Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on April 17, 2023 through April 19, 2023, South Broad Street Dialysis Center was found was identified to have the following standard level deficiency that was determined to be in substantial 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.
Plan of Correction:
494.62(d)(1) STANDARD
ESRD EP Training Program
Name - Component - 00
§494.62(d)(1): Condition for Coverage:
(d)(1) Training program. The dialysis facility must do all of the following:
(i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles.
(ii) Provide emergency preparedness training at least every 2 years.
Staff training must:
(iii) Demonstrate staff knowledge of emergency procedures, including informing patients of-
(A) What to do;
(B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated;
(C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and
(D) How to disconnect themselves from the dialysis machine if an emergency occurs.
(iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and
(v) Properly train its nursing staff in the use of emergency equipment and emergency drugs.
(vi) Maintain documentation of the training.
(vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures.
Observations:
Based on a review of medical records (MR), facility policy and an interview with the facility administrator, the facility did not provide emergency training to patients according to policy for five (5) of seven (7) MR's. (MR# 3, 4, 5, 6 and 7)
Findings include:
A review of facility policy "Facility Emergency Mangement Plan" was conducted on April 19, 2023 at approximately 9:45 am. Policy states, "1. Training: b. Patients: ii. Quarterly 1. Fire Safety Preparedness..."
A review of MR's was conducted on April 18, 2023 from 8:35 am to 2:30 pm and April 19, 2023 from 9 am to 10:00 am.
MR#3, Admission Date: 4/12/216, did not have a fire drill documented for the second, third and fourth quarter of 2022.
MR#4, Admission Date: 5/27/14, did not have a fire drill documented for the third and fourth quarter of 2022.
MR#5, Admission Date: 9/24/19, did not have a fire drill documented for the third and fourth quarter of 2022.
MR#6, Admission Date: 8/25/2021, did not have a fire drill documented for the third and fourth quarter of 2022.
MR#7, Admission Date: 4/24/2012, did not have a fire drill documented for the second, third and fourth quarter of 2022.
An interview with the facility administrator conducted on April 19, 2023 at approximately 11:40 am confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-service for all clinical teammates starting on 04/21/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-07-01 "Facility Emergency Management Plan" with emphasis on but not limited to: 1) Facility Administrator or designee, is responsible to... Conduct and review quarterly fire safety and evacuation training and drills for compliance. 2) Fire safety drills are required on a quarterly basis; one drill to be conducted for each shift of patients. 3) Include patient emergency takeoff procedure, policy. 4) Document training for both patients and teammates: i. Patients use Reggie form "Emergency Evacuation Acknowledgement Form"; ii. Teammates use policy: "Training/In-service Documentation Form"; iii. Identify patients requiring assistance in an evacuation. 4) Document in Governing Body meeting. 5) Maintain with facility Emergency Management Plan.
Verification of attendance is evidenced by teammate's signature on the in-service sheet.
Fire drills were completed for all shifts of patients by 04/27/23. The Facility Administrator scheduled fire drills for remainder of 2023. The Facility Administrator will designate Safety Champion or designee to audit fire drill documentation which verifies fire drills are completed quarterly, (one for each shift of patients), and that the documentation is reviewed in Governing Body and filed with the facility Emergency Management Plan. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director in Quality Assessment Performance Improvement meetings known as Facility Health Meetings, and in Governing Body meetings, with supporting documentation included in the meeting minutes.
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on April 17, 2023 through April 19, 2023, South Broad Street 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:
494.60 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 an observational tour of the dialysis unit, and interview with the facility administrator, the facility failed to maintain a safe, functional, treatment environment for Dialysis Patients.
Findings include:
A review of facility policy titled "Emergency Equipment Checks" was conducted on April 19, 2023 at approximately 9:40 am. Policy states, "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..."
On April 17, 2023, at approximately 10:45 am, while conducting an observational tour that included inspection of the unit emergency equipment cart, it was revealed that the emergency equipment cart did not have a break away lock in place. At the time of this observation, an equipment checklist binder was unavailable for review to determine if there were other dates of non-compliance.
An interview with the facility administrator conducted on April 19, 2023 at approximately 11:40 am confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 04/21/23. Surveyor observations were reviewed. Education included but was not limited to review of Policy 1-02-08 "Emergency Equipment Checks" and Procedure 1-02-08E "Daily Zoll AED and Emergency Medication Lock Log" 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; Break away lock is intact.
Verification of attendance at in service is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator immediately replaced breakaway lock on emergency cart and reviewed the use of Procedure form 1-02-08 for documenting daily equipment and break away lock checks.
