Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on December 15, 2020, DCI Renal Services of Pittsburgh 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 completed on December 15, 2020, DCI Renal Services of Pittsburgh was found 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 review of facility policy, observation of patients (PT) during in-center dialysis treatment and interview with facility staff, it was determined the facility failed to ensure the patient's access sites and bloodline connections were visible during in-center hemodialysis treatment for two (2) of nine (9) in-center hemodialysis patient observations (PT7, PT8).
Findings Included:
Review of facility policy on 12/17/2020 revealed "Subject...Hemodialysis Treatment Readings...Policy:..the nursing staff will perform routine monitoring...of the patient's overall condition and the status of the treatment itself a minimum of every 30 minutes and more frequently if needed...Procedure; The following parameters will be monitored...l. Access visibility and secured..."
Observation on 12/14/2020 between approximately 9:45 AM and 10:20 PM revealed that patient PT7 seated at station 19 had access site (left arm) covered with a blanket. Surveyor continued to monitor this patient/station during time documented. No staff members uncovered and visually assessed patient PT7 access site/bloodline connections during the observation time.
Observation on 12/14/2020 between approximately 10:25 AM and 11:05 AM revealed that patient PT8 seated at station 10 had access site (left arm) covered with a blanket. Surveyor continued to monitor this patient/station during time documented. No staff members uncovered and visually assessed patient PT8 access site/bloodline connections during the observation time.
An exit conference was conducted on 12/15/2020 at approximately 12:00 PM directly with facility manager (EMP2) and via phone facility administrator (EMP1). Above findings were reviewed.
Plan of Correction:1) Area Operations Director will be responsible to present proposed Plan of Correction to Governing Body at the January 21, 2021 monthly meeting.
2) Nurse Educator will be responsible to:
a) Create a patient education handout providing rationale for patients to not cover the dialysis access
b) Educate the patient care staff at the January 4, 2021 staff meeting on:
i) The patient education handout entitled "Be Safe: Always Keep Your Access Site Uncovered"
ii) The existing policy "Hemodialysis Treatment Readings" to include:
1. Procedure Step 1: "The following parameters will be monitored at a minimum of 30 minute intervals, with legible documentation in the following areas
2. Procedure Step1l: "Access visibility and secured (Access Vis/Sec)"
3. Procedure Step 1m: "Connections bridge tapped (Bridge Taped)"
c) Create audit spreadsheet to review:
i) Flowsheets for compliance with documentation
ii) Distribution of the patient education handout
d) Provided education on the audit spreadsheet to the Charge Nurse or Designee
3) Direct Patient Care Staff will be responsible to:
a) Observe and document the following with each hemodialysis treatment reading:
i) Visibility of access site and connections
ii) Visibility of security of bridge taped connections
iii) Education provided to patient with each observation of covered access
b) Provide each patient with education and the handout entitled "Be Safe: Always Keep Your Access Site Uncovered" and obtain patients signature on the handout to indicate understanding and compliance.
4) Charge Nurse or designee will be responsible to perform audits beginning January 5, 2021 as follows:
a) 100% of flowsheets will be audited daily for 2 weeks
b) If 100% compliant, 100% of one treatment day's flowsheets will be audited weekly for 4 weeks
c) If 100% compliant, 100% of one treatment day's flowsheets will be audited monthly X 3 months
d) If 100% compliant, 100% of one treatment day's flowsheets will be audited quarterly X 2 quarters
e) 100% of patient education handouts will be distributed, signed, and filed in the medical record by January 31, 2020 and issued to new patients upon admission.
f) Audit frequency may be increased based on compliance
5) Nurse Manager or designee will be responsible to:
a) File the signed and dated January 4, 2021 staff meeting attendance list and agenda in each personnel file.
b) Review and initial audits per audit schedule
c) Failure to meet requirement will be addressed with staff through individual discussion, reeducation, or disciplinary action
d) Results will be documented in QAPI, presented to Governing Body and recorded in meeting minutes.
