QA Investigation Results

Pennsylvania Department of Health
BLOOMFIELD - PITTSBURGH DIALYSIS
Health Inspection Results
BLOOMFIELD - PITTSBURGH DIALYSIS
Health Inspection Results For:


There are  9 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 unannounced onsite Medicare recertification survey completed April 26, 2024, 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 unannounced onsite Medicare recertification survey completed April 26, 2024, Bloomfield-Pittsburgh Dialysis 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:




494.30(a)(1)(i) STANDARD
IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK

Name - Component - 00
Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory.


Observations:


Based on review of policy, observations and interview with the facility administrator the facility did not ensure precautions were in place to maintain a clean environment to prevent the possibility of spreading infectious diseases for seven (7) of eight (8) observations.
(OBS#1, OBS#2, OBS#3, OBS#4, OBS#5, OBS#6, OBS#8) and the facility failed to ensure visitors were provided PPE while in the treatment area for one (1) of eight (8) observations (OBS#7).


Findings include:

Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy: 1-05-01 with last revision date of April 2023. TITLE: Infection Control for Dialysis Facilities. PURPOSE: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment... POLICY: The Centers for Disease Control (CDC) Recommendations for Preventing Transmission of Infections among Chronic Hemodialysis Patients.... PPE (i.e., gown, gloves, eye protection, face shield). 5. Appropriate PPE will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas. PPE is to be: a. Removed prior to leaving the treatment area...c. PPE is not to be worn in non-treatment areas...6. Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-physicians and visitors when in the treatment area... DISINFECTION: 12. Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infection materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from the treatment area.

Review of facility policy completed on 4/25/24 at approximately 2:00 p.m. revealed: Policy: 4-08-09 with last revision date of October 2019. TITLE: Eyewash Station/Sink/Drench Shower/Hose Checks. POLICY: 1. Plumbed eyewash stations/sinks/drench showers/hoses are to be activated weekly to flush the line and verify proper operation. Self-contained stations are to be inspected according to manufacturer's specification...DEFINITION:...7. Nozzles are to be protected from airborne contaminants...

Observations of dialysis treatment and care completed on 4/23/24 between approximately 9:30 a.m. and 11:00 a.m. and 4/24/24 between approximatley 9:30 a.m. and 2:30 p.m. revealed the following:

OBS#1 on 4/23/24 at 10:21 a.m. revealed a suction machine located on the top of the code cart. Suction machine found to have a brown substance on the back of the machine. Found beside the suction machine was an unwrapped 60 cc syringe. Surveyor observed an orange colored backboard on the floor between the wall and the code cart.

OBS#2 on 4/23/24 at 10:29 a.m. in the lab area, the shelf under the refrigerator with brown dusty area.

OBS#3 on 4/23/24 at 10:45 a.m. an eye wash station without the cover on. This was on the side of the clinical floor that is closest to dialysis stations 8 and 9.

OBS#4 on 4/24/24 at 9:45 a.m. on clinical floor. Surveyor observed EMP7 toss gloves toward garbage bin that was located outside of station #19. Gloves landed on the floor. During discontinuation of dialysis, surveyor observed EMP7 took a sharps container from a common clean area to station # 19. Following use, the sharps container was returned to the common clean area without being wiped down.

OBS#5 on 4/24/24 at 9:55 a.m. on clinical floor. During discontinuation of dialysis, surveyor observed EMP8 take a sharps container and a biohazard bin from a common clean area to station # 14. Following use, the sharps container and the biohazard were returned to the common clean area without being wiped down.

OBS#6 on 4/24/24 at 10:00 a.m. on clinical floor. During discontinuation of dialysis, surveyor observed EMP5 take a sharps container and a biohazard bin from a common clean area to station # 10. Following use, the sharps container and the biohazard were returned to the common clean area without being wiped down.

