ensure patient was recording blood pressures every 30 minutes for one (1) of two (2) home hemodialysis MRs reviewed (MR #10).
Findings include:
Review of policy occurred on 5/12/22 at approximately 10 AM which revealed:
Policy 1-03-08 titled, "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" states, "Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes but is not necessarily limited to: measurement of patient temperature, measurement of blood pressure (BP)...heart or pulse rate...patient weight, respiration rate, patient's report of well-being..vascular access status. The nursing assessment will be performed and documented by a licensed nurse..includes the following components: review of patient reports, data collection, complaints and response to treatment, verification machine safety checks...prescription, review of documenation for accuracy, completion and patient data, a physical assessment...Intradialytic (during treatment) Data Collection/Assessment...abnormal findings or findings outside of any patient specific physician ordered paramaters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary....The license nurse notifies the physician..as needed of changes in patient status...Post treatment Data Collection/Assessment: The PCT of licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. If an abnormal finding(s) or concern is identifed post treatment, this needs to be reported to the license nurse. The licensed nurse will assess the patient prior to discharge. Licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician is necessary prior to discharge of the patient from the facility...Abnormal findings: Blood Pressure-Intradialytic: difference of 20 mm/Hg increase or decrease from patient's last Intradialytic treatment BP reading..."
Policy 12-03-07 titled, "Intradialytic Treatment Monitoring" states, "Home hemodialysis... Treatment checks should be completed at least every thirty (30) minutes or as prescribed by a physician. At a minimum obtain and document the following: blood pressure, heart rate, blood and dialysate flows, arterial and venous pressures, fluid removal and/or replacement...vascular access visible and line connections intact, patient status and subjective well-being and patient's face visible...changes are reporting to the registered nurse; appropriate action is taken and documented, including patient response..."
Policy 12-01-28 titled, "Home Dialysis Monitoring and Ongoing Patient Education" states, "The Home hemodialysis facility will: retrieve and review complete self-monitoring data and other information from home hemodialysis and/or self-care patients or their designated caregivers at least every two (2) months. The facility interdisciplinary team monitors the patient's states to determine if the patient if following the individualized treatment plan and/or is having any problems at home..."
A review of MR's was conducted on 5/10/22 and 5/11/22 from approximately 11:30 am to 2:00 pm.
MR #2, Start of Care: 2/3/21.
Treatment Record for: 3/7/2022:
12:31 PM: Intradialytic (during treatment) B/P 202/57. Comments: "BP high -C/O (no complaints)" documented by patient care tech (PCT)
13:01 PM: B/P 197/53
13:33 PM: B/P 107/30. Comments: "BP decreased...RN Aware"
No nurse documentation or post treatment nursing assessment is documented. In addition, Blood pressure was not rechecked until 13:01 (30 minutes post abnormal finding).
Treatment Record for: 3/14/2022
12:16 PM: Intradialytic B/P 224/104
12:19 PM: B/P 201/79
2:01 PM: B/P 80/31
No documentation of post treatment nursing assessment is documented.
Treatment Record for: 3/16/2022
12:31 PM: Intradialytic B/P 215/84
13:01 PM: B/P 178/50
No documentation of post treatment nursing assessment is documented. In addition, Blood pressure was not rechecked until 13:01 (30 minutes post abnormal finding).
MR #5, Start of Care: 2/3/22
Treatment Record for: 4/11/2022
2:10 PM: B/P 237/109. Comment by PCT "B/P High, Pt (patient) not feeling well. UF (ultrafiltration) off"
2:11 PM: B/P 219/81. Comment by PCT "Pt (patient) c/o (complained of) headache. RN aware"
2:16 PM: B/P 218/97. Comment by PCT, "Tx (treatment) stopped.."
"Discharge status: Discharge/transferred to another short-term general hospital for inpatient care."
No nurse documentation throughout patient complaints or post treatment nursing assessment is documented.
Treatment Record for: 4/18/2022
12:31 PM: B/P 201/75
12:39 PM: B/P 177/75
13:01 PM: B/P 204/83. Comments by PCT, "...RN Aware"
No nurse documentation or post treatment nursing assessment is documented
MR #10, Start of Care: 12/8/18.