6) Governing Body will determine frequency of future audits based upon compliance.
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 review of facility policy, medical records (MR) and interview with facility staff, the facility failed to assess and manage patient's blood pressure and/or fluid management needs for (3) of five (5) in center hemodialysis clinical records reviewed (MR3 - MR5).
Findings Included:
Review of facility policy on 12/17/2020 revealed "Subject...Hemodialysis Treatment Readings...Policy: "Subject...Hemodialysis Treatment Readings...Policy:..the nursing staff will perform routine monitoring...of the patient's overall condition and the status of the treatment itself a minimum of every 30 minutes and more frequently if needed...Procedure:..2. Normal parameters...will be established by the Medical Director...for use by the nursing staff...a. The Charge RN (registered nurse) will be notified of the following:..Blood Pressure Pre Treatment Systolic < 90 or > 200; Diastolic > 120...Blood Pressure Intra Treatment > 20 point drop from prior reading and/or Systolic < 90 or > 200; Diastolic > 120...Blood Pressure Post Treatment Systolic < 90 or > 200; Diastolic < 50 or > 120...b. The physician will be notified of the following:..Blood Pressure Pre Treatment Systolic < 90 or > 200; Diastolic < 50 or > 120 if symptomatic...Blood Pressure Post Treatment Systolic < 90 or > 200; Diastolic > 120 if symptomatic...3. Charge RN will obtain an order from the physician for patients that chronically fall outside the parameters outlined..."
Review of MR3 on 12/11/2020 at approximately 10:10 AM revealed admission date 9/25/2020. "...Hemodialysis...Standing Admission Orders...Intradialytic Vital Signs...Notify Charge Nurse of SBP (systolic blood pressure) < 90 or > 200 or if SBP drops > 20 mmHg (millimeters of mercury)..." A review of dialysis flowsheets from 11/27/2020 to 12/9/2020 revealed:
11/27/2020, 7:03 AM BP 153/75, 7:30 AM BP 127/68 (drop of 26 points between 30 minute checks).
12/2/2020, 6:30 AM BP 163/73, 7:00 AM BP 139/71 (drop of 24 points between 30 minute checks).
12/9/2020, 6:34 AM BP 161/83, 7:00 AM BP 126/57 (drop of 35 points between 30 minute checks).
There was no documented evidence of notification/interventions for patient blood pressures dropping below parameters per physician orders and/or facility policy noted in CR3 treatment records for aforementioned treatment dates.
Review of MR4 on 12/11/2020 at approximately 11:05 AM revealed admission date 2/12/2020. "...Hemodialysis...Standing Admission Orders...Vital Signs...Pre and Post Dialysis...Blood Pressure-Notify physician if systolic BP is < 90 or > 200 mmHg...and/or patient is symptomatic..."
A review of dialysis flowsheets from 11/27/2020 to 12/9/2020 revealed:
11/27/2020, Vital Signs, Pre, BP Sit 210/79.
12/7/2020, Vital Signs, Pre, BP sit 203/86.
There was no documented evidence of notifications/interventions for patient blood pressures above parameters per physician orders and/or facility policy noted in CR4 treatment records for aforementioned treatment dates.
Review of MR5 on 12/11/2020 at approximately 12:40 PM revealed admission date 10/14/2019. "...Hemodialysis...Standing Admission Orders...Vital Signs...Pre and Post Dialysis...Blood Pressure-Notify physician if systolic BP is < 90 or > 200 mmHg or diastolic BP is > 120 and/or patient is symptomatic...Intradialytic Vital Signs...Notify Charge Nurse of SBP < 90 or > 200 or if SBP drops > 20 mmHg..." A review of dialysis flowsheets from 11/25/2020 to 12/8/2020 revealed:
11/25/2020, Vital Signs, Pre, BP Stand 217/119 BP Sit 212/118.
