Initial Comments:
Based on the findings of an onsite unannounced complaint investigation conducted on January 5, 20223, and off-site on January 6, 2023, Renal Carepartners of Philadelphia, LLC, was identified to have the following standard level deficiency that was 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 clinical records (CR), facility documentation (daily flowsheets), nursing documentation and interview with the facility administrator, failed to document changes to patient ' s condition in a timely manner for one (1) of one (1) clinical record reviewed (CR1).
Review of flowsheets (documented daily activity for dialysis treatments - pre-treatment, during treatment, and post-treatment) for the timeframe of 12/2/2022 through 1/4/2023 on 1/5/2023 from approximately 12:07PM until approximately 1:30PM revealed:
An incident occurred during the evening of 12/2/2022 outside of the facility involving (CR1). The nursing note states, " Late Entry: On December 2, 2022, patient (CR1) left the facility in stable condition. Flowsheet reviewed post-treatment. Vital signs stable and afebrile. Patient was the last to leave the building. After fifteen (15) minutes or so, I (RN1) heard the doorbell ring to the facility. A pedestrian rang it, to let us know that patient (CR1) was feeling weak and was asking for a wheelchair. I (RN1) then grabbed a wheelchair and went outside to assess the situation. I (RN1) found the patient leaning against the pillar outside the facility. I (RN1) asked her (CR1) to come inside the facility to be further assessed. Patient (CR1) refused and stated, " I ' m just a little tired, could you bring me to my car? " " Once I (RN1) wheeled her (CR1) over to her vehicle, patient (CR1) got up and walked on her own into her vehicle. At no time was the patient (CR1) in any distress. I (RN1) then asked the patient (CR1) to just sit for a while in her car before driving " . The nursing note was signed by RN1 dated 12/9/2022 at 1:48PM which was one (1) full week after incident occurred.
During an interview with the facility administrator on 1/5/2022 at approximately 9:30AM, the facility administrator stated that RN1 was educated to call 911 on patient ' s behalf and have EMT (Emergency Medical Technician) provide patient assessment. Clinical record and nursing notes did not include documentation that CR1 ' s physician was notified of incident that occurred outside of facility on 12/2/2022.
Interview with the facility administrator, clinical specialist, and vice president of clinical services (via conference call) on 1/5/2023, confirmed the above findings.
Plan of Correction:
494.80(a)(1) PA-ASSESS CURRENT HEALTH STATUS /COMORBIDS V 0502
In-service on Policy C-AD-0440 "Medical Records" will be conducted by the FA on 1/19/2023 with the nursing staff. The FA or designee will audit 10 random patient's charts for 1 week for nurses' notes to ensure it was entered in a timely manner and to include the physician and/or physician extender was notified. If a late nurses' entry exists, the FA or designee will audit the late entry note, ensuring it was entered per policy C-AD-0440. Once sustained improvement has been established, auditing frequency will be decreased to 5 random patient's charts for 1 week. If weekly auditing results in continued sustained improvement, then auditing frequency will resume monthly or per the facility quality management schedule. Auditing frequency may increase as needed to ensure continued compliance. All audit findings will be reviewed by the Facility Administrator and discussed in monthly QAPI. Ongoing compliance will be monitored by Facility Administrator and designee. The Governing Body will provide continued oversight for sustained compliance.
Completion Date:
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