Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on December 7, 2020, Bloomfield - Pittsburgh 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 on the findings of an onsite unannounced Medicare recertification survey completed on December 7, 2020, Bloomfield - Pittsburgh Dialysis 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)(1) STANDARD
PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
(1) Evaluation of current health status and medical condition, including co-morbid conditions.
Observations:
Based on review of facility policy, medical records (MR) and interview with facility staff, the facility failed to ensure an evaluation of a patient medical condition was in accordance with the facility policy for one (1) of ten (10) in center hemodialysis patient medical records reviewed (MR9).
Findings included:
Review of National Institute of Diabetes and Digestive and Kidney Diseases on 12/8/2020 revealed the following: "Managing Diabetes...Many people with diabetes aim to keep their blood glucose at these normal levels: Before a meal: 80 to 130 mg/dL (milligrams per Deciliter)...About 2 hours after a meal starts: less than 180 mg/dL..Sometimes blood glucose levels drop below where they should be, which is called hypoglycemia. For most people with diabetes, the blood glucose level is too low when it is below 70 mg/dL...https://www.niddk.nih.gov/health-information/diabetes/overview/managing-diabetes..."
Review of facility policy on 12/7/2020 revealed: "Policy: 1-03-08...INTRADIALYTIC DATA COLLECTION/ASSESSMENT...11. Abnormal findings or findings outside of...specific physician ordered parameters will be reported to the licensed nurse immediately...The licensed nurse will use...clinical judgement...to determine if any clinical interventions are necessary...12. The licensed nurse notifies the physician...as needed of changes in patient status..."
Review of MR9 on 12/3/2020 at approximately 1:05 PM: Admission 3/27/2020. "...Primary Diagnosis...End stage renal disease...Comorbidities...Type 1 diabetes mellitus..." Patient in-center hemodialysis treatment records between 11/17/2020 and 12/1/2020 revealed the following:
11/17/2020, "...Medications & Ancillaries administered...Blood Glucose Testing (In-House) - Result: 52...2:50 PM... Administered By: [Patient Care Technician]...Notes: pt (patient) given candy/rn (registered nurse) notified..." There was no documented evidence of clinical interventions and or resolution provided for the patient blood glucose result of 52 in accordance with the facility policy.
11/21/2020, "...Medications & Ancillaries administered...Blood Glucose Testing (In-House) - Result: 405...1:02 PM... Administered By: [Patient Care Technician]..." There was no documented evidence of licensed nurse notification of the patient blood glucose result of 405 in accordance with facility policy.
An exit conference was conducted on 12/7/2020 at approximately 12:00 PM with the facility Administrator (EMP1) and Manager of Clinical Services (EMP9). EMP1 and EMP9 confirmed above findings.
Plan of Correction:V0502
The Governing Body (GB) meet on 12/04/20 to review the results of the recertification survey completed 12/07/2020. Members of the GB including the Medical Director, Facility Administrator (FA) and Regional Operations Director (ROD), reviewed policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment. The GB adopted guidance for episodes of hypoglycemia that includes specific parameters per Medical Director. PRN (as needed) order for treatment of hypoglycemia was added to all current diabetic patients. The FA conducted in-services on 12/4 and 12/7 with all direct care teammates (TMs) on updated treatment for hypoglycemia and parameters. Education included a review of Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment emphasizing: 1) Abnormal findings or findings outside of...specific physician ordered parameters will be reported to the licensed nurse immediately. 2) The licensed nurse will use clinical judgement to determine if any clinical interventions are necessary. The licensed nurse notifies the physician, as needed of changes in patient status. 3) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance is evidenced by TM signature on in-service sheet. The FA or designee will conduct post treatment flowsheet audits daily for two (2) weeks. If improved, then weekly for two (2) weeks. Instances of non-compliance will be addressed immediately. Results will reviewed with the Medical Director in Facility Health Meeting (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
494.80(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 ten (10) in center hemodialysis patient medical records reviewed (MR8).
Findings Included:
Review of facility policy on 12/7/2020 revealed: "Policy: 1-03-08 ...1. Patient data will be obtained and documented by the patient care technician (PCT or a licensed nurse...a...ii...blood pressure (BP) 1. sitting and standing BP...required pre and post treatment...POST TREATMENT DATA COLLECTION/ASSESSMENT...16. If an abnormal finding or concern is identified post treatment, this needs to be reported to the licensed nurse...17. Licensed nurse will use clinical judgment...to determine...clinical interventions or notification of physician...prior to discharge...from the facility...ABNORMAL FINDINGS...Blood pressure post treatment...sitting...systolic greater than 140 mm/Hg or less than 90 mm/Hg,..diastolic greater than 90 mm/Hg or less than 50 mm/Hg..."
Review of MR8 on 12/3/2020 at approximately 12:30 PM: Admission 11/12/2018. "...Primary Diagnosis...End stage renal disease...PRN (as needed) Orders...Hypotension, 11/9/2018...If patients bp (blood pressure)...during treatment <90 administer normal saline of 100 mls (milliliters) up to one liter if patient is symptomatic...If blood pressure is <100 systolic at end of treatment call MD for further orders if symptomatic..." Patient in-center hemodialysis treatment records between 11/16/2020 and 11/30/2020 revealed the following:
11/25/2020, "...Intradialytics: 2:27 PM, BP (blood pressure) 81/36, Notes: 300 ML (milliliter Normal Saline Rinseback (at treatment termination)...Post-Treatment Blood Pressure Sit: 81/36...Post Treatment Data Assessment...RN (registered nurse)...2:45 PM...Cardiac: VSS (vital signs stable)..."
11/27/2020, ""...Intradialytics: 2:44 PM, BP (blood pressure) 81/36, Notes: 300 ML (milliliter) Normal Saline Rinseback (at treatment termination)...Post-Treatment Blood Pressure Sit: 91/47...Post Treatment Data Assessment...RN (registered nurse)...2:51 PM...Cardiac: VSS (vital signs stable)..."
There was no documentation of blood pressure re-assessment/intervention post treatment after patient received normal saline rinseback (intravenous infusion) noted in MR8 hemodialysis treatment records for aforementioned treatment dates.
An exit conference was conducted on 12/7/2020 at approximately 12:00 PM with the facility Administrator (EMP1) and Manager of Clinical Services (EMP9). EMP1 and EMP9 confirmed above findings.
Plan of Correction:V0504
The GB meet on 12/04/20 to review the results of the recertification survey completed 12/07/2020. Members of the GB including the Medical Director, FA and ROD, reviewed policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment. GB adopted patient specific orders for patients with hypotension, per Medical Director. The FA conducted in-services on 12/4 and 12/7 with all direct care TMs to review Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment emphasizing: 1) if an abnormal finding or concern is identified post treatment, including hypotension, this needs to be reported to the licensed nurse. 2) Licensed nurse will use clinical judgment to determine clinical interventions or notification of physician prior to discharge from the facility. 3) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance is evidenced by TM signature on in-service sheet. The FA or designee will conduct post treatment flowsheet audits daily for two (2) weeks. If improved, then weekly for two (2) weeks. Instances of non-compliance will be addressed immediately. Results will reviewed with the Medical Director in FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
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