Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted November 27, 2023 through November 30, 2023, Swarthmore Dialysis 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 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services-Emergency Preparedness.
Plan of Correction:
494.62(d) STANDARD
EP Training and Testing
Name - Component - 00
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on a review of medical records (MR), facility policy, and an interview with the facility clinical manager, the facility did not follow its policy regarding the performance of fire drills for five (5) of eleven (11) active MR's (MR# 1, 3, 4, 9 and 11).
Findings include:
A review of agency policy "Fire Drill" was conducted on November 30, 2023 at approximately 11:00 am. Policy reads in part, " quarterly, all FKC (Fresenius Kidney Care) facilities shall perform a fire drill for each shift of patients and staff including home therapies patient present in the facility and nocturnal shifts .... document patient participation in fire and the disaster drills on the patient participation in fire and disaster drills form .... Document fire drills, alarms and signal received by the monitoring services or fire department, and the patient and staff participation on the QAI checklists."
A review of MR's was conducted on May 19, 2021 at approximately 9:30 am.
MR #1, admission date: 9/21/23, did not have fire drills conducted for the third quarter of 2023.
MR #3, admission date: 7/16/18, did not have fire drills conducted for the first quarter of 2023.
MR #4, admission date: 7/13/21, did not have fire drills conducted for the first quarter of 2023.
MR #9, admission date: 9/5/23, did not have fire drills conducted for the third quarter of 2023.
MR #11, admission date: 6/12/23, did not have fire drills conducted for the second quarter of 2023.
An interview with the facility clinical manager on November 30, 2023 at approximately 12:00 PM confirmed the above findings.
Plan of Correction:Before December 31, 2023, the Clinical Manager or designee will hold a fire drill for all shifts of patients for the 4th quarter 2023. The emphasis to staff will be that all patient receive training per the "Fire Drill" and Patient Education" policies, as reviewed. Any patient not in attendance for the fire drill will be educated before December 31, 2023. If patients are absent the education will be provided and documented, upon return to facility.
All documented fire drill education will be available for review, at the facility.
Emphasis will be placed on the importance of ensuring that all patient have Fire Drill education quarterly, and as needed per policies.
Effective December 30, 2023, the Clinic Manager or designee will conduct monthly fire drill audits for 3 months, to ensure that all patients have been trained on the fire drill evacuation processes. The Clinic Manager or designee will ensure all new admissions receive Fire Drill and Evacuation education upon admission.
The AA will create a patient list each quarter and cross out all patient's as they are educated to ensure no patient are missed.
The AA will insert the Fire Drill and Evacuation paperwork into the new admission packet. Direct patient care staff will return the completed form to the AA for filing same day as admission.
The Clinical Manager is responsible to review, analyze and trend all audit results as related to this Plan of Correction prior to presenting to the QAPI Committee monthly.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on November 27, 2023 through November 30, 2023, Swarthmore Dialysis 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 clinical manager, the facility failed to ensure the blood flow rate (BFR) and/or the dialysate flow rate (DFR) was administered per physician order for three (3) of eleven (11) incenter hemodialysis patient MR's reviewed. (MR #3, 9 and 10).
Findings include:
A review of facility policy titled "Unable to Achieve Prescribed Blood Flow Rate" was conducted on November 30, 2023 at approximately 11:00 am. The policy reads in part, "Policy: staff, patient and/or care partner will recognize and report to the nurse in charge the inability to achieve prescribed blood flow rate .... Actions To Achieve Prescribed Blood Flow Rate: staff, patient and/or care partner should take the following actions to reduce the possibility of poor access blood flow: projection bloodlines in a way that keeps them from restricting flow kinking, ensure access and bloodline clamps have been appropriately opened/removed, properly cannulate access, avoid the flipping needles, administer heparin as ordered. staff should review the following: ensure needle size is appropriate for prescribed the blood flow rate, monitor KECN, perform access flow testing per physician order, ensure adequate heparin to minimize dialyzer clotting .... Notification: notify physician/extender if unable to achieve prescribed the blood flow rate. Documentation: document in patient ' s treatment record what action taken to address the inadequate blood flow and if unable to resolve. The nurse shall document any physician orders."