The Facility Administrator or designee will conduct observational audits for presence of breakaway lock and proper log completion: daily for two (2) weeks then weekly for two (2) weeks. Ongoing compliance will be monitored monthly. Instances of non-compliance will be addressed immediately
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings and with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation 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 policies/procedure, medical records (MR), and an interview with the facility administrator, the facility failed to ensure the blood flow rate (BFR) and/or the dialysate flow rate (DFR) was administered per physician order for six (6) of seven (7) incenter hemodialysis patient MR's reviewed. (MR #1, 2, 3, 4, 5 and 6 ); and the facility failed to provide documentation that a patient requested early treatment termination for four (4) of seven (7) incenter hemodialysis patient MR's reviewed, (MR # 3, 4, 5,and 6).
Findings include:
A review of facility policy titled "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" on April 19, 2023 at approximately 9:55 am states, "Policy: 3. 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...Prescription components include but are not necessarily limited to: f. Blood flow rate (BFR) g. Dialysate flow rate (DFR)...Intradialytic Date Collection/Assessment: 10. If the dialysis prescription is not being met (including DFR or change to/inability to obtain prescribed BFR) the reason will be documented and the licensed nurse informed..."
A review of facility policy titled "CWOW-Prescribed Treatment Time Not Met" on April 19, 2023 at approximately 10:00 am states, "Policy: A. Completion of the Early Termination of Treatment Against Medical Advice Form: 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...3. The RN will obtain the patient's signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient's signature prior to rinse-back, the RN will obtain the patient's signature on the form prior to the patient's departure from the facility. 4. A RN must countersign all Early Termination of Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 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. Under such circumstances, the RN will sign the form and will also obtain a witness' signature on the form... B. Prescribed Treatment Time Not Met: 1. If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient's attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient's specific needs..."
A review of patient medical records (MR) was completed on April 18, 2023 from approximately 9:00 am to 2:30 pm and on April 19, 2023 from approximately 9:00 am to 10:00 am.
MR #1: Admission Date: 2/24/2023. Dialysis order date: 3/14/2023. Frequency: Tuesday, Thursday, and Saturday; Target Weight: 94 Kg; Dialyzer: Optiflux F180NR; Dialysate: 2 K, 2.5 CA, 35 HCO3, 136 NA; Treatment Duration: 240 minutes; BFR: 450; DFR: 600.
Review of Dialysis Treatment Details Reports revealed the BFR/DFR was not administered at prescribed rates on the following dates:
4/4/2023, during entire treatment the BFR was administered at 300 ml/hr and during entire treatment the DFR was administered at 500 ml/min.
4/8/2023, during entire treatment the BFR as administered at 400 ml/min and during entire treatment the DFR was administered at 500 ml/min.
4/11/2023, during entire treatment the BFR was administered at 400 ml/min.
4/13/2023, between 9:02 am and 11:02 am, the BFR was administered at 400 ml/min, and during entire treatment DFR was administered at 500 ml/min.
4/15/2023, during entire treatment the DFR was administered at 500 ml/min.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR/DFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR/DFR was administered at a rate different from the prescribed amount for any of the above dates.
MR # 2: Admission Date: 1/14/2019. Dialysis order date: 3/20/2023. Frequency: Monday, Wednesday, and Friday; Target Weight: 138 Kg; Dialyzer: Optiflux F180NR 1218; Dialysate: 2 K, 2.5 CA, 38 HCO3, 138 NA; Treatment Duration: 240 minutes; BFR: 500; DFR: 500.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
4/3/2023, during entire treatment the BFR was administered at 400 ml/hr.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates.
MR # 3: Admission Date: 4/12/2016. Dialysis order date: 3/20/2023. Frequency: Monday, Wednesday, and Saturday; Target Weight: 110 Kg; Dialyzer: Optiflux F180NR 1218; Dialysate: 1 K, 2.5 CA, 35 HCO3, 138 NA; Treatment Duration: 240 minutes; BFR: 495; DFR: 500.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
4/12/2023, during entire treatment the BFR was administered at 500 ml/hr.
4/8/2023, during entire treatment the BFR as administered at 400 ml/min.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates.
Review of Dialysis Treatment Details Reports revealed the patient requested early termination of treatment on the following date:
4/15/2023 Treatment time 144 minutes, short 96 minutes.
4/8/2023 Treatment time 183 minutes, short 57 minutes.
4/3/2023 Treatment time 187 minutes, short 53 minutes.
There is no documentation of an Early Termination of Treatment Against Medical Advice form in the MR for the above date
MR #4: Admission Date: 5/27/2014. Dialysis order date: 3/13/2023. Frequency: Monday, Wednesday, and Friday; Target Weight: 111.5 Kg; Dialyzer: Optiflux F180NR; Dialysate: 2 K, 2.5 CA, 35 HCO3, 138 NA; Treatment Duration: 240 minutes; BFR: 400; DFR: 700.
