Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on April 26, 2022 through April 28, 2022, Huntingdon Valley 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 April 26, 2022 through April 28, 2022, Huntingdon Valley 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 collection and assessment documentation for two (2) of seven (7) MR's reviewed, (MR #5 & 6). And facility failed to follow it's policy for reporting and documentation of abnormal findings during dialysis to the licensed nurse or physican for two (2) of seven (7) MR's reviewed, (MR #5 & 6).
Findings include:
Review of policy occurred on 4/27/22 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..."
Facility as needed standing order for Clonidine (blood pressure reducing medication) as approved last by the Governing Body on 1/26/22 states to give Clonidine "0.1 mg PO (by mouth) for BP Systolic (top number) greater than 180 and diastolic (lower number) greater than 100. May repeat after 1 hour."
A review of MR's was conducted on 4/26/22 from approximately 11:30 am to 2:30 pm.
MR #5, Start of Care: 2/1/2022.
Treatment Record for 4/18/2022:
7:07 PM - Intradialytic (during treatment) BP 206/98
Comments: "BP (blood pressure) High, Denies any c/o (complaints) will monitor" by RN
No post treatment data collection or nursing assessment is documented. In addition, No physician notification is documented. RN did not administer as needed standing order for Clonidine (to bring down BP). In addition, Blood pressure was not rechecked until 19:37 (30 minutes post abnormal finding).
MD note from 4/11/22 stated "B/P (blood pressure) still increasing on arrival 200 syst (systolic) part of it secondary to patient anxiety...started lisinopril recently...we'll monitor"
MD note from pre-treatment on 4/18/22: "No new complaints...B/P 168/70"
In interview with Facility Administrator (FA) on 4/26/22 at approximately 2:00PM FA stated that the nurse should of documented a call to the physician and performed a post-treatment data collection/assessment. In addition, FA stated the RN should have immediately re-taken the abnormal blood pressure and then re-assessed after that as needed.
MR #6. Start of Care: 3/10/2022.
Treatment Record for 4/16/22
2:34 PMIntradialytic BP: 168/108Comments: "Admin Clonidine per protocol" by RN
3:02 PM Intradialytic BP: 189/112. Comments: "No voiced discomfort at this time" by patient care tech (PCT)
3:18 PM Intradialytic BP: 183/112.Comments: "Deny any issue RN aware tx (treatment) cut off 21 mins (minutes) pt (patient) came late" by PCT
3:23 PM Intradialytic BP: 188/100.Comments: "Treatment terminated with 250 ML normal saline rinse back)" by PCT
No documentation of post treatment nursing assessment is documented.
Treatment Record for 4/19/2022:
2:02 PMIntradialytic BP: 208/108Comments: "Recheck" by PCT (rechecked at 2:03 PM and B/P was 170/89)
No nurse notification is documented and no post treatment nursing assessment is documented.
Treatment Record for 4/21/2022:
1:30 PMIntradialytic BP: 172/116.Comments: "BP elevated RN aware pt stable deny any issue" by PCT
No nursing documentation and no nursing post treatment assessment.
Treatment Record for 4/23/2022:
10:32 AM Intradialytic BP: 183/120.Comments: "No complaints" by PCT
11:02 AM Intradialytic BP: 176/116Comments: "No complaints" by PCT
No documentation of nursing post treatment assessment.
Treatment Record for 4/26/2022:
12:07 PM Intradialytic BP: 171/108. Comments: "No Complaints. RN aware of High BP" by PCT
No documentation by RN after abnormal blood presure notification by PCT and no documenation of RN post treatment assessment.
Physician documentation from 3/24/22 "B/P high: 196/108, 174/114..increase Nifedipine (blood pressure reducing medication) to 60 mg twice daily". Current medication list shows MR#6 is stilll on same dose of Nifedipine as of 4/27/22. Last nursing documentation updating physician about MR#6's high BP was on 4/6/22.
Interview with the FA on 4/26/22 at approximately 2:00PM stated that the nurse should have updated the physician order since 4/6/22 about the continued high blood pressure readings to possibly increase their blood pressure medication.
An interview with the facility administrator and regional operations director on 4/28/22 at approximately 12:00 PM confirmed the above findings.
Plan of Correction:03518 Huntingdon Valley PA CMS Core 042822
POC Completion Date: 06/27/22
V 543
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/02/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "Pre- Intra- Post treatment Data Collection Monitoring and Nursing Assessment" emphasizing but not limited to: 1) Patient identity, prescription and machine settings are verified by teammates prior to initiation of treatment with the exception of blood flow rate (BFR) which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription component are confirmed by a licensed nurse by 1 hour of treatment initiation along with the nursing assessment. 2) Intra dialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes vital signs and treatment monitoring at least every 30 minutes. 3) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the license nurse immediately. 4) The licensed nurse will use his/her clinical judgement based on individual patient needs to determine if any clinical interventions are necessary. 5) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 6) The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 7) If an abnormal findings or concern is identified post treatment, this needs to be reported to the license nurse. The license nurse will assess the patient prior to discharge. 8) Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record. "Blood pressure: Pre dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg; Diastolic greater than or equal to 100 mm/ Hg. "Blood pressure Intra-Dialytic: Difference of 20 mm/Hg increase or decrease from patient's last intradialytic treatment BP reading." Blood pressure Post treatment: If the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg; standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. Heart or Pulse rate Pre/Intra/ Post: less than 60 beats per minute or greater than 100 beats per minute and/ or an irregular heartbeat. 9) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet. The Facility Administrator or designee will conduct audits on flowsheets to verify documentation of proper notification to and response by the licensed nurse regarding abnormal findings: twenty five percent (25%) of the flow sheets daily for two (2) weeks then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review the audit results with teammates during homeroom meetings and with the Medical Director during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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