OBS#7 on 4/24/24 at 10:55 a.m. surveyor witnessed two (2) emergency medical technicians (EMTs) from a local ambulance service bringing a bed-bound patient into the facility. EMTs at chair side and transferred patient from stretcher to dialysis chair. Neither EMT was provided a gown to cover their clothing. Interview with manager of clinical services on 4/24/24 at 11:00 a.m. stated " should have gowns on but masks are personal preference. "

OBS#8 on 4/25/24 at 1:30 p.m. observed EMP7 leave the clinical floor with gown, face mask and face shield on. Observed EMP7 enter the water room and conduct a water test.
Complete water test and exit the water room with all PPE on.

Review of the findings was completed on 4/25/24 at approximately 3:00 p.m. with the facility administrator and manager of clinical services.










































Plan of Correction:

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/13/24. Surveyor observations were reviewed. Education included but was not limited to a review f Policy 1-05-01 "Infection Control for Dialysis Facilities", Policy 4-08-09 Eyewash Station / Sink / French Shower / Hose Checks" and Policy 4-05-01 "Personal Protective Equipment Plan" with emphasis on but not limited to:
A. Infection control policy: 1. Personal Protective Equipment (PPE): 1) Appropriate Personal Protective Equipment will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas. a. PPE is to be removed prior to leaving the treatment area.... c. PPE is not to be worn in non-treatment areas. 2) Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians and Non-Physician (NPP) and visitors when in the treatment area. B. Disinfection: 1) Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials (i.e. used or brought into the station) and prior to returning to clean/designated area or removal from treatment area.
B. Eyewash station... policy: 1) Plumbed eyewash stations/sinks/drench showers/hoses are to be
activated weekly to flush the line and verify proper operation. Self-contained stations are to be
inspected according to manufacturer's specification... 2) Nozzles are to be protected from airborne contaminants...
C. PPE plan policy: 1) all teammates must receive PPE training. The teammate training will include at a minimum: when PPE is necessary and what type of PPE is necessary... 2) Re-training will be provided but is not limited to: A previously trained teammate does not demonstrate an understanding of the need and use for PPE... Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
Upon learning of surveyor's observations, the Facility Administrator or designee directed these actions:
On 04/23/24: a. Code cart: suction machine cleaned, unwrapped syringe discarded, and orange back board was relocated; b. Lab area: shelf under refrigerator was cleaned; c. Eyewash station work order submitted for eyewash station cover, which was received and installed on 04/29/24.
On 04/29/24, discussions were held with teammates identified by surveyor observations regarding sharps containers, in addition to formal teammate education. Teammate who was identified by surveyor received PPE reminders from earlier training, on where PPE is appropriate and inappropriate. PPE reminders for EMS workers will be the responsibility of all teammates on the floor.
Facility Administrator or designee will conduct audits to verify appropriate fluid resistant / impervious gowns are worn and removed appropriately by all teammates, Physicians and non-physician practitioners; equipment and work surfaces will be cleaned and disinfected prior to returning to clean/ designated area; b. physical plant audits to verify physical environment is maintained to provide a clean environment for patients and teammates; eyewash station is maintained in good order, per policy: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored monthly during internal infection control audits, with the exception of the eyewash station which will be monitored with Monthly OSHA and Safety Checklist. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.


494.60 STANDARD
PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT

Name - Component - 00
The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment.


Observations:


Based on direct observations and staff interview it was determined the facility failed to maintain a safe, clean and comfortable environment for patients and staff, specifically the treatment area for four (4) of four (4) observations. (OBS#1-OBS#4).

Findings include:

Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy 4-07-01 with revision date of April 2024. TITLE: Facility Emergency Management Plan...Fire Safety Preparedness...3...b. Fire extinguishers shall be...located such they are readily accessible to teammates without subjecting the teammates to possible injury...c. Fire extinguishers shall be checked monthly to verify it is:...v. There are no obstructions to access or visibility...

OBS#1 on 4/23/24 at 930 a.m. upon entrance to the clinical floor, observed a hoyer lift in front of the fire extinguisher. This was confirmed at 9:40 am by facility administrator.

