Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on October 18, 2021, DCI Renal Services of Pittsburgh, Llc 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 October 18, 2021, DCI Renal Services of Pittsburgh, Llc was found 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:
494.80(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 (MR1, MR3, MR4).
Findings Included:
Review of facility policy on 10/18/2021 revealed "Subject...Hemodialysis Treatment Readings...Policy: "Subject...Hemodialysis Treatment Readings...Policy:..the nursing staff will perform routine monitoring...of the patient's overall condition...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:..Heart Rate < 50 or > 120 or irregularity...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:..Heart Rate < 50 or > 120 or irregularity if symptomatic...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 MR1 on 10/15/2021 at approximately 9:25 AM revealed admission date 7/27/2021. "...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 9/28/2021 to 10/12/2021 revealed:
10/7/2021, 10:30 AM BP 175/89, 11:02 AM BP 148/81 (drop of 27 points between 30 minute checks).
10/9/2021, 10:18 AM BP 178/78, 10:48 AM BP 124/53 (drop of 54 points between 30 minute checks).
There was no documented evidence of notification/interventions for patient blood pressures outside of outlined parameters per physician orders and/or facility policy noted in MR1 treatment records for aforementioned treatment dates.
Review of MR3 on 10/15/2021 at approximately 10:40 AM revealed admission date 7/8/2021. "...Hemodialysis...Standing Admission Orders...Vital Signs/Assessments Pre and Post Dialysis...Notify Physician if Systolic BP (blood pressure) is < 90 or > 200 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 (millimeters of mercury). Also if HR (heart rate) < 50 or > 120 BPM (beats per minute)..." A review of dialysis flowsheets from 9/28/2021 to 10/12/2021 revealed:
9/28/2021, Vital Signs (Pre) BP Sit 213/84. There was no post assessment of pulse (HR) documented.
9/30/2021, Vital Signs (Pre) BP Sit 208/87. Intradialytic...6:59 AM BP 170/88, 7:36 AM 140/81 (drop of 30 points between 30 minute checks). 8:27 AM HR 44, 8:58 AM HR 44, 10:01 AM HR 47.
10/2/2021, Vital Signs (Pre) BP Sit 210/96. Intradialytic...6:53 AM BP 193/83, 7:23 AM 156/75 (drop of 37 points between 30 minute checks).
10/7/2021, Vital Signs (Pre) BP Stand 226/90. Intradialytic...10:01 AM BP 201/106.
10/9/2021, Intradialytic...6:58 AM HR 47, 7:30 AM HR 43, 8:00 AM HR 49, 38:33 AM HR 48.
10/12/2021, Vital Signs (Pre) BP Sit 215/83.
There was no documented evidence of notification/interventions for patient blood pressures/heart rates outside of outlined parameters per physician orders and/or facility policy noted in MR3 treatment records for aforementioned treatment dates.
Review of MR4 on 10/18/2021 at approximately 9:15 AM revealed admission date 6/10/2015. "...Annual...Standing Orders...Vital Signs/Assessments Pre and Post Dialysis...Notify Physician if Systolic BP (blood pressure) is < 90 or > 200 or Diastolic BP is > 120 and/or patient is symptomatic...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 9/29/2021 to 10/11/2021 revealed:
10/6/2021, Intradialytic...6:58 AM BP 89/45, 7:28 AM BP 85/43, 7:59 AM BP 84/40, 8:58 AM BP 88/47.
10/8/2021, Intradialytic...6:57 AM BP 89/49, 7:27 AM BP 88/49, 7:57 AM BP 81/48, 8:21 AM BP 87/45, 8:27 AM BP 87/46, 8:57 AM BP 85/46, 9:27 AM BP 79/45, 9:41 AM BP 82/43, 9:52 AM BP 81/44, 10:00 AM BP 85/49...Vital Signs (Post) BP Sit 85/49.
10/11/2021, Intradialytic...7:39 AM BP 86/50, 8:39 AM BP 87/46, 9:10 AM BP 87/38, 9:39 AM BP 81/46...Vital Signs (Post) BP Sit 87/42.
There was no documented evidence of notification/interventions for patient blood pressures outside of outlined parameters per physician orders and/or facility policy noted in MR4 treatment records for aforementioned treatment dates.
An exit conference was conducted on 10/18/2021 at approximately 11:00 AM directly with facility manager (EMP3), Social worker (EMP7), Bio technician (EMP5) and facility administrator (EMP1) via phone. Above findings were reviewed.
Plan of Correction:1) Area Operations Director will be responsible to:
a) Present proposed Plan of Correction to Governing Body at the November 18, 2021 monthly meeting.
2) Nurse Manager will be responsible to:
a) Educate personnel on or before October 22, 2021 regarding:
i) "HEMODIALYSIS TREATMENT READINGS" policy focusing on actions to take if Blood Pressure or Heart Rate readings fall outside established parameters
ii) CHRONIC HEMODIALYSIS STANDING ORDERS focusing on appropriate interventions, documentation, and notification of RN or physician in the treatment of blood pressures or heart rates outside established parameters
iii) NORMAL PARAMETERS and actions as defined by the Medical Director
iv) Obtain specific orders for patients whose BP or HR chronically fall outside normal parameters and enter such orders into the "tickler" section
b) Create audit checklist by October 22, 2021:
i) To monitor that Charge Nurse, RN, or Physician notification is done in accordance with standing orders and normal parameters
ii) To monitor that documentation exists to indicate interventions for episodes of BP or HR outside established parameters
3) Direct Patient Care Staff will be responsible to:
a) Notify the RN or physician if BPs or HRs are outside of NORMAL PARAMETERS as indicated in the "HEMODIALYSIS TREATMENT READINGS" POLICY and CHRONIC HEMODIALYSIS STANDING ORDERS
b) Document interventions for provided on the hemodialysis flowsheet
4) Charge Nurse or designee will be responsible to perform audits beginning October 25, 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 2 weeks
c) If 100% compliant, 100% of one treatment day's flowsheets will be audited monthly X 3 months
5) Nurse Manager or designee will be responsible to:
a) Review and initial audits per audit schedule.
b) Document results of audits in QAPI and present findings to Governing Body monthly.
6) Governing Body will determine frequency of future audits based upon compliance.
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