Initial Comments:
Based on the findings of an onsite unannounced medicare recertification survey completed on August 16, 2018, 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 August 16, 2018, DCI Renal Services of Pittsburgh was identified 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-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 one (1) of five (5) in center hemodialysis patient medical records reviewed (MR3).
Findings Included:
Review of facility policy on 8/16/18 at approximately 3:00 PM revealed:
"HEMODIALYSIS TREATMENT READINGS...patient's blood pressures must be monitored...during...treatment and abnormally high or low values must be addressed...PROCEDURE:...1...b...RN must be notified and documentation must exist if BP is above or below Standing Order Parameters...2...a...Charge RN will be notified of the following Blood Pressure...Systolic <90 or >200; Diastolic >120..."
MR3, admission date 2/21/11 reviewed on 8/15/18 at approximately 2:00 PM; Patient most recent standing order parameters signed and dated by physician on 1/17/18: "...Hypotension...May ultrafiltration profiling...place patient in trendelenburg and elevate feet prn...place patient in minimum UFR prn...administer NSS 100-300cc IV Bolus prn-not to exceed 1000cc...decrease temperature in increments of 0.5-1.0 degrees to maximum of 35 degrees Celsius prn..." Review of hemodialysis treatment records (7/23/18 to 8/11/18) revealed the following:
8/8/18, 1:16 PM BP (blood pressure) 80/52; 2:15 PM BP 86/51.
8/6/18, 12:45 PM BP 82/49; 1:05 PM BP 86/44; 1:06 PM BP 85/50.
8/1/18, 3:34 PM BP 75/44; 3:36 PM BP 70/47.
7/27/18, 1:59 PM BP 67/52; 2:12 PM BP 75/48; 2:29 PM BP 78/53.
7/25/18, 2:32 PM BP 79/46; 2:54 PM BP 87/53; 3:02 PM BP 83/55.
There was no documented evidence of interventions/re-assessments provided for patient blood pressures below parameters per physician orders/facility policy noted in MR3 hemodialysis treatment records for aforementioned treatment dates .
During an interview on 8/16/18 at approximately 1:00 PM, the facility Clinical Manager (EMP2) and Nurse Educator (EMP8) confirmed the above findings. EMP2 and EMP8 confirmed interventions/re-assessments for patient with abnormally low blood pressures during dialysis treatments should be documented in the patient's hemodialysis treatment records.
Plan of Correction:
1) Area Operations Director will be responsible to:
a) Conduct a Staff Meeting to include all patient care staff to review the DOH survey findings and deficiencies on September 4, 2018.
b) Provide an agenda of meeting contents to all participants and retain a signed attendance list of attendees for presentation at the monthly Governing Body meeting on September 19, 2018.
c) Retain a copy of the signed attendance list and agenda for each employee's personnel file by September 7, 2018 to indicate acknowledgement and understanding of all processes presented.
d) Present proposed Plan of Correction including expectation of compliance and potential for disciplinary action with non-compliance to all staff meeting attendees by September 4, 2018.
2) Nurse Educator will be responsible to:
a) Educate the patient care staff at the September 4, 2018 staff meeting on the existing policy "Hemodialysis Treatment Readings" and "In-Center Hemodialysis Standing Admission Orders" to include:
i) Notification of the RN if the patient's BP falls outside the ranges stated on the In-center Hemodialysis Standing Admission Orders
ii) Notification of the physician by the RN to obtain specific orders on patients with blood pressures chronically outside the normal ranges. Documentation of this order will entered in the "tickler" section of the hemodialysis flowsheet
iii) Appropriate method of documentation to identify interventions taken for out of range blood pressures to including but not limited to: RN notified, UF rate adjustment, blood pressure recheck, repositioning patient into trendelenberg and outcomes of treatment
iv) Appropriate method of document to capture events and complications for thorough auditing
b) Create audit checklist by September 4, 2018:
i) To review flowsheet documentation to monitor that RN was notified of BP that is out of range
ii) To review that RN obtained and recorded in the "tickler" section of the hemodialysis flowsheet an order for patients that are exceptions to the BP parameters
iii) To review that documentation exists to indicate interventions taken
c) Instruct the Charge Nurse or designee on how to correctly complete the checklist for observation of notifications and interventions that are documented on the hemodialysis flowsheet (paper or electronic) by September 4, 2018.
