Initial Comments:
Based on an onsite, unannounced Medicare recertification survey completed on 12/8/23, Liberty Dialysis-Southpointe, LLC was found to be in compliance with the following 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 unannounced, onsite Medicare recertification survey completed on 12/8/23, Liberty Dialysis-Southpointe, LLC 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 a review of clinic policies, medical records (MRs), and staff (EMP) interviews, the facility staff did not assess the blood pressure and fluid management needs for two (2) of six (6) MRs reviewed. (MRs 1 and 3)
Findings included:
Nurse practice Act, Title 49, Section 21.11
" General functions ...(a) The registered nurse assesses human responses and plans, implements and evaluates nursing care for individuals or families for whom the nurse is responsible. ...the nurse performs all of the following functions: ... (6) Evaluates the effectiveness of the quality of nursing care provided ... "
Facility policy " Patient Assessment and Monitoring ...Published 05/01/2023 ...Reference Number: 45284 " reviewed on 12/5/23 at approximately 2:00 pm read, " Responsibility ...Direct patient care staff (RN, LPN/LVN, PCT) (as defined by job description, licensure, certification, state and federal regulations) ...Data Collection...Direct patient care staff may collect data such as weight, BP, pulse, respirations, temperature, general observations, access, and complaints reported by the patient. If the PCT/LPN note any changes or abnormal findings in the patient ' s condition or vascular access are observed or reported by the patient, or the patient was hospitalized, the registered nurse must assess the patient...The RN will notify the patient ' s physician/physician extender of any abnormal findings, if necessary, based on clinical judgment for additional instruction. The Registered Nurse will assess/reassess any findings addressed pre or during treatment as needed. ...Page 4 ...During Treatment...Obtain blood pressure and pulse rate every 30 minutes or more as needed ...Blood pressure ...Record blood pressure. Recheck blood pressures after a drop that requires interventions such as administering normal saline. ...Report to the nurse: Systolic blood pressures greater than 180 mm/Hg ...Diastolic blood pressures greater than 100 mm/Hg ...Blood Pressure less than or equal to 100 mm/Hg systolic...Pulse ...Record pulse. Verify pulses manually if automated readings display below 60 or greater than 100 beats per minute ...Report to the nurse patients whose heart rates have dropped below 60, risen above 100 or become irregular. Document any findings and interventions in the medical record .... "
A review of agency policy, "Nursing Supervision and Delegation" on 12/8/23 revealed: "Page 2 of 8...Background...The licensed RN cannot delegate any task, skill or practice that requires nursing judgement, critical decision making, or the use of the nursing process, which is, 1) assessment, 2) diagnosis, 3) identification of outcomes, 4) planning, 5) implementation and 6) evaluation...Page 5 of 8...Reporting of Patient Care Findings to the Team Nurse in Charge...the staff member who collects information pre, post and during treatment will document their findings. Any observed changes or abnormal findings in the patient's condition or vascular access, changes reported by the patient...must be reported to the registered nurse who will assess the patient. Registered nurses who are not the nurse in charge must report abnormal findings and interventions to the nurse in charge."
A review of medical records (MR) on 11/30/23 between approximately 10:00 am to 12:30 pm revealed the following:
MR#1: Admission Date: 10/14/22. Treatment sheets reviewed between 11/4/23 and 11/25/23.
Treatment Date and Start time: 11/09/2023, 05:22.
Patient Care Technician (PCT1) assessed HR 47 at 05:27, RN notification not documented.
PCT1 documented BP 198/103 at 05:45 RN notification not documented.
PCT1 documented BP 198/92 at 06:15, RN notification not documented.
PCT2 documented BP 202/152 and HR 56 at 06:42, RN notification not documented.
PCT3 documented BP 219/105 and HR 49, at 07:03 RN notification not documented.
PCT3 documentation at 07:04 noted, " ...rn bb notified ... "
PCT1 documented BP 202/113 and HR 52, at 07:22.
PCT1 documented BP 194/168 and HR 58, at 07:42.
PCT3 documented HR 45 at 08:02.
PCT1 documented BP 145/100 at 08:22.
Treatment ended 09:23 post treatment vitals and evaluation completed by PCT1. No documentation of RN assessment post treatment or after report of abnormal vital signs.
MR#3: Admission Date: 5/18/21. Treatment sheets reviewed between 11/9/23 and 11/25/23.
