Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 7/25/2022, PDI-Ebensburg 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 7/25/2022, PDI-Ebensburg was found to have the following standard level deficiencies that was/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:
494.40(a) STANDARD
BACT OF H20-MEDICAL DIRECTOR RESPONSIBLE
Name - Component - 00
4.1.2 Bacteriology of water: med dir resp
The facility medical director is responsible to ensure the manufacturer or supplier of a complete water treatment and distribution system demonstrates that the complete water treatment, storage, and distribution system is capable of meeting these requirements at the time of installation
Following installation of a water treatment, storage, and distribution system, the user is responsible for continued monitoring of the water bacteriology of the system and for complying with the requirements of this standard, including those requirements related to action levels.
Observations:
Based on review of agency policy, bacteriological testing log and staff (EMP) interview the facility failed to follow agency policy and ensure the medical director was notified of abnormal bacterial/endotoxin reports for one (1) of three (3) months reviewed.
Findings included:
A review was conducted of facility policy on 7/25/2022 at approximately 3:30 PM which revealed, Policy TITLE: WATER CULTURE POLICY PURPOSE: To provide guidance to reflect that water used to prepare dialysate and dilute concentrates meets or exceeds current (agency) standards. POLICY: 1. The Facility Administrator or designee is responsible for verifying that cultures are obtained, results recorded, reviewed and necessary actions taken, as applicable. 2. The Medical Director documents a review of all water culture results monthly. 3. Results and trends are reviewed during the Facility Health Meeting (FHM) and documented in the meeting minutes ...
8. Interpreting culture results:
Acceptable level:
Below 50 cfu/ml Action level:
50 - 99 cfu/ml Unacceptable level:
100 cfu/ml or greater
9. Required responses to action or unacceptable culture results:
Single site at or above the action level (all other results in acceptable range):
Notify Medical Director of results within 48 hours of receiving the result.
Reculture of the site within 7 days of original sample collection date.
If repeat sampling result is below the action level, no further action is required.
Waterlog review was conducted on 7/19/2022 at approximately 9:40 AM which revealed the following:
Waterlog Review: Documentation provided of Bacteria and Endotoxin report:
3/10/2022 revealed H2O CULT 120H
3/16/2022 revealed H2O CULT 1450H
3/22/2022 revealed H2O CULT <10 ...
The surveyor requested any documentation of the medical director being notified of the elevated water cultures. Per email from EMP1 on 7/20/2022 at approximately 8:54 AM confirmed "Proper notification per policy was not done." No documentation of the medical director being notified of test results was provided.
An interview on 7/21/2022 at approximately 2:00 PM was conducted with the group facility administrator and findings were reviewed.
Plan of Correction:01656 PDI Ebensburg PA CMS Core 072522
POC Completion Date 8/31/2022
V 0179
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 08/17/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 2-06-01 "Water Culture Policy" with emphasis on but not limited to: 1) culture results will be interpreted as follows: Acceptable level: Below 50 cfu/ml, Action level: 50-199 cfu/ml, Unacceptable level: 100 cfu/ml or greater 9. 2) Required responses to action or unacceptable culture results are as follows: Single site at or above the action level (all other results in acceptable range - Medical Director will be notified of results within 48 hours of receiving the result. Re-culture of the site within seven (7) days of original sample collection date. Verification of attendance will be evidenced by teammate's signature on in-service form. Teammates not present during in-service will be in-serviced within one week of returning to work. The Biomed Services Specialist (BSS) was given the Medical Director's contact information for notification as needed. In addition, the BSS or Facility Administrator will document communication to the Medical Director on the lab result sheet. Starting 08/19/22 the BSS will notify the Facility Administrator when cultures are sent and results are received. The Facility Administrator or designee will audit culture results monthly for three (3) months to verify compliance with follow-up cultures and notification of Medical Director if warranted. Any instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes.
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 (MR) and staff (EMP) interviews, the facility failed to ensure the evaluation of the appropriateness of the dialysis prescription including dialysate flow rate (DFR) for one (1) of four (4) in-center hemodialysis medical records (MR) reviewed (MR4).