OBS#2 on 4/23/24 at 10:32 a.m. four (4) Pharmvac refrigerators. Pharmvac #1 with white substance on the top. IV (intravenous) pump sitting on the top of it. Pharmvac #2 with boxes on the top of it. Pharmvac #3 with a rack on the top of it. Hoyer lift positioned in front of the Pharmvac refrigerators. Multiple IV pumps on poles in front of Pharmvac refrigerator area. Dialysis station #1 observed a large amount of white, powder like, substance in the corner behind the chair.

OBS#3 on 4/23/34 at 10:38 a.m. Under the sink on the side of the clinical floor that is closest to dialysis station 4, a plastic jug like container sitting on the floor. The black spray wand that was attached to it was on the floor. The container had the words " Steri-lab " written on the side/top.

OBS#4 on 4/23/24 at 10:50 a.m. observed white, powder like, substance in the corners of dialysis stations #15 and #16 behind the chairs.

Review of the findings was completed on 4/23/24 at approximately 3:00 p.m. with the facility administrator and manager of clinical services.

















Plan of Correction:

The Facility Administrator or designee held mandatory in-services for clinical teammates starting on 05/13/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 8-04-01 "Physical Environment" and Policy 4-07-01 "Facility Emergency Management Plan (EMP)" with emphasis on but not limited to:
A. Physical environment: 1) The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment. 2) The dialysis facility will implement and maintain a program to verify that all equipment, including emergency equipment ... are maintained and operated in accordance with the manufacturer's recommendations. 3) The dialysis facility will store supplies in a manner that is consistent with fire safety and other appropriate regulations...
B. Facility EMP: 1) Fire extinguishers shall be mounted, easy to identify, and located such they are readily accessible to teammates without subjecting the teammates to possible injury. 2) Fire extinguishers shall be checked monthly to verify... there are no obstructions to access or visibility... Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
Upon learning of surveyor's observations, the Facility Administrator or designee directed these actions:
On 04/23/24 Hoyer lift was relocated to prevent obstruction of fire extinguisher; Pharmavac refrigerators were cleaned and clutter removed from the tops; IV poles were relocated to appropriate storage area; jug with wand was removed and appropriately discarded; cleaning service was notified of bicarb collecting dialysis station corners, which was removed on 04/28/24 and ongoing routinely.
The Facility Administrator or designee will conduct physical plant audits to verify the facility maintains access to fire extinguishers, refrigerator exteriors are kept clean, supplies are in appropriate storage areas, bicarb accumulation is cleaned from floors: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the Monthly OSHA and Safety Checklist. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.


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 review of facility policy, review of medical records (MR) and interview with the facility administrator, it was determined that the facility failed to ensure to assess and/or manage patient's blood pressure for one (1 ) of ten (10) MRs reviewed (MR8).

Findings include:

Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy: 1-03-08 with last revision date of April 2024. TITLE: Pre-intra-post Treatment Data Collection, Monitoring and Nursing Assessment. POLICY: ...Intradialytic Data Collection Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the patient care technician (PCT) or licensed nurse include: a. Vital signs and treatment monitoring, iii. For non-nocturnal treatments is completed at least every thirty (30) minutes ...b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures ...

Review of MRs completed on 4/25/24 between approximately 9:00 a.m. and 12:30 p.m. revealed:

MR8-Admission date 1/17/2020. Review of treatment sheets dated between 4/5/24-4/22/24. Review of patient orders dated 4/5/24: blood flow rate (BFR) 500 and dialysate flow rate (DFR) 500.
Treatment sheet dated-4/8/24 revealed patient was assessed at 7:05 a.m. Patient was not assessed again until 8:01 a.m. (56 minutes between assessments).
Treatment sheet dated-4/19/24 revealed patient was assessed at 7:06 a.m. Patient was not assessed again until 8:00 a.m. (54 minutes between assessments).

Interview completed on 4/25/24 at approximately 12:30 p.m. with the facility administrator and manager of clinical services confirmed the above findings.






















Plan of Correction:

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/13/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: 1) Intra dialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes vital signs and treatment monitoring at least every 30 minutes. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures... 2) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct audits to verify vital signs and treatment monitoring are documented every thirty (30) minutes per policy: on twenty five percent (25%) of the flow sheets daily for two (2) weeks, then weekly for two (2) weeks, then ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.