Review of Dialysis Treatment Details Reports revealed the BFR/DFR was not administered at prescribed rates on the following dates:
4/3/2023, during entire treatment BFR was administered at 250 ml/min, and during entire treatment the DFR was administered at 500 ml/min.
4/5/2023, during entire treatment the BFR was administered at 250 ml/min, and during entire treatment the DFR was administered at 500 ml/min.
4/7/2023, during entire treatment the BFR was administered at 250 ml/min, and during entire treatment the DFR was administered at 500 ml/min.
4/10/2023, during entire treatment the BFR was administered at 250 ml/min, and during entire treatment the DFR was administered at 500 ml/min.
4/12/2023, during entire treatment the BFR was administered at 250 ml/min.
4/14/2023, during entire treatment the BFR was administered at 250 ml/min, and during entire treatment the DFR was administered at 500 ml/min.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR/DFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR/DFR was administered at a rate different from the prescribed amount for any of the above dates.
Review of Dialysis Treatment Details Reports revealed the patient requested early termination of treatment on the following date:
4/5/2023 Treatment time 195 minutes, short 45 minutes
There is no documentation of an Early Termination of Treatment Against Medical Advice form in the MR for the above date.
MR #5: Admission Date: 9/24/19. Dialysis order date: 3/20/2023. Frequency: Monday, Wednesday, and Friday; Target Weight: 79 Kg; Dialyzer: Optiflux F180NR; Dialysate: 3 K, 2.5 CA, 35 HCO3, 138 NA; Treatment Duration: 240 minutes; BFR: 400; DFR: 500.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
4/10/2023, between 2:34 pm and 3:04 pm, the BFR was administered at 350 ml/min
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for the above date and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for the above date.
MR # 6: Admission Date: 8/25/2021. Dialysis order date: 2/15/2023. Frequency: Monday, Wednesday, and Friday; Target Weight: 65.5 Kg; Dialyzer: Optiflux F180NR 1218; Dialysate: 2 K, 2.5 CA, 35 HCO3, 138 NA; Treatment Duration: 240 minutes; BFR: 450; DFR: 500.
Review of Dialysis Treatment Details Reports revealed the BFR was not administered at prescribed rates on the following dates:
4/14/2023, during entire treatment the BFR was administered at 400 ml/hr.
4/12/2023, during entire treatment the BFR was administered at 400 ml/min.
4/7/2023, during entire treatment the BFR was administered at 400 ml/min.
There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates.
Review of Dialysis Treatment Details Reports revealed the patient requested early termination of treatment on the following date:
4/12/2023 Treatment time 201 minutes, short 39 minutes.
4/7/2023 Treatment time 189 minutes, short 51 minutes.
4/3/2023 Treatment time 187 minutes, short 53 minutes.
There is no documentation of an Early Termination of Treatment Against Medical Advice form in the MR for the above date.
An interview with the facility administrator was conducted on April 19, 2023 at approximately 11:40 am confirmed the above findings.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 04/24/23. 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" and Policy 1-01-09 "CWOW-Prescribed Treatment Time Not Met" with emphasis on but not limited to:
A. Policy 1-03-08 "Pre- Intra- Post Treatment..." 1) Patient identity, prescription and machine settings are verified by teammates prior to initiation of treatment. Prescription components include but are not necessarily limited to ... Blood Flow rate, 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.
B. Policy 1-01-09 "CWOW- Prescribed Treatment Time..." 1. Completion of Early Termination of Treatment against Medical Advice Form: 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) The RN will obtain the patient's signature on the Early Termination of Treatment against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient's signature prior to rinse-back, the RN will obtain the patient's signature on the form prior to the patient's departure from the facility. 3) A RN must countersign all Early Termination of Treatment against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 4) 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. Under such circumstances, the RN will sign the form and will also obtain a witness' signature on the form. 2. Prescribed Treatment Time Not Met: 1) If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient's attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient's specific needs.
Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will complete daily audits of treatment records to verify treatment documentation is complete and appropriate, including Registered Nurse notification concerning prescribed blood flow rate, and dialysis flow rate if those components are not meeting treatment prescription. The audit will also verify the
"Early Termination of Treatment against Medical Advice" form is signed by the patient and Registered Nurse when treatment times are documented as "not met" on the treatment record as prescribed.
Each audit series will be conducted 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. The Facility Administrator or designee will review audit results with the teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment Performance Improvement meeting known as Facility Health Meeting, with supporting documentation in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
|