11/28/2020, Vital Signs, Pre, BP Sit 203/99; Intradialytic..9:00 AM BP 171/82, 9:30 AM BP 128/69 (drop of 43 points between 30 minute checks).
12/5/2020, Vital Signs, Pre, BP Stand 236/120, BP Sit 226/108; Intradialytic..6:08 AM BP 200/103, 6:30 AM BP 200/107.
12/8/2020, Vital Signs, Pre, BP Sit 226/108; Intradialytic..11:30 AM BP 202/100, 11:51 AM BP 200/102; , Post BP Sit 232/102.
There was no documented evidence of notifications/interventions for patient blood pressures above parameters or dropping below parameters per physician orders and/or facility policy noted in CR5 treatment records for aforementioned treatment dates.
An exit conference was conducted on 12/15/2020 at approximately 12:00 PM directly with facility manager (EMP2) and via phone facility administrator (EMP1). Above findings were reviewed.
Plan of Correction:1) Area Operations Director will be responsible to present proposed Plan of Correction to Governing Body at the January 21, 2021 monthly meeting.
2) Nurse Educator will be responsible to:
a) Educate the patient care staff at the January 4, 2021 staff meeting on the "Annual HD Standing Orders", "In-Center Hemodialysis Standing Admission Orders" existing policy "Hemodialysis Treatment Readings" to include:
i) Procedure Step 2 "Normal parameters for hemodialysis will be established by the Medical Director and will be posted and available for use by the nursing staff. For each parameter, guidance will be given regarding actions to take if readings fall outside the established parameters..."
ii) Procedure Step 2a "The Charge RN will be notified of the following:
1. Blood Pressure Pre Treatment Systolic <90 or >200; Diastolic >120
2. Blood Pressure Intra Treatment >20 point drop from prior reading and / or Systolic <90 or >200; Diastolic >120
3. Blood Pressure Post Treatment Systolic <90 or >200; Diastolic <50 or >120"
iii) Procedure Step 2b "The Physician will be notified of the following:
1. Blood Pressure Pre Treatment Systolic <90 or >200; Diastolic <50 or >120 if symptomatic
2. Blood Pressure Post Treatment Systolic <90 or >200; Diastolic >120 if symptomatic."
iv) Procedure Step 3 "Charge RN will obtain an order from the physician for patients that chronically fall outside the parameters outlined and it will be recorded in the tickler."
b) Create an audit spreadsheet to review:
i) Proper notification of the Charge Nurse for blood pressures outside normal parameters pre, intra, or post treatment
ii) Proper notification of the MD for blood pressures outside pre or post treatment
iii) Specific orders documented in the tickler for patients whose BP chronically fall outside normal parameters.
c) Provide education on the audit spreadsheet to the Charge Nurse or designee
3) Direct Patient Care Staff will be responsible to:
a) Readjust BP cuff if reading is outside of identified parameters and perform BP recheck
b) Evaluate each intra dialysis reading to ascertain drops >20 points from the last reading
c) Document on the hemodialysis flowsheets the actions taken for blood pressures that fall outside of normal parameters to include notification of the RN or Charge Nurse
d) The Charge RN will obtain and record in the tickler section of the hemodialysis flowsheet an order for patients that are exceptions to the BP parameters
4) Charge Nurse or designee will be responsible to perform audits beginning January 5, 2021 as follows:
a) 100% of flowsheets will be audited daily for 2 weeks
b) If 100% compliant, 100% of one treatment day's flowsheets will be audited weekly for 4 weeks
c) If 100% compliant, 100% of one treatment day's flowsheets will be audited monthly X 3 months
d) If 100% compliant, 100% of one treatment day's flowsheets will be audited quarterly X 2 quarters
e) Audit frequency may be increased based on compliance
5) Nurse Manager or designee will be responsible to:
a) File the signed and dated January 4, 2021 staff meeting attendance list and agenda in each personnel file.
b) Review and initial audits per audit schedule
c) Failure to meet requirement will be addressed with staff through individual discussion, reeducation, or disciplinary action
d) Results will be documented in QAPI, presented to Governing Body and recorded in meeting minutes.