494.90(a)(1) STANDARD
POC-ACHIEVE ADEQUATE CLEARANCE

Name - Component - 00
Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.


Observations:


Based on review of facility policy, review of medical records (MR) and interview with the facility administrator, it was determined that the facility failed to ensure blood flow rate (BFR) and/or dialysate flow rate (DFR) were delivered in accordance with the dialysis prescriptions ordered by the physician for five (5) of ten (10) MRs reviewed (MR1, MR2, MR3, MR7, MR8).

Findings include:

Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy: 1-03-08 with last revision date of April 2024. TITLE: Pre-intra-post Treatment Data Collection, Monitoring and Nursing Assessment. POLICY: ...Intradialytic Data Collection Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the patient care technician (PCT) or licensed nurse include: a. Vital signs and treatment monitoring, iii. For non-nocturnal treatments is completed at least every thirty (30) minutes ...b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures ...

Review of MRs completed on 4/25/24 between approximately 9:00 a.m. and 12:30 p.m. revealed:

MR1-Admission date 3/7/24. Review of treatment sheets dated between 4/6/24-4/13/24. Review of patient orders dated 3/19/24: blood flow rate (BFR) 400 and dialysate flow rate (DFR) 600.
Treatment sheet dated-4/9/24 DFR ran at 500 the entire treatment time. MR1 did not contain documentation as to why the DFR was changed.

MR2- Admission date 8/16/21. Review of treatment sheets dated between 4/5/24-4/22/24. Review of patient orders dated 4/9/24: blood flow rate (BFR) 500, dialysate flow rate (DFR) 500.
Treatment sheet dated-4/12/24 BFR ran at 450 the entire treatment time.
Treatment sheet dated-4/15/24 BFR ran at 355 at initiation of treatment and 400 the rest of the treatment time.
Treatment sheet dated-4/17/24 BFR ran at 400 the entire treatment time.
MR2 did not contain documentation as to why the BFR was changed.

MR3- Transfer date 11/12/18. Review of treatment sheets dated between 4/5/24-4/22/24. Review of patient orders dated 4/16/24: blood flow rate (BFR) 400, dialysate flow rate (DFR) 500.
Treatment sheet dated-4/19/24 BFR initated at 400 and was dropped down to 350 at 12:31 p.m. and remained at 350 for the rest of the treatment time. MR3 did not contain documentation as to why the BFR was changed.

MR7-Admission date 6/14/22. Review of treatment sheets dated between 4/6/24-4/23/24. Review of patient orders dated 4/6/24: blood flow rate (BFR) 400 and dialysate flow rate (DFR) 500.
Treatment sheet dated-4/9/24 BFR ran at 300 from initiation of treatment until 1:21 p.m and until the end of treatment at 1:27 p.m. BFR ran at 250. MR7 did not contain documentation as to why the BFR was changed.

MR8-Admission date 1/17/2020. Review of treatment sheets dated between 4/5/24-4/22/24. Review of patient orders dated 4/5/24: blood flow rate (BFR) 500 and dialysate flow rate (DFR) 500.
Treatment sheet dated-4/8/24 BFR ran at 350 at initiation of treatment and 450 for the rest of the treatment time. MR8 did not contain documentation as to why the BFR was changed.

Interview completed on 4/25/24 at approximately 12:30 p.m. with the facility administrator and manager of clinical services confirmed the above findings.





















Plan of Correction:

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 05/13/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: 1) Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. 2) Prescription components include but are not necessarily limited to: f. Blood flow rate g. Dialysate flow rate... 2) If the dialysis prescription is not being met [including dialysis flow rate or change to/inability to obtain prescribed blood flow rate] the reason will be documented and the licensed nurse informed. 3) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will conduct audits to verify teammates document abnormal findings, notify the licensed nurse, and the nurse responds to the findings per policy: on twenty five percent (25%) of the flow sheets daily for two (2) weeks, then weekly for two (2) weeks, then ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.