Findings included:
A review was conducted of facility policy on 7/25/2022 at approximately 2:40 PM which revealed, Policy "TITLE: PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT ...
2. The Nursing assessment will be performed and documented by a licensed nurse; specifically a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). a. The assessment includes the following components ...iii. Verification of prescription including machine parameters ...
3. Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to ...f. Blood flow rate g. Dialysate flow rate ... "
MR #4 admit date 8/23/2018, was reviewed on 7/20/2022, at approximately 3:15 PM. A review of the physician orders dated 7/11/2022 and Post Treatment sheets dated 6/29/2022 through 7/11/2022 revealed the physician ordered a DFR of 500 ml/min. DFR was delivered higher than prescribed on 7/11/2022 at 800 ml/min for the entire treatment. Documentation was completed on the treatment sheet of 7/11/2022 by three staff members.
An interview on 7/21/2022 at approximately 2:00 PM was conducted with the group facility administrator and findings were reviewed.
Plan of Correction:01656 PDI Ebensburg PA CMS Core 072522
POC Completion Date 8/31/2022
V 0503
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 08/17/22. 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" with emphasis on but not limited to: 1) Patient identity, prescription and machine settings are verified by the teammate prior to the initiation of treatment...The licensed nurse will confirm prescription components within one hour of treatment initiation... including dialysate flow rate... 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. At a minimum, obtain and document the following: blood and dialysate flows... 4) If the dialysis prescription is not being met [including dialysis flow rate ...] the reason will be documented and the licensed nurse informed. 4) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 5) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance is evidenced by teammate's signature on the in-service sheet. If a teammate is not present during in-servicing they will be in-serviced within one week of returning to work. Starting 08/15/22, the Facility Administrator or designee will review all treatment sheets: daily on treatment days for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately. Staff will also be in-serviced on POC by 08/19/2022. The Facility Administrator or designee will review audit results with the Medical Director during the 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.
494.90(a)(6) STANDARD
POC-P/S COUNSELING/REFERRALS/HRQOL TOOL
Name - Component - 00
The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis.
Observations:
Based on a review of agency policy, agency documents and staff (EMP) interview, the facility failed to ensure that a standardized mental and physical assessment tool was administered by the time of the first reassessment for one (1) of forty-three (43) active patient fifteen (15).
Findings included:
A review was conducted of facility policy on 8/24/2018 at approximately 2:40 PM which revealed, Policy "TITLE: SOCIAL WORK INTERVENTION AND DOCUMENTATION REQUIREMENTS PURPOSE: To establish intervention and documentation parameters for social workers...Social Work Assessment or Reassessment ...Complete a Quality of Life Assessment on all patients at 90 days and annually..."
A review of the KDQOL Survey report was conducted on 7/20/2022 at approximately 3:00 PM. Admission date of patient (15) was 2/7/2022. No documentation was provided by the agency to confirm the administration or refusal of an initial standardized mental and physical assessment tool (KDQOL).
An interview on 7/21/2022 at approximately 2:00 PM was conducted with the group facility administrator and findings were reviewed.
Plan of Correction:01656 PDI Ebensburg PA CMS Core 072522
POC Completion Date 8/31/2022
V 0552
The Facility Administrator or designee held mandatory in-services for all clinical teammates and the Interdisciplinary Team (IDT) starting on 08/17/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-14-03A "Social Worker Intervention and Documentation Requirements" with emphasis on but not limited to: 1) Social Work - Complete a Quality of Life assessment on all patients at 90 days and annually. 2) Complete a Quality of Life assessment on all patients using the assessment tool selected by DaVita. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. If a teammate is not present during in-servicing they will be in-serviced within one week of returning to work. The Facility Administrator or designee and the Social Worker will review electronic charting (CWOW and Helping hands) to verify all patients have a completed Quality of Life Assessment. Patients without a completed survey, will have one completed within the next thirty (30) days. The Facility Administrator or designee will audit CWOW monthly for three (3) months to verify compliance with completion of Quality of Life Assessments per policy. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit findings with the Interdisciplinary Team and the Medical Director during 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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