QA Investigation Results

Pennsylvania Department of Health
CALLOWHILL DIALYSIS CENTER
Health Inspection Results
CALLOWHILL DIALYSIS CENTER
Health Inspection Results For:


There are  11 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced Medicare recertification survey completed on January 11, 2021, Callowhill Dialysis Center 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 January 11, 2021, Callowhill Dialysis Center 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:




494.40(a) STANDARD
ACID CONC MIX SYS-EMPTY ALL/PREV CORROSION

Name - Component - 00
5.4.4.2 Acid concentrate mixing systems: empty completely/prevent corrosion
Acid concentrate mixing tanks should be designed to allow the inside of the tank to be completely emptied and rinsed according to the manufacturer's instructions when concentrate formulas are changed.

Acid concentrate mixing tanks should be emptied completely before mixing another batch of concentrate.

Because concentrate solutions are highly corrosive, mixing systems should be designed and maintained to prevent corrosion.



Observations:


Based on an observational tour of the area for water treatment dialysate preparation equipment, and their distribution systems, it was determined that the Facility failed discard a highly corrosive concentrate from a mixing tank that was no longer operational.

Findings include:

On January 6, 2021, at approximately 12:00 p.m., during an observational tour of the Dialysis Water system, it was revealed that in the corner of the Water treatment room, stood a 130 gallon tank filled with approximately 35 gallons of a black colored liquid. A closer observation revealed a whitish color ring around the inside of the tank.

On January 6, 2021, during the observation, and in an interview with the Bio-Technician, it was revealed that the black liquid in the tank was an, "acid solution." It was further revealed that the tank was, "not being used." Upon further questioning the Bio-Technician, it was revealed that the tank had been sitting unused for three, (3), years.

On January 8, at approximately 3:00 p.m., in an interview with the Administrator, and Clinical Manager, it was confirmed that an out of service tank stood with approximately 35 gallons of acid solution inside. The Administrator reported that the tank had been emptied and removed on January 6, 2021.
,









Plan of Correction:

V231
Following policy 2-07-11E Neutralization and Disposal of residual Acid Concentrate for Large Volume Equal to or Greater than 5 Gallons by a Designated and Trained Biomed Teammate (TM), the Biomed TM neutralized the acid concentrate within the tank and emptied it from the tank. Once completed, the tank was removed from the facility and discarded. The Facility Administrator (FA), Clinical Nurse Manager (CNM) and Biomed Technician held an in-service on 1/29/21 for all clinical TMs to review the surveyor's observation and the facility's failure to neutralize and remove tank not in use. In addition, a review of policy 8-04-01 Physical Environment emphasizing the building in which dialysis services are furnished will be constructed and maintained for the safety of the patients, the teammates and the public. Items not in use will be labeled anytime it has been identified as "Not in Use". Verification of attendance at in-service will be evidenced by TMs signature on in-service sheet. The Safety Manger or designee will conducted monthly audits to verify the facility is maintained in a safe manner. Instances of non-compliance will be addressed immediately. The results of the audits will be reviewed with the Medical Director during our monthly Facility Health Meeting (FHM/QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.



494.90(a)(6) STANDARD
POC-P/S COUNSELING/REFERRALS/HRQOL TOOL

Name - Component - 00
The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis.


Observations:


Based on documentation of ESRD Network documentation, medical record review, facility policy, and interview with Administrative Personnel, the facility failed to provide the necessary monitoring and social work interventions, for one, (1), of eight, (8), Medical Records, (MR), reviewed.
(MR #4).

Findings:

On January 7, 2021, at approximately 2:00 p.m., a review of MR #4, revealed a start of care on September 30, 2020. Primary Diagnose is End Stage Renal Disease, additional diagnosis' included Acute Kideny Failure, History of Renal Transplant, Renal Hypertension, Anemia and, Hyperparathyroidism. An additional review of the Treatment Log revealed that from September 30, 2020, through January 2, 2021, MR #4 had missed 12 treatments. The missed treatment days were:

1. October 28, 2020
2. November 11, 2020
3. November 13, 2020
4. November 27, 2020
5. December 7, 2020
6. December 11, 2021
7. December 16, 2020
8. December 18, 2020
9. December 23, 2020
10. December 26, 2020
11. December 30, 2020
12. January 2, 2021

On January 8, 2021, at approximately 3:00 p.m. an interview was conducted with the Administrator and the Clinical Manager, regarding Social Services documentation and interventions for excessive missed treatments. No Social Service documentation was available to the Administrator, or the Clinical Nurse Manager.

On January 8, 2021, at approximately 3:15 p.m. a review of a facility document titled, "Social Work Intervention and Documentation Requirements;" Procedure: 1-14-03A, revealed under the subheading, "Social Work Progress Note," revealed that, "Progress notes are, Quarterly or more frequently as needed. Documentation is individualized and reflects the specific social work needs of the Patient, current/and or anticipated social work problems,.......implementation of planned intervention, patient comprehension, and response to treatment/intervention. Any assessment, reassessment, POC or POC follow-up may serve as Social Work documentation."


In an interview with the facility Administrator, and Clinical Manager on January 8, 2021, at approximately 3:30 p.m.,. it was confirmed that the Patient had missed treatments excessively, and no there was no documented evidence that Social Services was involved.



