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) Enter a notation indicating that the RN was notified of the out of range BP
c) RN will notify MD of low BP status, document notification in patient progress note, and document orders received for the individual patient with specific parameters on "tickler"
d) Document interventions to stabilize blood pressure
4) Charge Nurse or designee will be responsible to perform audits beginning September 5, 2018 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 September 4, 2018 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 GB and recorded in meeting minutes.
6) Governing Body will determine at its monthly meeting the frequency of future audits based upon compliance.
494.80(d)(2) STANDARD
PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO
Name - Component - 00
In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted-
At least monthly for unstable patients including, but not limited to, patients with the following:
(i) Extended or frequent hospitalizations;
(ii) Marked deterioration in health status;
(iii) Significant change in psychosocial needs; or
(iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis.
Observations:
Based on review of medical records (MR) and interview with facility staff (EMP), it was determined the agency failed to complete a comprehensive reassessment and revised monthly plan of care for one (1) of one (1) in-center hemodialysis patient (classified as unstable) medical record reviewed (MR6).
Findings included:
MR6, admission 5/19/18 (following a transfer from another facility), reviewed on 8/16/18 at approximately 11:15 AM revealed a most recent IDT patient meeting report (comprehensive assessment) completed on 5/16/18 with an assessment/POC reason "unstable." MR6 did not contain evidence of monthly comprehensive re-assessments/revisions of the plan of care or documented evidence MR6 was determined by the interdisciplinary team to be stable.
During and interview on 8/16/18 at approximately 11:25 AM, the facility Social Worker (EMP3, facility staff person designated to oversee Plan of Care scheduling) confirmed the above finding. EMP3 stated "...did not see that [patient] was unstable, should have had Plan of Care done within 30 days..."
Plan of Correction:1) Area Operations Director will be responsible to:
a) Conduct a Staff Meeting to include all patient care staff to review the DOH survey findings and deficiencies on September 4, 2018.
b) Provide an agenda of meeting contents to all participants and retain a signed attendance list of attendees for presentation at the monthly Governing Body meeting on September 19, 2018.
c) Retain a copy of the signed attendance list and agenda for each employee's personnel file by September 7, 2018 to indicate acknowledgement and understanding of all processes presented.
d) Present proposed Plan of Correction including expectation of compliance and potential for disciplinary action with non-compliance to all staff meeting attendees by September 4, 2018.
2) Social Worker / Care Plan Manager will be responsible to:
a) Identify patients that are considered "unstable" according to CMS guidelines
b) Run the "Potentially Unstable Patients" report from Darwin Reporting Tool monthly
c) Review the "Potentially Unstable Patients" report with the interdisciplinary team to ensure that "unstable" patients are reviewed through assessments and care plans timely
d) With Nurse Manager, review active care plans on patients that transfer in from another provider to determine if the patient is presented to DCI as "stable" or "unstable"
3) Care Plan Manager will be responsible to perform audits beginning September 5, 2018 as follows:
a) Initially by September 5, 2018
b) Monthly X 3 months
c) Quarterly X 2 quarters
d) Audit frequency may be increased based on compliance
4) Nurse Manager or designee will be responsible to:
a) File the signed and dated September 4, 2018 staff meeting attendance list and agenda in the interdisciplinary team member's individual personnel files
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 GB and recorded in meeting minutes.
5) Governing Body will determine at its monthly meeting the frequency of future audits based upon compliance.
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 policies, medical records (MR), and staff (EMP) interviews, the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician as specified in the physician orders for two (2) of five (5) in-center hemodialysis patients medical records reviewed. (MR2, MR5).
Findings Included:
Review of facility policy on 8/16/18 at approximately 3:10 PM revealed:
"...CONTINUOUS HEPARIN INFUSION DURING DIALYSIS...POLICY: Continuous heparin infusion shall be performed when ordered by the...physician unless contraindicated...PROCEDURE: 1. verify hourly infusion order...6. For treatments via needle accesses, Heparin Stop time is 60 minutes prior to end of treatment unless otherwise indicated 7. for treatment via catheters, heparin is infused during entire treatment unless otherwise indicated..."
Review on 8/16/18 at approximately 3:30 PM of "Annual HD Standing Orders (reviewed November 2017)" revealed "...Heparinization...patients will receive systemic heparinization with hourly administration as per specific order...Routine heparin may be adjusted by 1,000 units for patients with increased clotting occurrences...total dose...not to exceed 10,000 units without notification of physician..."