494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P

Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;



Observations:


Based on review of medical records (MR), review of facility policies and procedures, and interview with the facility administrator, it was determined the facility did not ensure to receive from patients or their representative a signed, dated consent form for early termination of patient's treatment time per policy for one (1) of ten (10) MRs reviewed (MR1) and signed, dated consent form for dialysis treatment for one (1) of ten (10) MRs reviewed (MR3). The facility failed to ensure the nurse performed an assessment per policy prior to the patient starting treatment for three (3) of ten (10) MRs reviewed (MR7, MR8, MR9).

Findings include:

Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy:1-01-09 with a revision date of April 2024. TITLE: Prescribed treatment time not met. POLICY: A. Completion of the early termination of treatment against medical advice form. 1. The Registered Nurse (RN) will verify that a patients signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time...5. If a patient refuses to sign the Early Termination of Treatment Against Medical Advice form, the RN will document the patient's refusal with the words "patient refused" in the patient signature box along with the date...

Review of facility policy completed on 4/25/24 at approximately 1:30 p.m. revealed: Policy: 1-03-07 with revision date of April 2024. TITLE: Initial Patient Nursing Assessment for New Patients. POLICY: 1. A registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all patients prior to the initiation of their first treatment at the facility...


Review of MRs completed on 4/25/24 between approximately 9:00 a.m. and 12:30 p.m. revealed:

MR1-Admission date 3/7/24. Patient treatment orders dated 3/19/24 listed treatment time of 210 minutes. Treatment Details Report for treatment on 4/9/24 revealed patient dialysis start time 11:43 a.m. Patient terminated treatment at 2:16 p.m. 153 minutes difference. There was no documented evidence of a Early Termination of Treatment Against Medical Advice form signed by the patient.

MR3- Transfer date 11/12/18. Patient's initial treatment flow sheet was dated 12/23/10. Transfer first treatment sheet 11/12/18. Documentation revealed that a dialysis consent was signed by MR3 but did not include the date of the signature.

MR7-Admission date 6/14/22. Initial dialysis treatment was started on 6/14/22 at 11:11 a.m. The initial RN assessment was conducted on 6/14/22 at 11:20 a.m., 9 minutes after start of treatment.

MR8-Admission date 1/17/2020. Initial dialysis treatment was started on 1/17/2020 at 11:46 a.m. The initial RN assessment was conducted on 1/17/2020 at 11:52 a.m., 6 minutes after start of treatment.

MR9-Admission date 3/14/24. Initial dialysis treatment was started on 3/14/24 at 11:06 a.m. The initial RN assessment was conducted on 3/14/24 at 11:13 a.m., 7 minutes after start of treatment.

Interview completed on 4/25/24 at approximately 2:30 p.m. with the facility administrator and manager of clinical services confirmed the above findings.















































Plan of Correction:

