QA Investigation Results

Pennsylvania Department of Health
DIALYSIS CLINIC, INC.
Health Inspection Results
DIALYSIS CLINIC, INC.
Health Inspection Results For:


There are  11 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey completed 10/17/2019, Dialysis Clinic Inc. was found to be in compliance with the 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:




Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey completed 10/17/2019, Dialysis Clinic Inc. 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:




494.80(a)(2) STANDARD
PA-APPROPRIATENESS OF DIALYSIS RX

Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:

(2) Evaluation of the appropriateness of the dialysis prescription,




Observations:


Based on a review of facility policies and procedures, medical records and staff (EMP) interviews, the facility failed to communicate with physicians when blood flow rates (BFR) required adjustment beyond the current physicians' orders for one (1) of five (5) in-center hemodialysis medical records (MR) reviewed (MR5).

Findings included:

Review of the facility policy and procedures on 10/17/2019 at approximately 3:00 PM revealed, Policy "POLICY NUMBER 2207...Patient Monitoring During Dialysis...After the treatment has been initiated continuous monitoring of the patient is necessary. The following parameters are monitored: 1. Every 30 minutes: a. routine B/P and HR (located on the home screen.) b. Visual inspection of patient access (Access vis/sec) c. Level Consc-Note level of consciousness, alert and oriented, sleeping, confused, etc d. Note any complaints of nausea, headache, dizziness,cramps, etc. (comments) 2. Every 60 minutes: a. BFR/DFR-Blood flow rate (home screen) set at ordered rate Dialysate flow rate (set from home screen) b. AP/VP-Arterial and venous pressures (home screen) c. LP letters processed (home screen) d. UFR/FR- Ultrafiltration rate and fluid removed (home screen) e. Fluids/Blood-Document any normal saline or blood products administered f. Heparin-Hourly rate set at ordered rate and amount left in Heparin syringe g. Bridge taped-Verify bridge tape if not done h. Machine Conductivity-Current conductivity (Press Report navigation key, then navigation key i. Staff-initial check completed 0 be sure to sign full name on top of flowsheet Some patients may require more frequent vital signs. Patients receiving Mannitol, HSS and/or Normal Saline for the treatment of hypotension and/or cramps must have B/P, HR and assessment of effectiveness of medication rechecks every 15 minutes until Symptoms resolve."

MR5 SOC 12/8/2014, was reviewed on 10/17/2019 at approximately:07 PM. The patients primary diagnosis was Diabetes with renal manifestations Type 2. A review of six (6) Hemodialysis Flowsheets dated 9/27/2019 to 10/9/2019 revealed under the section "Treatment Plan" a BFR of 450 ml/min. The BFR was not delivered per physician orders on the fooling date.

10/4/2019 BFR set at 450 ml/min at 10:12 AM
10/4/2019 BFR set a 430 from 11:12 AM until 1:12 PM
10/4/2019 BFR set at 440 from 1:13 PM until 1:43 PM

No documentation was made available to confirm the patient's inability to achieve blood flow or that a change was reported to the physician.

An exit interview was conducted with the nurse manager and the area operations director (via phone) on 10/17/2019 at approximately 3:00 PM confirmed the above findings.
























Plan of Correction:

1. All clinical staff will be re-trained on the facility's "Patient Monitoring during Dialysis" policy #2207 by 11/15/19. Training will include the responsibility to document the reason when unable to achieve the prescribed BFR and notification to Charge Nurse. The Charge Nurse will be responsible for notifying physician if unable to achieve prescribed BFR for three (3) consecutive treatments.

2. The "Standing Orders" will be reviewed with all clinical staff with particular emphasis on physician orders for machine settings to include "blood flow rate (BFR)" by 11/15/19.

3. All clinical staff will review and sign acknowledgement of understanding of policy and standing orders. A copy of the acknowledgement will be placed in the facility's education manual.

4. Initially, Nurse Manager and/or Designee will audit 50% of treatment flow sheets daily for one (1) week to ensure that staff is following the policy with emphasis on documentation of physician orders not being met and notifying the physician per policy. If standards are met, 50% of the treatment flow sheets will be audited weekly for four (4) weeks. If standards are met, 50% of the treatment flow sheets will be audited monthly for three (3) months. If standards are met, 50% of the treatment flow sheets will be audited semi-annually. The audit results will be reviewed at monthly QAPI meetings.



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 facility failed to ensure treatments were delivered in accordance with the dialysis prescription ordered by the physician for two (2) of five (5) in-center hemodialysis medical records (MR) reviewed (MR4 and MR5).

Findings Included:

Review of the facility policy and procedures on 10/17/2019 at approximately 3:00 PM revealed, Policy "POLICY NUMBER 2207...Patient Monitoring During Dialysis...After the treatment has been initiated continuous monitoring of the patient is necessary. The following parameters are monitored: 1. Every 30 minutes: a. routine B/P and HR (located on the home screen.) b. Visual inspection of patient access (Access vis/sec) c. Level Consc-Note level of consciousness, alert and oriented, sleeping, confused, etc d. Note any complaints of nausea, headache, dizziness,cramps, etc. (comments) 2. Every 60 minutes: a. BFR/DFR-Blood flow rate (home screen) set at ordered rate Dialysate flow rate (set from home screen) b. AP/VP-Arterial and venous pressures (home screen) c. LP letters processed (home screen) d. UFR/FR- Ultrafiltration rate and fluid removed (home screen) e. Fluids/Blood-Document any normal saline or blood products administered f. Heparin-Hourly rate set at ordered rate and amount left in Heparin syringe g. Bridge taped-Verify bridge tape if not done h. Machine Conductivity-Current conductivity (Press Report navigation key, then navigation key i. Staff-initial check completed 0 be sure to sign full name on top of flowsheet Some patients may require more frequent vital signs. Patients receiving Mannitol, HSS and/or Normal Saline for the treatment of hypotension and/or cramps must have B/P, HR and assessment of effectiveness of medication rechecks every 15 minutes until Symptoms resolve."

