Initial Comments:
Based upon the findings of an unannounced onsite Medicare recertification survey conducted on 4/9/2021 and 4/12/20211-4/13/2021, US Renal Care York Dialysis 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 upon the findings of an unannounced onsite Medicare recertification survey conducted on 4/9/2021 and 4/12/20211-4/13/2021, US Renal Care York Dialysis was identified to have the following standard level deficiency 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:
494.50(b)(1) STANDARD
MONITOR-DIALYSIS/PT'S CLINICAL COURSE
Name - Component - 00
13 Monitoring
13.1 Dialysis: patient's clinical course
The clinical course of the patient should be observed and recorded during each dialysis to identify possible complications caused by new or reprocessed dialyzers. Dialyzer failures should be recorded and systematically evaluated. Applicable home dialysis patients and their assistants should be instructed in the appropriate observation, recording requirements, and reporting procedures.
Observations:
Based upon review of agency policy, medical records (MR) including treatment flow sheets, and interview with facility administrator (EMP # 1), agency failed to monitor and record the patient's clinical course every thirty (30) minutes per policy during dialysis treatment for three (3) of five (5) files reviewed. ( MR # 1; MR # 4; MR # 9).
Findings included:
Review of agency policy titled " Intradialytic monitoring of patient" on 4/13/2021 between approximately 2:00 PM-3:15 PM stated " During patient care staff will monitor the following parameters duing each dialysis treatment: (5)(a) " during every 30 minute monitoring...".
Review of MR on 4/9/21 between approximately 11:00 AM-11:30 AM; 4/13/2021 between approximately 10:00 AM-11:00 AM and 12:00 PM-3:00 PM revealed:
MR # 1, Start of care (SOC) 4/24/2017; Diagnosis: Hypertension Chronic Kidney Disease.
Physician treatment order 3/12/2021. Dialysis 3x/week for 3 hours and 45 minutes. Dialysate: 2 K/2.5 Ca. BFR 400 and DFR 600. Dialyzer: Optiflux 160 NRe. Dry weight: 75.5 KG.
Treatment flow sheet: 4/7/2021 9:01 AM nursing notes: " Late entry: patient resting and eyes closed. Dialysis in progress; Respirations regular. Access visualized and lines secure."
Next entry 4/7/2021 9:40 AM, thirty-nine (39) minutes after prior notation. (nine (9) minutes past required notation).
Treatment flow sheet: 4/9/2021 9:12 AM nursing notes: " Late entry: BP stable patient is alert watching TV no complaints. Lines are visible and secure. Feet are elevated."
Next entry 4/9/2021 10:19 AM, one hour seven minutes (67) minutes after prior notation. (thirty seven (37) minutes past required notation).
MR # 4, SOC 5/20/2020; Diagnosis: Type 2 Diabetes kidney disease.
Physician treatment order 4/5/2021. Dialysis 3x/week for 4 hours and 0 minutes. Dialysate: 3K/2.5Ca. BFR 450 and DFR 800. Dialyzer: Optiflux 200 NRe. Dry weight: 123 KG.
Treatment flow sheet: 4/2/2021 11:00 AM nursing notes: " patient resting and eyes closed. Dialysis in progress; Respirations regular. Access visualized and lines secure."
Next entry 4/2/2021 11:40 AM, forty (40) minutes after prior notation. (ten (10) minutes past required notation).
MR # 9, SOC 7/1/2020; Diagnosis: Ischemia & infarct of kidneyDiabetes Hypertension
Physician treatment order 3/17/021. Dialysis 3x/week for 3 hours and 45 minutes. Dialysate: 2K/2Ca. BFR 450 and DFR 800. Dialyzer: Optiflux 200 NRe. Dry weight: 112.5 KG.
Treatment flow sheet: 3/31/2021 8:31 AM nursing notes: " patient resting and eyes closed. Dialysis in progress. Respirations regular. Access visualized and lines secure."
Next entry 3/31/2021 9:31 AM, one (1) hour after prior notation. (thirty (30) minutes past required notation)
Treatment flow sheet: 4/7/2021 9:01 AM nursing notes: " patient resting and eyes closed. Dialysis in progress. Respirations regular. Access visualized and lines secure."
Next entry 4/7/2021 9:46 AM, forty-five (45) minutes after prior notation. (fifteen (15) minutes past required notation)
Interview with EMP # 1 on 4/13/2021 at approximately 3:15 PM confirmed above findings.
Plan of Correction:York POC 4.2021
FA or designee to educate clinical staff regarding policy "C-ID-0010 Intradialytic Monitoring of Patient". Education emphasized that staff are required to document an intradialytic monitoring comment every 30 minutes regarding patient status and response to treatment in addition to noting vital signs and delivery of the dialysis prescription. FA or designee will complete flowsheet audits on 10% of all treatment sheets to ensure treatment documentation is being completed every 30 minutes. The audit will be completed 3 times per week for 2 weeks. If the Governing Body deems that substantial improvement has occurred, audits will continue weekly x 4 and then monthly x 2. Audit results will be reviewed with staff and during monthly QAPI meetings. The Governing Body will review QAPI meeting minutes to ensure continued compliance. Identified non-compliance will result in additional staff in-servicing and increased frequency of auditing.
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