On 05/10/24, Governing Body meeting with the Medical Director, Facility Administrator, Nursing Manager and Regional Operations Director was held to review the results of the survey ending on 04/26/24. The Governing Body reviewed Policy COMP-DD-017 "Medical Director Qualifications and Responsibilities" with the Medical Director, who acknowledges that he/she is responsible to ensure all policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and non-physician providers. Plans of correction have been developed and initiated to correct identified deficiencies and to sustain compliance.
The Facility Administrator or designee will hold mandatory in-services starting 05/13/24 for all clinical teammates. Surveyor observations were reviewed. Education included but was not limited to a review of facility policies with areas of emphasis on but not limited to:
1. Policy 1-01-09 "Prescribed Treatment Time Not Met" with emphasis on but not limited to: 1) The RN will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. 2) If a patient refuses to sign the Early Termination of Treatment against Medical Advice form, the RN will document the patient's refusal with the words "patient refused" in the patient signature box along with the date
The Facility Administrator or designee will conduct audits to verify the "Early Termination of Treatment against Medical Advice" form is signed by the patient and Registered Nurse when treatment times are not met on the treatment record as prescribed, per policy: on twenty five percent (25%) of treatment records: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored monthly with ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.
2. Policy 1-03-07 "Initial Patient Nursing Assessment for New Patients" with emphasis on but not limited to: 1) A registered nurse (RN) as required by federal regulation will perform an initial pretreatment evaluation of all patients prior to the initiation of their first treatment at the facility. 2) This pre-treatment evaluation will be documented on the New Patient Pre-Treatment Initial Nurse Assessment" Policy 1-03-07A. The Facility Administrator or designee will conduct an audit of one hundred percent (100%) new patient medical records to verify documentation of new patient pre-treatment initial nurse assessment is completed prior to first treatment in the facility: monthly for three (3) months. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with IDT weekly.
3. Medical records Signed Consent: A. Policy 3-02-01 "Medical Records Custodian and Maintenance" with emphasis on but not limited to: 1) All medical record entries and documents are properly dated and authenticated by the physician and/or clinical teammate according to DaVita policy, state and federal regulations. B. Policy 3-02-05 with emphasis on but not limited to: 1) An informed consent (Authorization for and Verification of Consent to Hemodialysis Procedure or Authorization for and Verification of Consent to Peritoneal Dialysis Procedure) signed by the patient or personal representative and witnessed by the Registered Nurse. 2) The current, original signed consent form must be filed in the patient's current medical record at all times. 3) A new consent form must be signed: a. When a patient transfers to another DaVita facility; b. When the patient is readmitted to DaVita after discharge/transfer... The Facility Administrator or designee will conduct an audit of one hundred percent (100%) new patient medical records to verify informed consent form is signed and dated prior to the first treatment in the facility: monthly for three (3) months. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.
Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Medical Director will review progress of teammate education, results of audits, and adherence to this plan of correction during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meeting. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed if applicable to achieve sustained compliance. Supporting documentation will be included in the meeting minutes. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.


494.180 STANDARD
GOV-ID GOV BODY W/FULL AUTHORITY/RESPONS

Name - Component - 00
The ESRD facility is under the control of an identifiable governing body, or designated person(s) with full legal authority and responsibility for the governance and operation of the facility. The governing body adopts and enforces rules and regulations relative to its own governance and to the health care and safety of patients, to the protection of the patients ' personal and property rights, and to the general operation of the facility.


Observations:


Based on review of facility policy, review of facility documents and interview with the facility administrator, it was determined that the governing body failed to ensure complete documentation of the Daily Zoll AED and Emergency Medication Lock Log for four (4) of seven (7) months reviewed in 2023 and 2024. (October, November, December 2023 and January 2024), failed to ensure that the communication book that is used to correspond with the dialysis facility and the skilled nursing facility is filled out after dialysis treatment for one (1) of one (1) patient with a communication book (P15). The governing body failed to ensure complete documentation of the Weekly Eyewash and Drench Shower/Hoses Inspection for one (1) week in the month of April 2024 (week of April 8, 2024).

Findings include:

1. Review of facility policy completed on 4/26/24 at approximately 1:30 p.m. revealed: Policy: 1-02-08 with revision date of April 2024. TITLE: Emergency Equipment Checks. PURPOSE: Verify that emergency is maintained in a ready-to-use condition. POLICY: ...3. The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: Daily:..Break away lock is intact...Weekly...Emergency cart (crash cart) is clean, operational and supplies/medications have not expired. 4. The Emergency Equipment Checklist may be used for documentation of emergency equipment checks. 5. The emergency checklist will be developed by the facility based on Medical Director input as to the supplies needed on the emergency (crash) cart and will be used to verify that the cart has been checked...