A review of patient medical records (MR) was conducted on November 27, 2023 starting from approximately 12:50 AM and November 28, 2023 starting from 9:30 AM.
MR #3: Admission Date: 7/16/18. Total treatment records reviewed: 7, Treatment record reviewed between 11/13/23 to 11/27/23.
Order reads in part the following: Frequency: Monday, Wednesday, Friday, target weight: 102.5 kg; Blood Flow Rate (BFR): 400 mL/min; Dialysate Flow Rate (DFR): 600 mL/min
Review of Dialysis Treatment Details Reports revealed the BFR and DFR were not administered at prescribed rates on the following dates:
On 11/17/23, during entire treatment, the BFR was administered at 450 mL/min, and the DFR was administered at 800 mL/min.
On 11/22/23, during entire treatment, the DFR was administered at 800 mL/min.
On 11/27/23, during entire treatment the BFR was administered at 420 mL/min, end the DFR was administered at 700 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 #9: Admission Date: 9/5/23. Total treatment records reviewed: 6, Treatment record reviewed between 11/13/23 to 11/24/23.
Order reads in part the following: Frequency: Monday, Wednesday, Friday, target weight: 69 kg; Blood Flow Rate (BFR): 450 mL/min; Dialysate Flow Rate (DFR): 675 mL/min.
Review of Dialysis Treatment Details Reports revealed the BFR and DFR was not administered at prescribed rates on the following dates:
On 11/13/23, between 12:16 PM to 12:51 PM, the BFR was administered at 300 mL/min, and the DFR was administered at 800 mL/min.
On 11/13/23, between 12:51PM to 2:52 PM, the BFR was administered at 300 mL/min, and the DFR was administered at 500 mL/min.
On 11/13/23, between 2:52 PM to 3:53 PM, the BFR was administered at 325 mL/min, and the DFR was administered at 600 mL/min.
On 11/15/23, between 9:44 AM to 10:02 AM, the BFR was administered at 300 mL/min, and the DFR was administered at 500 mL/min.
On 11/15/23, between 10:02 AM to 10:27 AM, the BFR was administered at 325 mL/min, and the DFR was administered at 800 mL/min.
On 11/15/23, between 10:27 AM to 11:02 AM, the BFR was administered at 300 mL/min, and the DFR was administered at 800 mL/min.
On 11/15/23, between 11:02 AM to 1:45 PM, the BFR was administered at 300 mL/min, and the DFR was administered at 800 mL/min.
On 11/17/23, between 10:50 AM to 11:29 AM, the BFR was administered at 300 mL/min, and the DFR was administered at 800 mL/min.
On 11/17/23, between 11:29 AM to 12:02 PM, the BFR was administered at 250 mL/min, and the DFR was administered at 800 mL/min.
On 11/17/23, between 12:02 PM to 12:29 PM, the BFR was administered at 270 mL/min, and the DFR was administered at 800 mL/min.
On 11/17/23, between 12:29 PM to 1:00 PM, the BFR was administered at 250 mL/min, and the DFR was administered at 800 mL/min.
On 11/17/23, between 1:00 PM to 1:26 PM, the BFR was administered at 300 mL/min, and the DFR was administered at 800 mL/min.
On 11/17/23, between 1:26 PM to 2:44 PM, the BFR was administered at 350 mL/min, and the DFR was administered at 800 mL/min.
On 11/22/23, between 11:06 AM to 11:36 AM, the BFR was administered at 350 mL/min, and the DFR was administered at 800 mL/min.
On 11/22/23, between 11:36 AM to 3:05 PM, the BFR was administered at 400 mL/min, and the DFR was administered at 800 mL/min.
On 11/24/23, during entire treatment, the BFR was administered at 400 mL/min, and the DFR was administered at 800 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 #11: Admission Date: 6/12/23. Total treatment records reviewed: 6, Treatment record reviewed between 11/13/23 to 11/24/23.