MR2, admission date 12/15/17 reviewed on 8/14/18 at approximately 2:45 PM; Review of hemodialysis treatment records (7/24/18 to 8/11/18) revealed the following:
7/24/18, physician order "...Duration 03:30...Heparin Loading 2500 UNITS, Hourly 1,000...Maximum 6,000..." There was documentation patient received heparin loading dose (2500 Units) at 6:33 AM. There was no documented evidence in the 7/24/18 hemodialysis treatment record of the patient receiving the hourly heparin dose as ordered nor was there a documented reason why the hourly dose was not given.
MR5, admission date 7/11/18 reviewed on 8/16/18 at approximately 10:15 AM; Review of hemodialysis treatment records (7/25/18 to 8/10/18) revealed the following:
8/8/18, physician order "...Duration 03:30...Heparin Loading 1000 UNITS, Hourly 1,000...Maximum 5,000..." There was documentation patient received heparin loading dose (1000 Units) at 11:47 AM. There was no documented evidence in the 8/8/18 hemodialysis treatment record of the patient receiving the hourly heparin dose as ordered nor was there a documented reason why the hourly dose was not given.
7/30/18, physician order "...Duration 03:30...Heparin Loading 1000 UNITS, Hourly 1,000...Maximum 5,000..." There was documentation patient received heparin loading dose (1000 Units) at 11:52 AM. There was no documented evidence in the 7/30/18 hemodialysis treatment record of the patient receiving the hourly heparin dose as ordered nor was there a documented reason why the hourly dose was not given.
7/25/18, physician order "...Duration 03:30...Heparin Loading 1000 UNITS, Hourly 1,000...Maximum 5,000..." There was documentation patient received heparin loading dose (1000 Units) at 11:44 AM. There was no documented evidence in the 7/25/18 hemodialysis treatment record of the patient receiving the hourly heparin dose as ordered nor was there a documented reason why the hourly dose was not given.
During an interview on 8/16/18 at approximately 1:00 PM, the facility Clinical Manager (EMP2) and Nurse Educator (EMP8) confirmed the above findings.
Plan of Correction:1) Area Operations Director will be responsible to:
a) Conduct a Staff Meeting to include all patient care staff to review the DOH survey findings and deficiencies on September 4, 2018.
b) Provide an agenda of meeting contents to all participants and retain a signed attendance list of attendees for presentation at the monthly Governing Body meeting on September 19, 2018.
c) Retain a copy of the signed attendance list and agenda for each employee's personnel file by September 7, 2018 to indicate acknowledgement and understanding of all processes presented.
d) Present proposed Plan of Correction including expectation of compliance and potential for disciplinary action with non-compliance to all staff meeting attendees by September 4, 2018.
2) Nurse Educator will be responsible to:
a) Educate the patient care staff at the September 4, 2018 staff meeting on the existing policy "Continuous Heparin Infusion During Dialysis" and the "Annual Hemodialysis Standing Orders" to include:
i) Administration of Heparin as prescribed by the physician
ii) Heparin dosing may be adjusted by 1,000 units for patients with increased clotting occurrences or increased treatment times
iii) Verification of individual patient bolus or hourly heparin dosing prescription to include stop time that is dependent on access type
b) Educate personnel at September 4, 2018 staff meeting regarding the follow the "Heparin Bolus" and "Continuous Heparin Infusion during Dialysis" policies focusing on need to verify prescribed heparin dosing and compare to actual heparin infusion from Phoenix machine infusion pump
c) "Create audit checklist by September 4, 2018:
i) To review that heparin is administered as prescribed by the physician
d) Instruct the Charge Nurse or designee on how to correctly complete the checklist for observation correct heparin dosing documented on the flowsheet (paper or electronic) by September 4, 2018.
e) Review the "Charge Nurse Duties and Responsibilities" with the Registered Nurses emphasizing need to verify individual patient heparin prescriptions is delivered within 30 minutes of initiation of dialysis
3) Direct Patient Care Staff will be responsible to:
a) Review treatment prescription orders to determine prescribed heparin dosing and document accurately on the flowsheet.
b) If unable to achieve prescribed heparin dosing, reason will be documented on the flowsheet and the charge nurse will be notified.
