Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 9, 2024 through September 11, 2024, FMC Dialysis Services - Graduate 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)(2) STANDARD
EP Testing Requirements
Name - Component - 00
§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2).
*[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]:
(2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following:
(i) Participate in a full-scale exercise that is community-based every 2 years; or
(A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or
(B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event.
(ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed.
*[For Hospices at 418.113(d):]
(2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following:
(i) Participate in a full-scale exercise that is community based every 2 years; or
(A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or
(B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed.
*[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):]
(2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed.
*[For PACE at §460.84(d):]
(2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or
(B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed.
*[For LTC Facilities at §483.73(d):]
(2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise.
(B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed.
*[For ICF/IIDs at §483.475(d)]:
(2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following:
(i) Participate in an annual full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or.
(B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event.
(ii) Conduct an additional annual exercise that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed.
*[For HHAs at §484.102]
(d)(2) Testing. The HHA must conduct exercises to test the emergency plan at
least annually. The HHA must do the following:
(i) Participate in a full-scale exercise that is community-based; or
(A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or.
(B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event.
(ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following:
(A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or
(B) A mock disaster drill; or
(C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed.
*[For OPOs at §486.360]
(d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following:
(i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event.
(ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed.
*[ RNCHIs at §403.748]:
(d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following:
(i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan.
(ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.
Observations:
Based on a review of the facility emergency preparedness program, facility policy, and an interview with the facility administrator, the facility failed to conduct exercises to test the emergency plan at least annually.
Findings include:
A review of facility policy titled "Guidelines for Emergency Preparedness" on September 11, 2024, at approximately 10:00 am states, "Community Based Drill: Annually, each facility MUST participate in a community-based disaster drill...Mock Table Top Drill: In addition to the community drills, facilities must select an event of high likelyhood and conduct a table-top drill...Actual Emergency: If facility is involved in an actual disaster, it can take the place of community-based drill or tabletop drill..."
A review of the facility emergency preparedness program was conducted on September 11, 2024 at approximately 9:30 am, revealed no documentation of emergency plan training exercises for 2023.
An interview with the facility administrator confirmed that there was no documentation of emergency plan exercises for 2023.
Plan of Correction:The meeting will emphasize the importance of ensuring the facility conducts an emergency plan training exercises
annually, including facility participation in a community based disaster drill and a facility mock table top drill. The facility will ensure documented evidence of participation in the drills will be available for review.
The in-service will be completed by 9/27/2024. Documentation of the meeting will be onsite at the facility.
For ongoing compliance, the CM or designee will conduct audits quarterly when the community and table top drills are scheduled, for the next two (2) drills. A POC audit tool will be used for the audits. At that time if 100% compliance is sustained the audits will be completed following the QAPI auditing schedule.
Staff found to be non-compliant will be re-educated and counseled.
The CM will present the results of the audits at the QAPI meetings. The QAPI committee is responsible to review the findings, provide oversight and take actions if indicated.
Completion Date: 10/16/24
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on September 9, 2024 through September 11, 2024, FMC Dialysis Services - Graduate, 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:
494.60(c)(4) STANDARD
PE-HD PTS IN VIEW DURING TREATMENTS
Name - Component - 00
Patients must be in view of staff during hemodialysis treatment to ensure patient safety, (video surveillance will not meet this requirement).
Observations:
Based on a review of facility policy, observations of the treatment area, and an interview with the facility administrator, the facility failed to follow its policy regarding assessment and monitoring of patient's access site for six (6) patients of fifteen (15) patients observed while receiving incenter hemodialysis. (Patient at station #1, 3, 4, 6, 8, and 10).
Findings include:
A review of facility policy titled "Patient Assessment and Monitoring" conducted on September 11, 2024 at approximately 11:15 AM states, "During treatment: Observe connections are secure and visible...Ensure access remains uncovered throughout the treatment..."
Observation of the dialysis treatment area was conducted on September 10, 2024 from 9:45 AM through 12:00 PM.
At 9:45 AM, the patient's at the following stations were observed to have their dialysis access sites covered by a blanket, were not visible for inspection, and remained covered throughout the remaing duration of their treatment:
Station #1
Station #3
Station #4
Station #6
Station #8
Station #10
An interview with the facility administrator conducted on September 11, 2024 at approximately 12:10 PM confirmed the above findings.
Plan of Correction:The meeting will focus on ensuring that patient's vascular access remains uncovered and is visible at all times throughout the treatment. The meeting will also include ensuring patient monitoring and safety checks are being performed, verifying patient's access remains uncovered and visible.
Inservicing will be completed by 9/27/2024. All training documentation is on file at the facility.