Order reads in part the following: Frequency: Monday, Wednesday, Friday, target weight: 65 kg; Blood Flow Rate (BFR): 400 mL/min; Dialysate Flow Rate (DFR): 800 mL/min.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
On 11/13/23, between 4:20 PM to 4:52 PM, the BFR was administered at 200 mL/min, and the DFR was administered at 500 mL/min.
On 11/13/23, between 4:52 PM to 7:24 PM, the BFR was administered at 370 mL/min, and the DFR was administered at 600 mL/min.
On 11/13/23, between 7:24 PM to 7:56 PM, the BFR was administered at 350 mL/min, and the DFR was administered at 600 mL/min.
On 11/15/23, between 4:15 PM to 4:53 PM, the BFR was administered at 200 mL/min, and the DFR was administered at 500 mL/min.
On 11/15/23, between 4:53 PM to 7:28 PM, the DFR was administered at 600 mL/min.
On 11/17/23, between 3:13 PM to 4:02 PM, the BFR was administered at 200 mL/min.
On 11/17/23, between 4:02 PM to 6:42 PM, the BFR was administered at 350 mL/min, and the DFR was administered at 500 mL/min.
On 11/20/23, between 4:10 PM to 4:51 PM, the BFR was administered at 200 mL/min, and the DFR was administered at 500 mL/min.
On 11/20/23, between 4:51 PM to 5:36 PM, the BFR was administered at 350 mL/min.
On 11/20/23, between 5:36 PM to 5:53 PM, the BFR was administered at 330 mL/min, and the DFR was administered at 600 mL/min.
On 11/20/23, between 5:53 PM to 7:26 PM, the BFR was administered at 350 mL/min, and the DFR was administered at 600 mL/min.
On 11/20/23, between 7:26 PM to 7:38 PM, the BFR was administered at 300 mL/min, and the DFR was administered at 500 mL/min.
On 11/22/23, between 3:25 PM to 3:54 PM, the BFR was administered at 200 mL/min, and the DFR was administered at 500 mL/min.
On 11/22/23, between 3:54 PM to 4:22 PM, the BFR was administered at 350 mL/min.
On 11/22/23, between 4:22 PM to 6:56 PM, the BFR was administered at 300 mL/min.
On 11/24/23, between 4:05 PM 4:24 PM, the BFR was administered at 200 mL/min, and the DFR was administered at 500 mL/min.
On 11/24/23, between 4:24 PM to 6:52 PM, the BFR was administered at 335 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.
An interview with the facility clinical manager was conducted on November 30, 2023, at approximately 12:00 pm confirmed the above findings.
Plan of Correction:For ongoing compliance, the Clinical Manager or designee will in-service all patient care staff on policies: "Unable to Achieve Prescribed Blood Flow Rate" and "Patient Assessment and Monitoring". This meeting will focus on ensuring that all dialysis machine settings are monitored every 30 minutes, not to exceed 45 minutes.
The in-service will focus on ensuring that the patient's physician orders, to included but not limited to blood flow rate and dialysate flow rate are set as prescribed or RN is alerted to investigate reason why order(s) not obtained. Physician communication as needed, when order(s) not obtainable.
In-service will be completed by December 15, 2023, and the training documentation will be available for review at the facility.
Effective December 18, 2023, the Clinic Manager or designee will conduct daily audit for 2 weeks. If after 2 weeks, compliance is observed at 100%, the audit will be completed 2 times a week for 2 weeks, At that time, if compliance is maintained, the audit will follow the monthly QAPI schedule. A Plan of Correction specific auditing tool will be used for audits.
Issues of non-compliance will be addressed by the Clinical manager with re-education and counseling.
The Clinical Manager will review the audit results and report the findings at the monthly QAPI meeting for ongoing oversight and compliance. is responsible to review, analyze and trend all data and Monitor/Audit results as related to this Plan of Correction prior to presenting to the QAPI Committee monthly.
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