4) Charge Nurse or designee will be responsible to perform audits beginning September 5, 2018 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) Charge Nurse will be responsible to:
a) Verify patient prescription for heparin is delivered correctly by performing patient rounds within 30 minutes of patient treatment beginning
6) Nurse Manager or designee will be responsible to:
a) File the signed and dated September 4, 2018 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 GB and recorded in meeting minutes.
7) Governing Body will determine at its monthly meeting the frequency of future audits based upon compliance.
494.90(a)(5) STANDARD
POC-VA MONITOR/PREVENT FAILURE/STENOSIS
Name - Component - 00
The patient's vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis.
Observations:
Based on a review of facility policy, medical records (MR) and staff interview, it was determined the facility failed to document patient monitoring every 30 minutes for one (1) of five (5) in center hemodialysis medical records reviewed (MR5).
Findings Included:
Review of facility policy on 8/16/18 at approximately 3:00 PM revealed:
"HEMODIALYSIS TREATMENT READINGS..."POLICY: While the patient is receiving a hemodialysis treatment...staff will perform routine monitoring (reading) of patient's overall condition and the status of treatment...minimum of every 30 minutes...Legible documentation...will be completed and will not exceed 30 minutes between each reading..."
MR5, admission date 7/11/18 reviewed on 8/16/18 at approximately 10:15 AM; Review of hemodialysis treatment records (7/25/18 to 8/10/18) revealed the following:
8/10/18 patient assessed at 12:36 PM, patient not assessed again until 1:23 PM (47 minutes between assessments).
8/8/18 patient assessed at 11:51 AM, patient not assessed again until 1:37 PM (106 minutes between assessments); patient assessed at 2:14 PM, patient not assessed again until 3:26 PM (72 minutes between assessments).
8/1/18 patient assessed at 11:37 AM, patient not assessed again until 12:26 PM (49 minutes between assessments); patient assessed at 1:08 PM, patient not assessed again until 1:59 PM (51 minutes between assessments).
7/27/18 patient assessed at 11:55 AM, patient not assessed again until 2:27 PM (152 minutes between assessments); patient assessed at 2:27 PM, patient not assessed again until 3:20 PM (53 minutes between assessments).
7/25/18 patient assessed at 11:49 AM, patient not assessed again until 1:25 PM (96 minutes between assessments).
During an interview on 8/16/18 at approximately 1:00 PM, the facility Clinical Manager (EMP2) and Nurse Educator (EMP8) confirmed the above findings.
Plan of Correction:1) Area Operations Director will be responsible to:
a) Conduct a Staff Meeting to include all patient care staff to review the DOH survey findings and deficiencies on September 4, 2018.
b) Provide an agenda of meeting contents to all participants and retain a signed attendance list of attendees for presentation at the monthly Governing Body meeting on September 19, 2018.
c) Retain a copy of the signed attendance list and agenda for each employee's personnel file by September 7, 2018 to indicate acknowledgement and understanding of all processes presented.
d) Present proposed Plan of Correction including expectation of compliance and potential for disciplinary action with non-compliance to all staff meeting attendees by September 4, 2018.
2) Nurse Educator will be responsible to:
a) Educate the patient care staff at the September 4, 2018 staff meeting on the existing policy "Hemodialysis Treatment Readings" to indicate:
i) While the patient is receiving hemodialysis, documentation on the hemodialysis flowsheet (paper or electronic) will be completed to indicate that treatment readings were performed and do not exceed 30 minutes between readings
ii) Educate the staff to not electronically "dismiss" blood pressure readings that are out of range while attempts are made to obtain a recheck
b) Create audit checklist by September 4, 2018 to review flowsheet documentation to monitor that treatment readings are performed no greater than 30 minutes apart
c) Instruct the Charge Nurse or designee on how to correctly complete the checklist for observation of timely and legible treatment readings on the hemodialysis flowsheet by September 4, 2018
3) Direct Patient Care Staff will be responsible to:
a) Perform treatment readings no greater than 30 minutes apart
b) Appropriately document recheck of BP including readjusting BP cuff or use of manual doppler
4) Charge Nurse or designee will be responsible to perform audits beginning September 4, 2018 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) Review and initial audits per audit schedule
b) Failure to meet requirement will be addressed with staff through individual discussion, reeducation, or disciplinary action
c) Results will be documented in QAPI, presented to GB and recorded in meeting minutes.
7) Governing Body will determine at its monthly meeting the frequency of future audits based upon compliance.
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