Treatment Date and Start time: 11/09/2023, 11:07.
PCT3 documented BP 98/53 at 12:42.
PCT3 documented BP 91/52 at 13:02.
PCT3 documented note, " RN Notified ...pt asymptomatic ...temp decreased to 35.5 for bp support per rn bb, " at 13:03.
PCT3 documented BP 91/38 at 13:22.
PCT2 documented BP 90/51 at 13:45.
PCT3 documented BP 94/60 at 14:01.
Treatment ended at 14:11 post treatment vitals and evaluation completed by PCT2. No documentation of RN assessment post treatment or after 13:03 adjustment of HD machine temperature for hypotension.
Findings of undocumented RN assessments and notifications discussed during 11/30/23 chart review between approximately 10:00 am and 12:00 pm with EMP2 RN Clinical manager and EMP3 RN Clinical manager and on 12/4/23 at approximately 12:00 pm during web conference call.
Plan of Correction:V504 PA-Assess B/P & fluid management needs
To ensure compliance the Clinical Manager (CM) or designee will in-service all DPC staff on policy:
Patient Assessment and Monitoring
Nursing Supervision and Delegation
Nurse Practice Act, Title 49, Section 21.11 "General Functions . . . (a)
Emphasis will be placed on patient vital signs (VS) related to blood pressures and fluid assessment needs, every thirty (30)
minutes, and not exceeding forty-five (45) minutes, per policy, before, during, and after treatment. The patient care staff will
report to the following to the RN: systolic blood pressures greater than 180 mm/Hg, diastolic blood pressures greater than 100
mm/Hg, Blood pressures less than or equal to 100 mm/Hg systolic, heart rates below 60 or above 100 beats per min, report to
RN. The RN will investigate for possible cause and notify physician as needed.
Inservicing will be completed by December 29, 2023. All training documentation will be on file at the facility.
Starting January 03. 2024, the CM or designee will perform daily 10% treatment sheet audits for 2 weeks. At that time if
compliance is observed the audits will then be completed weekly audits for 2 weeks to ensure that compliance is maintained. At
that time the audits will then follow the monthly QAPI schedule. A POC specific audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The covering CM will review the audit results and report the findings to the QAPI Committee at the monthly meeting. Sustained
compliance will be monitored by the QAPI committee.
Completion Date: January 30, 2024
494.80(a)(3) STANDARD
PA-IMMUNIZATION/MEDICATION HISTORY
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
Immunization history, and medication history.
Observations:
Based on review of policy, medical records, and interviews with staff, the clinic failed to ensure that all eligible patients were offered pneumococcal vaccination for one (1) of six (6) MR ' s reviewed.
Findings include:
A review of clinic policy titled, " Pneumococcal Policy and Algorithm " on 11/29/23 between approximately 12:00 pm and 1:30 pm revealed: " ...1. Establish Patient Pneumococcal Vaccination Status ...3. Patient Previously Vaccinated ...Vaccinated with Prevnar 13 and Pneumovax 23 prior to age 65...Schedule administration of Pneumovax 23, 5 years following administration of Pneumovax 23 ... "
A review of medical records conducted 11/29/23 between approximately 12:00 pm and 1:30 pm with EMP 2, RN clinical manager, revealed the following:
MR 4, Admission date: 5/30/2020. Year of Birth: 1946. Patient age: 77. Date of Pneumovax 23: 1/15/2008 at age 62. Date of Prevnar 13: 11/10/2017. MR did not contain evidence of Pneumovax 23 dosing after the age of 65.
A review of clinic ' s Infection Surveillance Platform (ISP) on 11/29/23, during clinical record review, initially listed the patient as " Series Complete. "
An interview with EMP2, Clinical Nurse Manager, during the clinical record review determined that the ISP algorithm did not display MR 4 as requiring vaccination. EMP2 had notified ISP on 11/29/23 at 15:38 that an error had occurred so that updates could be made to the surveillance platform. As of 11/30/23 clinical record review, EMP2 was unaware of how many additional patient files were affected.
The findings were reviewed with EMP1, administrator, and EMP2, clinical manager, via web conference on 12/4/23 at approximately 1:00 pm.
