Initial Comments:
Based on the findings of an on-site unannounced Medicare recertification survey completed on 7/7/2023, Dialysis Clinic, Inc. At Chestnut Ridge 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 7/7/2023, Dialysis Clinic, Inc. At Chestnut Ridge 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:
494.40(a) STANDARD
CARBON ADSORP-MONITOR, TEST FREQUENCY
Name - Component - 00
6.2.5 Carbon adsorption: monitoring, testing freq
Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours.
Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet.
Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L].
Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly.
Observations:
Based on a review of facility policy and procedure, direct observation (OBS) of staff and Staff (EMP) interview the facility staff failed to implement and confirm the chlorine testing as per facility policy and procedure for one (1) of two (2) staff observed, and two (2) of two (2) staff interviewed (EMP7 and EMP8).
Findings Included:
Review of the agency policy and procedures on 6/28/2023 at approximately revealed, Policy "Total Chlorine Testing with RPC Ultra-Low Total Chlorine Test Strip PURPOSE: To define the steps involved for testing the presence of Chlorine and Chloramine using the RPC Ultra-Low Total Chlorine Test Strip ...SUPPLIES: RPC Ultra-Low Total Chlorine Test Strip, Technical Module Water System Log, Sample Cup (100 ml minimum) Timer PROCEDURE 1. Ensure the RO has been running for a minimum of 15 min with water usage before starting test. 2. Prior to collecting the sample, rinse the clean, dry sample cup with the water to be tested. 3. Collect a fresh 100 ml sample of water in a plastic sample cup...4. Set Time for 60 seconds. Remove one test strip from its foil package and dip it in the sample for 60 seconds ...5. While dipping the strip, move it back and forth at a constant gentle rate of approximately two, 1-2 inch wide strokes (one forward-one backward) per second. 6. Remove the strip and shake once, briskly, to remove excess water. 7. Wait 20 seconds for the test strip color to develop. While waiting, fold the white plastic handle of the test strip under the regency area aperture so that it provides a consistent viewing background. 8. After the 20 second wait period, immediately compare the strip color to the K100-0118v color chart to determine the Total Chlorine level in the sample..."
Observation (OBS) of staff EMP7 performing Total Chlorine testing using RPC Ultra-Low Total Chlorine Test Strips was conducted on 6/28/2023 at approximately 12:05 PM. EMP7 placed the testing strip into the water sample and moved the strip back and forth for approximately 60 seconds then removed the strip from the sample water then immediately took the strip to the RN on duty to confirm the test strip. The surveyor asked EMP7 what is step is to be done after the 60 second stirring. EMP7 confirmed that it is taken directly to the RN on duty to confirm the test strip with the color chart.
EMP7 yearly "RPC Ultra-Low Total Chlorine Test Strips SKILLS CHECKLIST" for total chlorine testing was last completed on 3/20/2023. The skills checklist was initial by the employee and the instructor.
The surveyor requested from EMP1 administrator, an interview with staff member EMP8. The surveyor confirmed with EMP8 that they also conduct daily chlorine testing. An interview was conducted with EMP8 on 6/28/2023 at approximately 12:10. The surveyor asked EMP8 to describe the required steps for the chlorine testing. All steps confirmed, except no mention of the 20 second wait time for the test strip to develop.
EMP8 yearly "RPC Ultra-Low Total Chlorine Test Strips SKILLS CHECKLIST" for total chlorine testing was last completed on 3/20/2023. The skills checklist was initial by the employee and the instructor.
An exit interview was conducted with the director, nurse manager, chief technician, and social worker on 6/30/2023 at approximately 12:20 PM which confirmed the above findings.
Plan of Correction:1. All clinical staff will be re-trained on the facility's "Total Chlorine Testing with RPC Ultra-Low Total Chlorine Test Strip" procedure on 6/28/2023. In addition, staff will complete a written quiz by 7/24/23.
2. All staff will review and sign acknowledgement of understanding of policy. Acknowledgement will be placed in facility's education manual and/or personnel file.
3. Initially, Technical Manager will observe clinical staff perform procedure for one (1) week to ensure that clinical staff is following proper procedure for total chlorine testing. If standards are met, the Technical Manager will observe weekly for four (4) weeks. If standards are met, the Technical Manager will observe clinical staff monthly for three (3) months. If standards are met, the clinical staff will be observed annually. The audit results will be reviewed at monthly QAPI meetings.
494.40(a) STANDARD
RO-MEETS AAMI/MONITORED, RECORDED ON LOG
Name - Component - 00
5.2.7 Reverse osmosis: meets AAMI/monitored/recorded on log
Refer to RD62:2001, 4.3.7 Reverse osmosis: When used to prepare water for hemodialysis applications, either alone or as the last stage in a purification cascade, reverse osmosis systems shall be shown to be capable, at installation, of meeting the requirements of Table 1, when tested with the typical feed water of the user, in accordance with the methods of [AAMI] 5.2.2.