Plan of Correction:

V552
The FA held a mandatory in-service with the Interdisciplinary and Nursing Team, which included the Social Worker on 1/29/21 to review policy 1-14-03 Provision of Social Services and 1-14-03A Social Worker Intervention and Documentation Requirements. TMs were instructed using Surveyor's observation emphasizing but was not limited to: 1) the Social Worker will provide ongoing evaluation and support of patient's psychosocial needs. 2) Progress notes are, quarterly or more frequently as needed. Documentation is individualized and reflects the specific social work needs of the Patient, current/and or anticipated social work problems ...implementation of planned intervention, patient comprehension, and response to treatment/intervention. A review of all patients will be conducted monthly during our weekly Core Team Meetings, identifying any patient that has not achieved expected goals according to his/her Plan of Care including treatment attendance as prescribed in the Physician's Standing Order. Patients failing to meet expected goals or treatment attendance will be deemed as unstable, thus requiring a monthly Interdisciplinary Team assessment with a plan of care to achieve expected goals. Verification of attendance at in-service will be evidenced by TMs signature on in-service sheet. The FA or designee will audit ten percent (10%) of the medical records monthly to verify social worker progress notes are up to date. Instances of non-compliance will be addressed immediately. The audit results will be reviewed with the Medical Director during our monthly FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.



494.90(b)(3) STANDARD
POC-OUTCOME NOT ACHIEVED-ADJUST POC

Name - Component - 00
If the expected outcome is not achieved, the interdisciplinary team must adjust the patient's plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must-
(i) Adjust the plan of care to reflect the patient's current condition;
(ii) Document in the record the reasons why the patient was unable to achieve the goals; and
(iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section.



Observations:


Based on documentation of ESRD Network documentation, medical record review, facility policy, and interview with Administrative Personnel, the facility failed to provide the necessary monitoring, documentation and social work interventions, for one, (1), of eight, (8), Medical Records, (MR), reviewed.
(MR #4).

Findings:

On January 7, 2021, at approximately 2:00 p.m., a review of MR #4, revealed a start of care on September 30, 2020. Primary Diagnose is End Stage Renal Disease, additional diagnosis' included Acute Kideny Failure, History of Renal Transplant, Renal Hypertension, Anemia and, Hyperparathyroidism. An additional review of the Treatment Log revealed that from September 30, 2020, through January 2, 2021, MR #4 had missed 12 treatments. The missed treatment days were:

1. October 28, 2020
2. November 11, 2020
3. November 13, 2020
4. November 27, 2020
5. December 7, 2020
6. December 11, 2021
7. December 16, 2020
8. December 18, 2020
9. December 23, 2020
10. December 26, 2020
11. December 30, 2020
12. January 2, 2021

On January 8, 2021, at approximately 3:00 p.m. an interview was conducted with the Administrator and the Clinical Manager, regarding Social Services documentation and interventions for excessive missed treatments. No Social Service documentation was available to the Administrator, or the Clinical Nurse Manager.

On January 8, 2021, at approximately 3:05 p.m., upon request, the facility was not able to submit evidence that the interdisciplinary team, had adjusted or completed a care plan for MR #4. There was no document in the record with reasons why the patient was unable to achieve the goals. There was no evidence to reflect the patient's current condition, or issues encountered to prevent meeting goals.

On January 8, 2021, at approximately 3:15 p.m. a review of a facility document titled, "Social Work Intervention and Documentation Requirements;" Procedure: 1-14-03A, revealed under the subheading, "Social Work Progress Note," revealed that, "Progress notes are, Quarterly or more frequently as needed. Documentation is individualized and reflects the specific social work needs of the Patient, current/and or anticipated social work problems,.......implementation of planned intervention, patient comprehension, and response to treatment/intervention. Any assessment, reassessment, POC or POC follow-up may serve as Social Work documentation."


In an interview with the facility Administrator, and Clinical Manager on January 8, 2021, at approximately 3:30 p.m.,. it was confirmed that the Patient had missed treatments excessively. There was no care plan, no documented evidence that Social Services was involved.







Plan of Correction:

V559
The FA held a mandatory in-service with the Interdisciplinary and Nursing Team, which included the Social Worker on 1/29/21 to review policy 1-14-03 Provision of Social Services and 1-14-03A Social Worker Intervention and Documentation Requirements and Policy 1-14-01 Interdisciplinary Team (IDT) Patient Assessment and Plan of Care . TMs were instructed using surveyor's observations as examples with emphasis placed on: 1) the Social Worker will provide ongoing evaluation and support of patient's psychosocial needs. 2) Progress notes are, quarterly or more frequently as needed. Documentation is individualized and reflects the specific social work needs of the Patient, current/and or anticipated social work problems ...implementation of planned intervention, patient comprehension, and response to treatment/intervention. 3) If the expected outcome is not achieved, the IDT, or individual IDT member, will adjust the patient's plan of care to achieve the specified goal. When a patient is unable to achieve the desired outcomes, the team will: Adjust the plan of care to reflect the patient's current condition; Document in the patient's medical record the reasons why the patient was unable to achieve the goals; and implement plan of care changes to address the issues identified. Verification of attendance at in-service will be evidenced by TMs signature on in-service sheet.
The Plan of Care Manager or designee will track assessments and care plans. The Plan of Care Manager will monitor and review due dates with IDT during weekly Core Team Meetings to ensure timely completion. The FA or designee will audit ten percent (10%) of the medical records monthly to verify social worker progress notes, assessments and plan of care are up to date. Instances of non-compliance will be addressed immediately. The audit results will be reviewed with the Medical Director during our monthly FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.