Plan of Correction:V506 PA-Immunization/medication history
On or before December 29, 2023, the Clinical Manager (CM) or designee will hold a staff meeting, elicit input, and reinforce the
expectations and responsibilities of the facility nursing staff on the importance that all eligible patients are offered the
pneumococcal vaccination. Nursing in-service will be completed on policy, " Pneumococcal policy and Algorithm".
Emphasis will be placed on the importance of vaccinations being offered to all eligible patients.
Effective January 3, 2024, the Clinic Manager or designee will conduct weekly vaccination audits for 4 weeks utilizing plan of
correction tool. Once compliance is sustained 90 %, the Governing Body will decrease frequency to resume regularly scheduled
audits based on the QAPI calendar. Monitoring will be done through the QAPI Process.
The Medical Director will review the results of audits each month at the QAPI Committee meeting monthly.
The Clinical Manager is responsible to review, analyze and trend all data and Monitor/Audit results as related to this Plan of
Correction prior to presenting to the QAPI Committee monthly.
The Director of Operations is responsible to present the status of the Plan of Correction and all other actions taken toward the
resolution of the deficiencies at each Governing Body meeting through to the sustained resolution of all identified issues.
The QAPI Committee is responsible to provide oversight, review findings, and take actions as appropriate. The root cause
analysis process is utilized to develop the Plan of Correction. The Plan of correction is reviewed in QAPI monthly.
The Governing Body is responsible to provide oversight to ensure the Plan of Correction, as written to address the issues
identified by the Statement of Deficiency, is effective and is providing resolution of the issues.
The QAPI and Governing Body minutes, education and monitoring documentation, are available for review at the clinic.
Completion Date: 01/30/2024
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 a review of facility policies, medical records (MRs), and staff (EMP) interviews, the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician for one (1) of four (4) hemodialysis patient records reviewed MR1.
Findings included:
Facility policy " Patient Assessment and Monitoring ...Published 05/01/2023 ...Reference Number: 45284 " reviewed on 12/5/23 at approximately 2:00 pm read, " Responsibility ...Direct patient care staff (RN, LPN/LVN, PCT) (as defined by job description, licensure, certification, state and federal regulations) ...Page 6 of 7 ...3 ...Machine Parameters and Extracorporeal Circuit ...Check machine settings and measurements: ...Check dialysate flow rate setting is correct, and the prescribed flow is being delivered ... "
Review of medical records (MR) on 11/30/23 between approximately 10:00 am to 12:30 pm revealed the following:
MR1, admission date 10/14/22. Treatment sheets reviewed between 11/4/23 and 11/25/23. Physician orders verified 11/04/23-DFR: Manual 800 mL/min. 11/4/23 Start time 6:18 am DFR recorded as 500 at 6:25, 6:43, 7:03, 7:33, 7:44, 8:01, 8:23, 8:47, 9:21, 9:50, 10:02 and 10:21. No updated orders for dialysis on 11/4/23, verified with RN Clinical Manager (EMP2) during chart review.
The findings also were reviewed with (EMP2) and administrator (EMP1) on 11/4/23 at approximately 12:00 pm during a telephone conference call.
Plan of Correction:V543 POC-Manage volume status
On or before December 29, 2023, the Clinic Manager (CM) or designee will in-service all direct patient care (DPC) staff on
policy:
Patient Assessment and Monitoring
The in-service will focus on ensuring that the physician's treatment orders are carried out as prescribed. This includes the patient
care technicians (PCT) reporting any out of range finding to the registered nurse (RN). These include machine parameters such
as: dialysate flow rate (DFR) and blood flow rate (BFR). The meeting will also review that monitoring and safety checks must be
completed every 30-45 minutes with documentation. The reason the DFR/BFR are not being met must be documented as well as
any interventions taken to remedy the issue. The RN must complete an assessment, intervene as needed and notify the physician
if indicated.
In-service training documentation will be on file at the facility.
Starting January 3, 2024, the CM or designee will perform daily audits on ten percent (10%) of patients per shift for two (2)
weeks. At that time if ninety-five (95) % compliance is observed the audits will then be completed 2 times/week for 2 weeks. At
that time, if compliance is maintained, the audits will then follow the monthly QAPI schedule. A POC specific auditing tool will
be used for the audits.
Issues of non-compliance will be addressed by the CM with re-education and counseling.
The Clinical Manager will review the audit results and report the findings at the monthly QAPI meetings for ongoing oversight
and compliance.
Completion Date: 01/19/2024
|