5.2.7 Reverse osmosis
Users should carefully follow the manufacturer's instructions for feed water treatment and monitoring to ensure that the RO is operated within its design parameters.
6.2.7 Reverse osmosis
All results of measurements of RO performance should be recorded daily in an operating log that permits trending and historical review.
Observations:
Based on the review of the facilities policy and procedures, daily waterlog sheets and staff (EMP) interviews the facility failed to ensure staff followed water treatment and monitoring to ensure that the RO is operated within its design parameters for one (1) of thirteen (13) set of water and dialysate logs review.
Findings included:
Review of the agency policy and procedures on 7/7/2023 at approximately 8:15 AM revealed, Policy "Technical Module: Water System Documentation...SUPPORTIVE DATA: The Technical Module is a quality control and quality assurance tool that was created to ensure ongoing conformance to policies and procedures, CMS condition of coverage, and AAMI standards regarding water quality used to produce dialysate...POLICY...The comment section of the written record will be used to document remarks to be entered into the Technical Module Water System Log. 3. All out of range data documented as a work order in the technical module and will be reported to the Chief Technician..."
Review of the agency policy and procedures on 7/7/2023 at approximately 8:15 AM revealed, Policy "Daily Water Treatment Monitoring PURPOSE: Ensure proper operation of the Water Treatment System and its components that will provide AAMI Standard Quality Water for Hemodialysis Treatments...POLICY: 1. Monitoring water systems: Acceptable parameters and location descriptions are defined on the Water System Log in the Technical Module. Verify the RO is in NORMAL OPERATING MODE: and that the RO has run for a minimum of 15 minutes before performing any testing. All pressure readings, flow readings and testing are documented daily on the Water System Log and the data entered into the Technical Module; If a reading is out of range, a work order must be completed for the out of range results so its repair can be documented and tracked..."
A review of the daily water system log was conducted on 6/27/2023 at approximately 9:28 AM for the dates from 3/27/2023 to 6/24/2023. On the following date of 3/29/2023, the reading were out of range for the following:
Post Booster Pump Pressure, Range 40-70 psi, reading 72
Post Particulate Filter Pressure, Range 40-70 psi, reading 76
Post Carbon Worker Pressure, Range 40-70 psi, reading 72
No documentation was provided by the agency to confirm the readings were reported as outside the acceptable limits to management or the biomedical technician, at the time daily readings were conducted or when review of the daily water treatment logs where completed.
An exit interview was conducted with the director, nurse manager, chief technician, and social worker on 6/30/2023 at approximately 12:20 PM which confirmed the above findings.
Plan of Correction:1. The "Daily Water Treatment Monitoring" policy, Item #1 "Monitoring water systems" will be revised to state "If a reading is out of range, the Technical Manager is to be notified. A notation is to be made under the comment section in the Technical Module stating the date and time that the Technical Manager was notified."
2. The "Technical Module: Water System Documentation" policy, Item #3 will be revised to state "All out of range data documented in the technical module will be reported to the Technical Manager."
3. All clinical staff will be retrained on the revised "Daily Water Treatment Monitoring" and "Technical Module: Water System Documentation" policies by 7/24/23.
4. All staff will review and sign acknowledgement of understanding of policies. Acknowledgement will be placed in facility's education manual and/or personnel file.
5. Initially, Technical Manager will audit water treatment logs daily for one (1) week to ensure that staff is following proper procedure for notification of any out of range water treatment readings. If standards are met, the Technical Manager will audit weekly for four (4) weeks. If standards are met, the Technical Manager will audit water treatment logs monthly for three (3) months. If standards are met, the water treatment logs will be audited quarterly. The audit results will be reviewed at monthly QAPI meetings.
494.40(a) STANDARD
DIALYS PROPORT-MONITOR PH/CONDUCTIVITY
Name - Component - 00
5.6 Dialysate proportioning: monitor pH/conductivity
It is necessary for the operator to follow the manufacturer's instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient.
Observations:
Based on review of agency policy, testing logs and staff (EMP) interview the facility failed to ensure documentation identy of the phoenix meters used were re-calibrated per protocol for two (2) of two (2) months of meter testing logs reviewed.
Findings included:
Review of the agency policy and procedures on 7/7/2023 at approximately 8:15 AM revealed, Policy "Phoenix Meter Disinfection, Calibration, Use and Storage, PURPOSE: To assure the pHoenix Meter is properly verified, calibrated, and disinfected prior to use. To assure that the dialysis machine's conductivity, pH and temperature are accurate when compared to an independent meter. SUPPORTIVE DATA: According to CMS Guidelines, the conductivity and pH of the machine should be verified with an external meter prior to patient use. It is (Agency) policy to check temperature as well. POLICY: 1. The pHoenix meter will be disinfected with a 1% solution of Bleach daily prior to use. 2. The meter will be verified against 14.0 mS conductivity and 7.0 pH standard solutions daily prior to use, and/or whenever inaccurate readings are suspected or documented on the "Daily Phoenix Meter Log" sheet. Conductivity should read 14 mS (+or -) .1; pH should read 7(+or -) .1. The meter will be calibrated when the conductivity or pH are out of range..."