Review of Daily Zoll AED and Emergency Medication Lock Log on 4/23/24 approximately 10:15 a.m. revealed a lack of documentation for Zoll AED illuminated green for 2023-10/5, 10/14, 11/4, and 11/18. Lack of documentation for Emergency Medication Breakaway Lock intact for 2023-10/5, 10/9, 10/14, 10/16, 10/17, 10/18, 10/19, 10/20, 10/30, 10/31, 11/2, 11/3, 11/4, 11/7, 11/8, 11/10, 11/11, 11/14, 11/15, 11/16, 11/17, 11/18, 11/20, 11/21, 11/22, 11/24, 12/8, 12/9, 12/11, 12/12, 12/13, 12/15, 12/16, 12/18, 12/19, 12/22, 12/23, 12/27, 12/28 and 12/29. Lack of documentation for Emergency Medication Breakaway Lock intact for 2024- 1/2, 1/3, 1/4, 1/6, 1/9, 1/11 and 1/12.

Interview completed on 4/24/24 at approximately 8:30 a.m. with the facility administrator confirmed the above findings.

2. Review of the communication book for P15 on 4/24/24 at approximately 1:35 p.m. revealed the dialysis facility did not complete the dialysis communication form for the following dates: 4/12/24, 4/16/24, 4/17/24 and 4/19/24.

Interview completed on 4/24/24 at approximately 1:40 p.m. with the manager of clinical services confirmed the above findings.
3. Review of Procedure: 4-08-09A last revised November 2015 on 4/26/24 at approximately 11:00 a.m.. TITLE: Weekly Eyewash and Drench Shower/Hoses Inspection. All eyewash and drench showers/hoses must be inspected weekly. The inspection for each eyewash and drench shower/hoses must be documented...

Review of the Weekly Eyewash and Drench Shower/Hoses Inspection log on 4/26/24 at approximatley 11:00 a.m. revealed the log did not show an inspection for the required areas for the week of April 8, 2024.

Interview completed on 4/26/24 at approximately 11:30 a.m. with the facility administrator and manager of clinical services confirmed the above findings.
































Plan of Correction:

On 05/10/24, Governing Body meeting with the Medical Director, Facility Administrator, Nursing Manager and Regional Operations Director was held to review the results of the survey ending on 04/26/24. The Governing Body reviewed Governing Body Bylaws with emphasis on but not limited to: The Governing Body shall maintain responsibility for the governance and operation of the Facility. The Governing Body shall: (a) Adopt, enforce ... policies, rules and regulations relative to i) its own governance, ii) the health and safety of Facility patients, iii) the protection of the patients' personal and property rights, and iv) the general operation of the Facility. Plans of correction have been developed and initiated to correct identified deficiencies and to sustain compliance.
The Facility Administrator or designee will hold mandatory in-services starting 05/13/24 for all clinical teammates. Surveyor observations were reviewed. Education included but was not limited to a review of facility policies with areas of emphasis on but not limited to:
1. Policy 1-02-08 "Emergency Equipment Checks" with emphasis on but not limited to: 1) The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: Daily: Check Status Indicator for green check for Zoll AED, refer to Checking Status Indicator of Zoll Automated External Defibrillator (AED); Break away lock is intact. The Facility Administrator or designee will audit emergency equipment checklist and emergency medication lock log to verify RN completion per policy: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored monthly per policy. Instances of non-compliance will be addressed immediately.
2. Communication book: Use of the communication book is a best demonstrated practice in the area for nursing home patients; not per DaVita policy. The Nursing Home sends a book with the communication form regarding patient's vital signs medications, changes. The top portion is for the Nursing Home to complete before they send the patient and the bottom portion is for Dialysis to complete with patient's return, which is also signed by the dialysis RN. The Facility Administrator or designee will audit the communication book to verify completeness: daily for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. Instances of non-compliance will be addressed immediately.
3. Procedure 4-08-09A "Weekly Eyewash and Drench Shower/Hoses Inspection" with emphasis on but not limited to: 1) All eyewash and drench showers/hoses must be inspected weekly. The inspection for each eyewash and drench shower/hoses must be documented. The Facility Administrator or designee will audit the communication book to verify completeness: weekly for two (2) weeks, and monthly for two (2) months. Instances of non-compliance will be addressed immediately.
Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Medical Director will review progress of teammate education, results of audits, and adherence to this plan of correction during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meeting. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed if applicable to achieve sustained compliance. Supporting documentation will be included in the meeting minutes. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.