The CM or designee will perform daily audits for two (2) weeks. At that time if one hundred percent (100%) compliance is observed the audits will then be completed 2x/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A Plan of Correction (POC) specific 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 will be monitored by the QAPI committee.
Completion Date: 10/16/24
494.80(a)(2) STANDARD
PA-ASSESS B/P, FLUID MANAGEMENT NEEDS
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
Blood pressure, and fluid management needs.
Observations:
Based on a review of facility policy, medical records (MR), and an interview with the facility administrator, the facility did not follow its policy for patient assessment and monitoring for four (4) of seven (7) MRs reviewed, (MR # 1, 3, 4, and 6).
Findings include:
A review of facility policy titled "Patient Assessment and Monitoring" conducted on September 11, 2024 at approximately 11:15 AM states, "If the PCT/LPN (patient care technician/licensed practical nurse) note any changes or abnormal findings in the patient's condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient. The nurse will notify the patient's physician of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The registered nurse ill assess/re-assess any findings addressed pre or during treatment as needed...During treatment: Blood Pressure: Recheck blood pressures after a drop that requires interventions...Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings, Report to the nurse: Systolic blood pressures greater than 180 mm/Hg; Diastolic blood pressures greater than 100 mm/Hg; Blood Pressure less than or equal to 100 mm/Hg systolic...Reported by patient: Report to the nurse any complaints by the patient during treatment...Document any findings and interventions in the medical record..."
A review of MRs was conducted on 9/9/2024 from approximately 12:20 PM to 2:20 PM and on 9/10/2024 from approximately 8:30 AM to 9:30 AM.
MR #1, Start of Care: 6/22/2022. Review of treatments sheets for 8/26/2024, 9/3/2024, and 9/7/2024 revealed the following:
8/26/2024:
Pre-treatment blood pressure: 105/58
RN documented at 3:01 PM, B/P 85/39 "RN notified"
RN post assessment at 4:46 PM states, "tolerated treatment well and ended successfully with no problems. met estimated dry weight (EDW)."
There is no documentation of a recheck of the blood pressure and no documentation of RN acknowledgement/patient assessment or if any interventions were performed at the time of occurrence.
9/3/2024:
Pre-treatment blood pressure: 114/65
PCT documented at 12:30 PM, B/P 88/56 "RN notified"
PCT documented at 1:30 PM, B/P 84/42 "RN notified"
RN post assessment at 3:51 PM states, "Treatment tolerated well, bleeding stopped, bandaids intact, reinforce medication compliance. Review EDW, diet, and fluid restrictions. Out ambulatory with walker, no distress noted."
There is no documentation of a recheck of the blood pressure and no documentation of RN acknowledgement/patient assessment or if any interventions were performed at the time of occurrence.
9/7/2024:
PCT documented at 12:51 PM: "Resting comfortably, Access visible; RN notified, Patient alert, UF goal down 2500, complained of feeling hot"
RN post assessment at 3:41 PM states, "treatment tolerated well, bleeding stopped, bandaids intact, reinforce medication compliance. Review EDW, diet, and fluid restrictions. Out ambulatory with walker, denies complaints. No distress noted. No standing BP - balance."
There is no documentation RN acknowledgement/patient assessment or if any interventions were performed at the time of occurrence.
MR #3, Start of Care: 7/29/29. Review of treatment sheet for 8/28/2024 revealed the following:
8/28/2024:
Pre-treatment B/P 156/89
PCT documented at 8:03 AM, B/P 175/104 "Resting comfortably, patient alert"
RN post assessment at 12:53 PM states, "treatment completed as ordered. EDW met. D/C from clinic in stable condition."
There is no documentation of a recheck of the blood pressure and no documentation of RN notification and therefore, no RN patient assessment or if any interventions were performed at the time of occurrence.
MR #4, Start of Care: 2/22/2022. Review of treatment sheet for 9/4/2024 revealed the following;
9/4/2024:
PCT documented at 6:34 AM "200 NSS given complained of cramping, uf off, goal lowered to 3.5"
PCT documented at 9:26 AM, B/P 101/54 "complained of lightheadedness bp low; 200 nss given, uf off"
PCT documented at 9:53 AM "complained of nausea, dizziness"
RN post assessment at 11:36 AM states, "Patient terminated treatment early per request, offered patient a treatment for tomorrow due to missed treatment on 9/2. patient declined. education provided. patient verbalized understanding. Nurse practioner aware."
There is no documentation that PCT notified the RN of any of the above findings and therefore, no RN patient assessment performed at the time of occurances.
