Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 10/6/2022, Dialysis Clinic Inc Hastings 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 10/6/2022, Dialysis Clinic Inc Hastings was found 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)(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 a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile of potential adverse effects, drug reactions, drug interactions and noncompliance for one (1) of seven (5) MR's reviewed (MR5).
Findings Included:
Review of the agency policy and procedures on 10/6/2022 at approximately 8:45 AM revealed, PROCEDURE/POLICY NO: 1020 ...Medication Reconciliation Post Hospital Discharge SUPPORTIVE DATA: Transitions of care between healthcare settings are particularly vulnerable times for our patients. A discharge from an inpatient stay presents the greatest risk for medication errors. Discharge Instruction form inpatient stays frequently have multiple medication changes related to the reason for the hospitalization but may not have correct information for other home medications. Reconciling these differences as soon as possible after discharge to create an accurate list of home medications can prevent adverse drug events and reduce the risk for readmission. POLICY ...3. Medication reconciliation should be completed by a licensed nurse (LPN or RN). 4. All patients with discharge from a hospital, skilled nursing facility, or inpatient rehabilitation to home, or from one facility to another will have medication and medication allergy lists reconciled and updated in the patient ' s electronic medical record within 7 calendar days post discharge..."
Review of MR5 on 10/5/2022 at approximately 11:00 AM revealed, start of care date of 7/19/2022. Review of the document "CURRENT MEDICATIONS BY CLASS" (printed 10/3/2022), listed under section "ALLERGIES: INAPSINE, ZEMPLAR." The surveyor reviewed a chart documents which revealed "(Fax date 7/18/2022) Listed under the section "Allergies: Calcium Channel Blockers" was listed. The allergy listed on the documents did not match.
An exit interview was conducted on 10/6/2022 at approximately 2:50 PM with the administrator, nurse manager and technical manager which confirmed the above findings.
Plan of Correction:1. All RN staff will be re-trained on the facility's "Medication Reconciliation – Patient Home Medications" policy #1019 and "Medication Reconciliation Post Hospital Discharge" policy #1020 by 10/31/22. Training will include the responsibility for primary nurses to review all H & P/Medical documents received by the clinic to include the reconciliation of listed medications and/or allergies and to update the patient's electronic medical record.
2. All RN staff will review and sign acknowledgement of understanding of policies. A copy of the acknowledgement will be placed in the facility's education manual.
3. Primary nurses will conduct a review of all current electronic medical records to ensure that medications and/or allergies have been reconciled and are up to date in the medical records.
4. Initially, Nurse Manager and/or Designee will audit the medical record for 20% of our patients monthly for three (3) months to ensure that primary nursing staff are following the policy. If standards are met, the medical record for 20% of our patients will be audited quarterly for one year. The audit results will be reviewed at monthly QAPI meetings.
494.100(b)(2),(3) STANDARD
H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS
Name - Component - 00
The dialysis facility must -
(2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and
(3) Maintain this information in the patient ' s medical record.
Observations:
Based on review of facility medical records, and staff (EMP) interview the facility failed to ensure home dialysis treatment records were reviewed for accuracy with post-treatment assessment documentation for determining if patients were following their treatment plans and/or having problems with their dialysis at home for one (1) of (1) PD records reviewed (MR4).
Findings Included:
Review of the agencies "Routine Standing Orders for Home Peritoneal Dialysis" on 10/6/2022 at approximately 12:32 PM revealed, "...Diabetic Protocol: For symptomatic hypoglycemia (i.e. blurred vision, dizziness, trembling, garbled speech, altered mental status, altered LOC, diaphoresis, confirm blood sugar with glucometer. Administer 1 Glucose Tablet BOX1-2 doses prn for symptomatic blood glucose <100 Administer Dextrose 50% 25 cc x 1-2 doses for blood glucose <80 or for patients with decreased LOC. *Recheck blood glucose 15 minutes following above therapy and notify MD if blood glucose remains <80. *Notify MD if blood glucose is greater than 320 mg/dl..."
Review of the agency policy and procedures on 10/6/2022 at approximately 1:30 AM revealed, "PROCEDURE NO: 206.0...Daily Home Treatment Record PURPOSE: Provide guidelines for proper documentation of home peritoneal dialysis (PD) treatments and to collect data needed to assess the patient's response to PD treatments. SUPPORTIVE DATA: PD Training will include instructions on how to self-monitor health status and record and report health status information. Recording treatment and health status information for PD patients includes documentation of the dialysis process, using peritoneal dialysis specific treatment records...POLICY...2. Each PD patient will be instructed to complete documentation of each treatment procedure on the Daily Home Treatment Record (See Attachment 206A or 206B) and/or by means of an electronic data card...4. Home training staff member will review completed Daily Home Treatment Records to assist in evaluation the patient's progress and self-care decision making process. This will assist staff in making changes to the plan of care if and when warranted or to focus retraining as needed..."
Review of MR5 completed on 10/5/2022 at approximately 10:00 AM revealed a start of care 1/10/2020. The document "PERITONEAL DIALYSIS CLINIC VISIT...Current problems (Flagged)...ESRD CAUSE: Type 2 diabetes mellitus w diabetic chronic kidney disease. " Review of the "(Agency) CURRENT MEDICATIONS BY CLASS" revealed "Group Name: ENDOCRINAL DRUG NAME...INSULIN GLARGINE (BASAGLAR KWIKPEN) STRENGTH 100 U/ML, Dose 0.24 ML, Act. Ingred, 24 UNIT, Frequency QAM...Start Date 3/16/2021..." Also listed was "INSULIN NPH Human (ISOPHANE)(NOVOLIN N FLEZXPEN) STRENGTH 100 U/ML, Dose 0.15 ML, Act. Ingred, 15 UNIT, Frequency QHS...Start Date 6/13/2022..."
Records review revealed "Amia Patient Clinical Data Report" most recently dated 8/23/2022 to 9/25/2022 reviewed by staff 9/27/2022. The records did not contain evidence of PD flow sheets recording in the column "Blood Glucose (mg/dL) Pre, Post" for the dates 8/23/2022 to 9/25/2022. No additional documentation was provided to confirm the staff conducting patient instruction/teaching for the missing information.
An exit interview was conducted on 10/6/2022 at approximately 2:50 PM with the administrator, nurse manager and technical manager which confirmed the above findings.
Plan of Correction:1. Home Dialysis Nurse reviewed orders for all home patients with diagnosis of diabetes. None contained orders for pre/post treatment glucose monitoring.
2. Home Dialysis Nurse will follow standing orders for glucose monitoring during training or clinic visit.
3. Home Dialysis Nurse will review physician orders for each home patient with diabetes to ensure that orders for monitoring glucose pre/post treatment are followed and documented on treatment sheet.
4. Treatment records will be edited to remove/include glucose testing results as ordered by the physician.
5. Initially, Home Dialysis Nurse Manager and/or designee will audit the flowsheets for home patients with a diabetes diagnosis for three (3) months to ensure that physician orders are being followed appropriately. If standards are met, the flowsheets will be audited quarterly for one year. The audit results will be reviewed at monthly QAPI meetings.
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