6) Governing Body will determine frequency of future audits based upon compliance
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 a review of facility policy, medical records (MR), and interview with facility staff, it was determined the facility failed to provide the necessary care and services to manage the patient's volume status for two (2) of five (5) in-center hemodialysis clinical records reviewed (MR4, MR5).
Findings Included:
Review of facility policy on 12/17/2020 revealed "Subject...Hemodialysis Treatment Readings...Policy: "Subject...Hemodialysis Treatment Readings...Policy:..the nursing staff will perform routine monitoring...of the patient's overall condition and the status of the treatment itself a minimum of every 30 minutes and more frequently if needed...Procedure:..2. Normal parameters...will be established by the Medical Director...for use by the nursing staff...a. The Charge RN (registered nurse) will be notified of the following:..Pre Treatment Weight Gain > 6 kg (kilograms)...Post Treatment Weight Loss > or < 1 kg from EDW (estimated dry weight)...3. Charge RN will obtain an order from the physician for patients that chronically fall outside the parameters outlined..."
Review of MR4 on 12/11/2020 at approximately 11:05 AM revealed admission date 2/12/2020. "...Hemodialysis...Standing Admission Orders...Estimated Dry Weight (EDW) may be increased or decreased by 0.5 - 1.0 kg by charge RN for hypertension, edema, and/or SOB..."A review of dialysis flowsheets from 11/27/2020 to 12/9/2020 revealed:
11/27/2020, Ordered EDW 46.5 kg, weight post-treatment 55.6 kg (patient 9.1 kg over EDW weight post-treatment).
11/30/2020, Ordered EDW 46.5 kg, weight post-treatment 54.3 kg (patient 7.8 kg over EDW weight post-treatment).
12/2/2020, Ordered EDW 46.5 kg, weight post-treatment 54.0 kg (patient 7.5 kg over EDW weight post-treatment).
12/4/2020, Ordered EDW 46.5 kg, weight post-treatment 54.5 kg (patient 8.0 kg over EDW weight post-treatment).
12/7/2020, Ordered EDW 46.5 kg, weight post-treatment 51.2 kg (patient 4.7 kg over EDW weight post-treatment).
Surveyor was unable to discern that EDW was revised and plan of care for volume status was individualized for this patient.
Review of MR5 on 12/11/2020 at approximately 12:40 PM revealed admission date 10/14/2019. "...Hemodialysis...Standing Admission Orders...Estimated Dry Weight (EDW) may be increased or decreased by 0.5 - 1.0 kg by charge RN for hypertension, edema, and/or SOB..."A review of dialysis flowsheets from 11/25/2020 to 12/8/2020 revealed:
11/25/2020, Ordered EDW 149.0 kg, weight post-treatment 154.3 kg (patient 4.3 kg over EDW weight post-treatment).
11/28/2020, Ordered EDW 149.0 kg, weight post-treatment 160.0 kg (patient 11.0 kg over EDW weight post-treatment).
12/5/2020, Ordered EDW 149.0 kg, weight post-treatment 159.3 kg (patient 10.3 kg over EDW weight post-treatment).
12/8/2020, Ordered EDW 149.0 kg, weight post-treatment 163.7 kg (patient 14.7 kg over EDW weight post-treatment).
Surveyor was unable to discern that EDW was revised and plan of care for volume status was individualized for this patient.
An exit conference was conducted on 12/15/2020 at approximately 12:00 PM directly with facility manager (EMP2) and via phone facility administrator (EMP1). Above findings were reviewed.
Plan of Correction:1) Area Operations Director will be responsible to present proposed Plan of Correction to Governing Body at the January 21, 2021 monthly meeting.
