Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey conducted October 17, 2022 through October 19, 2022, Fresenius Medical Care of Greene County, 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 unannounced onsite Medicare recertification survey conducted October 17, 2022 through October 19, 2022, Fresenius Medical Care of Greene County
was found 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 a review of facility policy, medical records (MR) and staff (EMP) interviews, it was determined that the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician for two (2) of five (5) MRs reviewed (MR4, MR9).
Findings include:
Review of facility policy completed on 10/19/22 at approximately 1:15 p.m. revealed: "Patient Monitoring and Safety Checks During Hemodialysis Treatment. Policy: Patient monitoring and safety check guidelines...Safety Check Machine Checks-Monitor and document Machine Checks every 30 minutes or more frequently as needed but not to exceed 45 minutes or per state regulations in the FKC treatment record...Machine checks include...Verify...DFR, BFR and UFR is set and functioning per treating physician order."
Review of MR4 completed on 10/18/22 between approximately 2:00 p.m. and 3: 30 p.m. revealed an admission date 10/3/22. Treatment sheets reviewed dated between 10/3/22 - 10/17/22. Patient orders dated 10/5/22 blood flow rate (BFR) 450, dialysate flow rate (DFR) 800. (Note: Treatment sheets below: facility uses military time).
10/5/22 BFR ran at 450 the entire treatment time. DFR ran at 600 the entire treatment time with exception for 12:07, DFR ran at 500.
10/7/22 At 12:43, 13:05, 13:22, 13:48, 14:03, 14:27 and 14:46 BFR ran at 500.
At 14:03, 14:27 and 14:46 DFR ran at 500.
10/10/22 BFR ran at 500 the entire treatment time.
At 12:00 and 12:40 DFR ran at 600. At 14:09 and 14:40 DFR ran at 500.
10/12/22 Patient orders blood flow rate (BFR) 500, dialysate flow rate (DFR) 800.
10/12/22 At 10:52, 11:12, 11:25, 11:49 and 12:10 DFR ran at 600. At 12:31, 12:43, 13:01, 13:20, 14:04 and 14:51 DFR ran at 500.
Review of MR9 completed on 10/18/22 between approximately 2:00 p.m. and 3: 30 p.m. revealed an admission date 5/19/21. Treatment sheets reviewed dated between 8/22/22 - 9/5/22. Patient orders dated 8/29/22 blood flow rate (BFR) 450, dialysate flow rate (DFR) 500. (Note: Treatment sheets below: facility uses military time).
8/29/22 BFR ran at 400 the entire treatment time.
9/2/22 BFR ran at 400 the entire treatment time.
Interview completed on 10/19/22 at approximately 1:00 p.m. with the Director of Operations and the Clinical Manager confirmed the above findings.
Plan of Correction: V 544 To ensure compliance the Clinic Manager (CM) or designee will in-service the direct patient care (DPC) staff on the following policy:
- Patient Monitoring and Safety Checks During Hemodialysis Treatment
The in-service will provide re-education on ensuring that the physician treatment orders are followed for every treatment. Emphasis will be placed on ensuring that any machine parameters not within the prescribed limits must be reported to the Registered Nurse (RN) for evaluation, intervention and if not resolved, physician notification. These parameters include the dialysate flow rate (DFR) and the blood flow rate (BFR). The reason the DFR and/or the BFR are not being achieved must be documented as well as the documentation of the RN notification by the patient care technician (PCT) with documentation by the RN of any intervention and physician notification.
The training will be completed by October 31, 2022, with documentation on file at the facility.
The CM or designee will perform audits for the next two (2) weeks to ensure an assessment was completed timely per policy. At that time, if compliance is sustained, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A plan of correction (POC) 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 audit results and report the findings to the QAPI Committee at the monthly meeting. Sustained compliance and oversight will be monitored by the QAPI committee.
Completion Date: November 30, 2022
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