MR #6, Start of Care: 8/13/2024. Review of treatment sheets for 9/5/2024 revealed the following:
9/5/2024:
Pre-treatment B/P 142/89
PCT documented at 1:07 PM, B/P 131/101 "Resting comfortable"
RN post assessment at 4:32 PM states, "UF removal tolerated, no difficulties during treatment reported. 1.6 kg above EDW post treatment. stable at time of discharge, no complaints."
There is no documentation of recheck of the blood pressure or that the PCT notified the RN of the above finding and therefore, no RN patient assessment performed at the time of occurrence.
An interview conducted with the facility administrator on 9/11/2024 at approximately 12:10 PM confirmed the above findings.
Plan of Correction:The meeting will focus on:
Ensuring Patient care technician (PCT), Licensed practical nurse (LPN) are notifying the Registered nurse (RN) and attending physician as necessary of all patients with hypertensive episodes, hypotensive episodes or any abnormal findings for further evaluation.
Ensuring direct patient care (DPC) staff refers to RN team leader or charge nurse if patient presents with a systolic blood pressure greater than 180 mm/Hg and /or diastolic blood pressure greater than 100 mm/Hg and/or systolic blood pressure less than 100 mm/Hg.
RN staff will ensure interventions are documented as specified by the Physician.
Inservicing will be completed by 9/27/2024. All training documentation is on file at the facility.
The CM or designee will perform daily audits of 10% of patient treatment sheets for two (2) weeks. At that time if one hundred percent (100%) compliance is observed the audits will then be completed 2x/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A Plan of Correction (POC) specific 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 will be monitored by the QAPI committee.
Completion Date: 10/16/24
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 facility administrator, 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 seven (7) incenter hemodialysis patient MR's reviewed. (MR #1, 6, and 7).
Findings include:
A review of facility policy titled "Patient Assessment and Monitoring" on September 11, 2024 at approximately 11:15 AM states, "During Treatment: Machine Parameters and Extracorporeal Circuit: Check machine settings and measurements: Check prescribed blood flow rate is being achieved or reason is documented in medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct and the prescribed flow is being delivered...Document any findings and interventions in the medical record..."
A review of MRs was conducted on 9/9/2024 from approximately 12:20 PM to 2:20 PM and on 9/10/2024 from approximately 8:30 AM to 9:30 AM.
MR #1, Start of Care: 6/22/2022. Current Dialysis Orders: BFR: 400, DFR: Manual 500 ml/min. A review of Dialysis Treatment records revealed the BFR/DFR was not administered at prescribed rates on the following dates:
8/27/2024:
11:30 AM through 12:40 PM: No DFR is recorded.
12:40 PM through end of treatment at 2:43 PM: BFR was administered at 300 ml/min.
9/3/2024:
During entire treatment BFR was administered at 350 ml/min, and during entire treatment 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/DFR 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/DFR was administered at a rate different from the prescribed amount for any of the above dates.
MR #6: Admission Date: 8/13/2024. Current Dialysis orders: BFR: 400; DFR: Manual 600 ml/min. A review of Dialysis Treatment Details Reports revealed the DFR was not administered at prescribed rates on the following date:
8/29/2024:
During the entire treatment, 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 DFR to be administered at a rate different from the prescribed amount the above date and there was no documentation of a reason why the DFR was administered at a rate different from the prescribed amount for the above date.
MR #7: Admission Date: 12/5/2023. Current Dialysis order: BFR: 400; DFR: Manual 500 ml/min. A review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
8/31/2024:
During the entire treatment BFR was administered at 450 ml/min.
9/3/2024:
From 8:01 AM through 10:32 AM, the BFR was administered at 350 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 administrator conducted on September 11, 2024 at approximately 12:10 PM confirmed the above findings.
Plan of Correction:The meeting will focus on:
Providing guidance to the registered nurse on his/her responsibilities for patient oversight including evaluation and verification of patient treatment prescriptions.
Ensuring all physician treatment prescriptions contain specific orders or parameters for the BFR/DFR rate and is followed as prescribed.
Reporting to Charge Nurse/Team Leader if the dialysis prescription order is not achievable or reporting to the attending Physician for further orders if the treatment prescription cannot be carried out as ordered.
Ensuring physician is notified when the patient's prescribed BFR/DFR orders could not be met.
Ensuring all staff complete accurate documentation of all care provided to the patients on the treatment sheet, inclusive of prescription changes during treatment and rational for changes to physician order.
Inservicing will be completed by 9/27/2024. All training documentation is on file at the facility.
The CM or designee will perform daily audits of 10% of patient treatment sheets for two (2) weeks. At that time if one hundred percent (100%) compliance is observed the audits will then be completed 2x/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A Plan of Correction (POC) specific 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 will be monitored by the QAPI committee.
Completion Date: 10/16/24
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