2) Nurse Educator will be responsible to:
a) Educate the patient care staff at the January 4, 2021 staff meeting on the "Annual HD Standing Orders", "In-Center Hemodialysis Standing Admission Orders" existing policy "Hemodialysis Treatment Readings" to include:
i) Procedure Step 2 "Normal parameters for hemodialysis will be established by the Medical Director and will be posted and available for use by the nursing staff. For each parameter, guidance will be given regarding actions to take if readings fall outside the established parameters..."
ii) Procedure Step 2a "The Charge RN will be notified of the following:
1. Post Treatment Weight Loss > or < 1 kg from EDW"
iii) Procedure Step 2b "The Physician will be notified of the following:
1. Post Treatment Weight Loss if an extra treatment is needed"
iv) Annual HD Standing Order stating:
1. "EDW may be increased or decreased by 0.5-1.0 kg by Charge RN for hypertension, edema, and / or SOB
2. Consider bringing patient back for additional short hemodialysis or isolated UF treatment the following day if required for further fluid removal.
3. Notify Charge RN if patient's post-treatment weight is over goal by 1 kg."
v) Procedure Step 3 "Charge RN will obtain an order from the physician for patients that chronically fall outside the parameters outlined and it will be recorded in the tickler."
b) Create an audit spreadsheet to review:
i) Proper notification of the Charge Nurse for post treatment weight that is > 1kg over goal
ii) Documentation to support that additional treatment was offered to patient for additional fluid removal
iii) Documentation to support that the MD was notified of need for the additional treatment or adjustment of EDW
iv) Documentation in the Patient's Plan of Care to indicate a review and/or revision of the patient's volume status
c) Provide education on the audit spreadsheet to the Charge Nurse or designee
3) Direct Patient Care Staff will be responsible to:
a) Notify the Charge Nurse if the patient's post treatment weight is > 1 kg over goal
b) The Charge RN will notify the MD for need for additional treatment or adjustment of EDW
4) IDT will be responsible to evaluate the patient's volume status periodically and adjust the individual plan of care
5) Charge Nurse or designee will be responsible to perform audits beginning January 5, 2021 as follows:
a) 100% of flowsheets will be audited daily for 2 weeks
b) If 100% compliant, 100% of one treatment day's flowsheets will be audited weekly for 4 weeks
c) If 100% compliant, 100% of one treatment day's flowsheets will be audited monthly X 3 months
d) If 100% compliant, 100% of one treatment day's flowsheets will be audited quarterly X 2 quarters
e) Audit frequency may be increased based on compliance
6) Nurse Manager or designee will be responsible to:
a) File the signed and dated January 4, 2021 staff meeting attendance list and agenda in each personnel file.
b) Review and initial audits per audit schedule
c) Failure to meet requirement will be addressed with staff through individual discussion, reeducation, or disciplinary action
d) Results will be documented in QAPI, presented to Governing Body and recorded in meeting minutes.
7) Governing Body will determine frequency of future audits based upon compliance
494.170 STANDARD
MR-COMPLETE, ACCURATE, ACCESSIBLE
Name - Component - 00
The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.
Observations:
Based on a review of medical records (MR) and interview with facility staff, the facility failed to maintain complete, accurate, and accessible records on all patients for five (5) of five (5) in-center hemodialysis clinical records reviewed. (MR1 - MR5)
Findings Included:
Review of MR1 on 12/11/2020 at approximately 8:30 AM revealed admission date 2/20/2018. A review of six handwritten dialysis flowsheets from 11/27/2020 to 12/9/2020 revealed illegible signatures and initials without titles. Surveyor was unable to discern who is an RN (registered nurse) and who is a PCT (patient care technician). Flowsheet written entries of times, blood pressures, blood flow rates, venous pressures, arterial pressures, and comments contained sections of illegible documentation.
Review of MR2 on 12/11/2020 at approximately 9:15 AM revealed admission date 3/29/2017. A review of six handwritten dialysis flowsheets from 11/27/2020 to 12/9/2020 revealed illegible signatures and initials without titles. Surveyor was unable to discern who is an RN and who is a PCT. Flowsheet written entries of times, blood pressures, blood flow rates, venous pressures, arterial pressures, and comments contained sections of illegible documentation.