Treatment Records
4/20/22: No B/P measurements from 6:54 PM through 9:37 PM.
4/22/22: No B/P measurements from 4:31 PM through 7:59 PM.
4/24/22: No B/P measurements from 5:05 PM through 7:39 PM.
4/25/22: No B/P measurements from 5:26 PM through 7:26 PM
4/27/22: No B/P measurements from 5:22 PM through post-treatment at 9:11 PM.
4/28/22: No B/P measurements from 6:07 PM through 7:07 PM and from 7:39 PM through 9:08 PM
4/29/22: No B/P measurements from 4:26 PM through 6:10 PM and from 6:10 PM through post-treatment at 8:05 PM
5/5/22: No B/P measurements from 9:20 PM through 11:29 PM and from 11:58 PM through end of treatment at 1:04 AM
A review of nursing documentation and clinical visits from March and April 2022 did not reveal any documentation of patient education concerning the need for B/P checks every 30 minutes during treatment.
An interview with the facility administrator and clinical manager on 5/12/22 at approximately 12:00 PM confirmed the above findings.
Plan of Correction:100% of clinical ICHD teammates were in-serviced on Policy 1-03-08 "Pre- Intra-Post Treatment Data Collection, Monitoring, and Nursing Assessment". Verification of attendance will be evidenced by a signature sheet. Teammates will be instructed using surveyor observations as examples with emphasis on, but not limited to, the following: 1) Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring i. For non-nocturnal treatments is completed at least every thirty (30) minutes, 2) Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. Data collection includes but is not necessarily limited to; measurement of patient temperature, measurement of blood pressure (BP)...heart or pulse rate...patient weight, respiration rate, patient's report of well-being...vascular access status, 3) The nursing assessment will be performed and documented by a licensed nurse...includes the following components: review of patient reports, data collection, complaints and response to treatment, verification of machine safety checks...prescription, review of documentation for accuracy, completion and patient data, a physical assessment..., 4) Intradialytic Data Collection/Assessment...abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately, 5) The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary..., 6) The licensed nurse notifies the physician... as needed of changes in patient status..., 7) Post Treatment Data Collection/Assessment: the PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings, 8) If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse, 9) The licensed nurse will assess the patient prior to discharge, 10) Licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions or notification of physician is necessary prior to discharge of the patient from the facility..., and 11) Abnormal findings; Blood Pressure-Intradialytic: difference of 20 mm/Hg increase or decrease from patient's last intradialytic treatment BP reading.... 100% of facility HHD teammates were in-serviced on Policy 12-03-07 "Intradialytic Treatment Monitoring" and Policy 12-01-28 "Home Dialysis Monitoring and Ongoing Patient Education". Verification of attendance will be evidenced by a signature sheet. Teammates will be instructed using surveyor observations as examples with emphasis on, but not limited to, the following: 1) Home hemodialysis... Treatment checks should be completed at least every thirty (30) minutes or as prescribed by a physician. At a minimum, obtain and document the following: blood pressure, heart rate, blood and dialysate flows, arterial and venous pressures, fluid removal and/or replacement...vascular access visible and line connections intact, patient status and subjective well-being and patient's face visible...changes are reported to the registered nurse; appropriate action is taken and documented, including patient response..., and 2) The Home hemodialysis facility will: retrieve and review complete self-monitoring data and other information from home hemodialysis and/or self-care patients or their designated caregivers at least every two (2) months. The facility interdisciplinary team monitors the patient's status to determine if the patient is following the individualized treatment plan and/or is having any problems at home.... The Facility Administrator (FA) or designee will audit 25% of ICHD post treatment flow sheets each shift daily x 2 weeks and then 25% post treatment flow sheets weekly x 2 to verify that post treatment data assessment and licensed nurse documentation is per policy. The FA or designee will audit 100% of home treatment forms for the next 3 months to verify compliance. Ongoing compliance will be monitored by 10% of flow sheets monthly per the medical record audit. The Facility Administrator will report findings to the Medical Director in the monthly QAPI meeting, known as the Facility Health Meeting (FHM). The FA is responsible for ongoing compliance with this Plan of Correction (POC).
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