MR4 start of care date (SOC) 4/25/2017, was reviewed on 10/17/2019, at approximately 12:54 PM. Primary diagnosis was Type 2 diabetes mellitus with diabetic chronic kidney disease. A review of seven (7) Hemodialysis flowsheets dated 9/26/2019 to 10/10/2019 revealed the physician ordered a BFR of 400 ml/min. The BFR was not delivered per physician's orders on the following dates:

10/1/2019 BFR at 360 ml/min from 8:57 AM until 10:27 AM then changed to 350 ml/min from 11:27 AM until 12:12 PM.
10/3/2019 BFR set at 370

MR5 SOC 12/8/2014, was reviewed on 10/17/2019 at approximately:07 PM. The patients primary diagnosis was Diabetes with renal manifestations Type 2. A review of six (6) Hemodialysis Flowsheets dated 9/27/2019 to 10/9/2019 revealed under the section "Treatment Plan" a BFR of 450 ml/min. The BFR was not delivered per physician orders on the following date.

9/27/2019 BFR set at 350 from 10:06 AM until 12:05 PM

No documentation was made available to confirm the patient's inability to achieve blood flow or that a reported was submitted to notify the physician.

An exit interview was conducted with the nurse manager and the area operations director (via phone) on 10/17/2019 at approximately 3:00 PM confirmed the above findings.























Plan of Correction:

1. All clinical staff will be re-trained on the facility's "Patient Monitoring during Dialysis" policy #2207 by 11/15/19. Training will include the responsibility to document the reason when unable to achieve the prescribed BFR and notification to Charge Nurse. The Charge Nurse will be responsible for notifying physician if unable to achieve prescribed BFR for three (3) consecutive treatments.

2. The "Standing Orders" will be reviewed with all clinical staff with particular emphasis on physician orders for machine settings to include "blood flow rate (BFR)" by 11/15/19.

3. All clinical staff will review and sign acknowledgement of understanding of policy and standing orders. A copy of the acknowledgement will be placed in the facility's education manual.

4. Initially, Nurse Manager and/or Designee will audit 50% of the treatment flow sheets daily for one (1) week to ensure that staff is following the policy with emphasis on documentation of physician orders not being met and notifying the physician per policy. If standards are met, 50% of the treatment flow sheets will be audited weekly for four (4) weeks. If standards are met, 50% of the treatment flow sheets will be audited monthly for three (3) months. If standards are met, 50% of the treatment flow sheets will be audited semi-annually. The audit results will be reviewed at monthly QAPI meetings.



494.170(a) STANDARD
MR-PROTECT PT RECORDS FM LOSS/CONFIDENTIAL

Name - Component - 00
The dialysis facility must-
(1)Safeguard patient records against loss, destruction, or unauthorized use; and
(2) Keep confidential all information contained in the patient's record, except when release is authorized pursuant to one of the following:
(i) The transfer of the patient to another facility.
(ii) Certain exceptions provided for in the law.
(iii) Provisions allowed under third party payment contracts.
(iv) Approval by the patient.
(v) Inspection by authorized agents of the Secretary, as required for the administration of the dialysis program.



Observations:



Based on agency policy, observations tour of the facility (OBV) and staff (EMP) interview the agency failed to provided safeguard against unauthorized use of patient's medical records on one (1) of one (1) facility observation tour.

Findings included:

Review of the facility policy and procedures on 10/17/2019 at approximately 3:00 PM revealed, Policy "PROCEDURE NO: 1510...POLICY: Physical Security 1. The clinic will store all medical records in such a manner as to avoid casual viewing from non-(agency) staff as well as (agency) staff that does not have authorization to view the medical record. 2. Medical records stored outside the view of the facility staff must be locked at all times. If the medical records are physically on the treatment floor or in areas that are in plan view of staff at all times, it is acceptable to leave them unlocked. All other medical records must be locked and secured. This applies to active charts, thinned charts and closed charts. 3. When the clinical is closed, medical records must either be placed in a locked room or in a storage unit with a lockable mechanism...4. Cleaning staff should not have access to locked storage..."

During the flash observation tour of the facility with EMP2 on 10/11/2019 at approximately 8:50 AM The Surveyor observed a room referred to as the "records room" located off the treatment floor behind a partial partition. Where active patient incenter medical records were placed in cart with an open frame structure. The surveyor confirmed the cart was not lockable. The surveyor confirmed with EMP2 the medical records were of active patients and a contracted cleaning service had access to the medical records room.

An exit interview was conducted with the nurse manager and the area operations director (via phone) on 10/17/2019 at approximately 3:00 PM confirmed the above findings.

























Plan of Correction:

1. A Key Pad will be ordered and installed on the "Record Room" door (located in the treatment area) by 11/30/19. Only authorized staff will be given key-code access to the room. Until the key pad can be installed on the door, the room will be kept locked and housekeeping personnel will not be permitted access to the room. Trash will be placed outside the door for disposal.

2. All staff will be re-trained on the facility's "Storage of Medical Records" policy #1510 by 11/30/19.

3. All clinical staff will review and sign acknowledgement of understanding of policy. A copy of the acknowledgement will be placed in the facility's education manual.

4. Nurse Manager and/or Designee will perform annual medical record security audits to ensure compliance to the "Storage of Medical Records" policy. The audit results will be reviewed at monthly QAPI meetings.