Review of MR3 on 12/11/2020 at approximately 10:10 AM revealed admission date 9/25/2020. A review of six handwritten dialysis flowsheets from 11/27/2020 to 12/9/2020 revealed illegible signatures and initials without titles. Surveyor was unable to discern who is an RN and who is a PCT. Flowsheet written entries of times, blood pressures, blood flow rates, venous pressures, arterial pressures, and comments contained sections of illegible documentation.
Review of MR4 on 12/11/2020 at approximately 11:05 AM revealed admission date 2/12/2020. A review of six handwritten dialysis flowsheets from 11/27/2020 to 12/9/2020 revealed illegible signatures and initials without titles. Surveyor was unable to discern who is an RN and who is a PCT. Flowsheet written entries of times, blood pressures, blood flow rates, venous pressures, arterial pressures, and comments contained sections of illegible documentation.
Review of MR5 on 12/11/2020 at approximately 12:40 PM revealed admission date 10/14/2019. A review of six handwritten dialysis flowsheets from 11/25/2020 to 12/8/2020 revealed illegible signatures and initials without titles. Surveyor was unable to discern who is an RN and who is a PCT. Flowsheet written entries of times, blood pressures, blood flow rates, venous pressures, arterial pressures, and comments contained sections of illegible documentation.
An exit conference was conducted on 12/15/2020 at approximately 12:00 PM directly with facility manager (EMP2) and via phone facility administrator (EMP1). EMP2 confirmed above findings.
Plan of Correction:1) Area Operations Director will be responsible to present proposed Plan of Correction to Governing Body at the January 21, 2021 monthly meeting.
2) Nurse Educator will be responsible to:
a) Educate personnel at the January 4, 2021 staff meeting regarding the following:
i) "Hemodialysis Treatment Readings" policies focusing on need document legibly
ii) Review "DCI Policy 301 Fundamentals of Documentation in the Medical Record", "Documentation Module 2", and "What Picture Will You Paint" Policies or Education Modules focusing on need to write legibly and record full signature (first name, last name, and credentials) on the hemodialysis flowsheet. Employee to sign and date the "Documentation Module 2" Power Point handout
b) Create audit checklist:
i) To monitor that each employee that has initials on the hemodialysis flowsheet also has a corresponding full signature (first name, last name, and credentials)
ii) Create a full signature and initial spreadsheet to be able to identify staff documenting on the flowsheet
c) Instruct the Charge Nurse or designee on how to correctly complete the checklist for observation of legible documentation including a full signature with credentials and corresponding initials by January 4, 2021.
3) Direct Patient Care Staff will be responsible to:
a) Use legible handwriting on all documentation
b) Complete the signature spreadsheet entering a full signature (first name, last name, and credentials) and initials
c) Write a full signature (first name, last name, and credentials) and initials on each flowsheet when documenting patient care
4) Charge Nurse or designee will be responsible to perform audits beginning January 5, 2021 as follows:
a) 100% of flowsheets will be audited daily for 2 weeks
b) If 100% compliant, 100% of one treatment day's flowsheets will be audited weekly for 4 weeks
c) If 100% compliant, 100% of one treatment day's flowsheets will be audited monthly X 3 months
d) If 100% compliant, 100% of one treatment day's flowsheets will be audited quarterly X 2 quarters
e) Audit frequency may be increased based on compliance.
5) Nurse Manager or designee will be responsible to:
a) File the signature spreadsheet in each patient's medical record
b) File the signed and dated "Documentation Module 2" in each employee's personnel file
c) Failure to meet requirement will be addressed with staff through individual discussion or disciplinary action
d) Results will be documented in QAPI, presented to GB and recorded in meeting minutes
6) Governing Body will determine frequency of future audits based upon compliance.
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