Review of "DAILY PHOENIX METER LOG" for April and May of 2023 was conducted on 6/27/2023 at approximately 1:07 PM. The log sheets under section "pHoenix Meter Serial #" were blank. The surveyor was unable to identify which phoenix meter was tested, calibrated and/or used on a daily basis from 4/1/2023 until 5/18/2023.
An interview with EMP3 (biomed) on 6/27/2023 at approximately 1:50 PM confirmed logs should have been labeled to confirm which meter was being calibrated and/or used.
An exit interview was conducted with the director, nurse manager, chief technician, and social worker on 6/30/2023 at approximately 12:20 PM which confirmed the above findings.
Plan of Correction:1. The "Daily Phoenix Meter Log" will be revised on 6/27/23 to include the Meter#/Serial# of the meter pre-filled in on the log. The "Technical Module: Water System Documentation" policy, Item #3 will be revised to state "All out of range data documented in the technical module will be reported to the Technical Manager."
2. All clinical staff will be retrained on the "Phoenix Meter Disinfection, Calibration, Use and Storage" policy with emphasis on the completion of the revised "Daily Phoenix Meter Log." by 7/24/23.
3. All staff will review and sign acknowledgement of understanding of policy and completion of Log. Acknowledgement will be placed in facility's education manual and/or personnel file.
4. Initially, Technical Manager will audit Daily Phoenix Meter Log daily for one (1) week to ensure that staff is following proper procedure for completion of Daily Phoenix Meter Log. If standards are met, the Technical Manager will audit weekly for four (4) weeks. If standards are met, the Technical Manager will audit water treatment logs monthly for three (3) months. If standards are met, the water treatment logs will be audited quarterly. The audit results will be reviewed at monthly QAPI meetings.
494.60(b) STANDARD
PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU
Name - Component - 00
The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer's recommendations.
Observations:
Based on review of facility policy, facility maintenance records and staff (EMP) interview, it was determined the facility failed to ensure that annual preventive maintenance was completed according to manufactures directions for use for one (1) out of three (3) hemodialysis machine reviewed.
Findings included:
Review of facility policy was conducted on 6/27/2023 at approximately 12:02 PM revealed, Manufacture directions for use "1.0 INTRODUCTION Preventive Maintenance for the 2008T Hemodialysis System is simple and straightforward. Scheduled maintenance is performed based on timed intervals or number of hours as machine is operated, whichever comes first. Them time and hour intervals are as follows: Machines without Extended Life Pump Components3 *Six (6) months *Annually or after 4000 hours of operation Machines with Extended Life Pump Components3 * Six (6) months *Annually or after 4000 hours of operation *Concentrate (acid), Bicarbonate & UF Pumps with extended life components3 are rebuilt every 2 years or after 8000 hours of operation, 2008T BlueStar Premium machine are equipped with extended life components3 and can be identified by the 2008T BlueStar logo (shown below) on the keyboard. Six (6) months *Annually or after 4000 hours of operation *Concentrate (acid), Bicarbonate & UF Pumps with extended life components3 are rebuilt every 2 years or after 8000 hours of operation ...Checklists are provided in the back of this manual to record the work done. Make copies of these checklists as needed. Your initials on the checklist certifies that each procedure has been completed and that the machine is performing according to the specifications given ...2008T Preventive Maintenance Procedures P/N 508033 Rev.R."
Review of facility maintenance records was conducted on 6/27/2023 at approximately 1:07 PM revealed the following: The document "Fresenius 2008T PM ...Nickname T06, Status: completed Printed 03/24/2022 ...Due Date: 03/31/2022, Machine Hour: 9185, Schedule Type: Annual..." The surveyor requested any additional documentation to confirm annual maintenance was conducted for after the date of 3/25/2023. No documentation was provided.
An exit interview was conducted with the director, nurse manager, chief technician, and social worker on 6/30/2023 at approximately 12:20 PM which confirmed the above findings.
Plan of Correction:1. Completion of the Annual Fresenius Preventive Maintenance procedure was performed on machine T06 on 6/28/23.
2. Equipment Technical staff will be retrained on the manufacturer's preventive maintenance schedule for the Fresenius 2008T BlueStar dialysis machine by 7/24/2023.
3. All staff will review and sign acknowledgement of understanding of preventive maintenance schedule. Acknowledgement will be placed in facility's education manual and/or personnel file.
4. Initially, Technical Manager will audit Preventive Maintenance records weekly for four (4) weeks to ensure that all medical equipment is up to date and that staff is following their required maintenance schedule. If standards are met, the Technical Manager will audit monthly. The audit results will be reviewed at monthly QAPI meetings.
494.80(a)(2) STANDARD
PA-APPROPRIATENESS OF DIALYSIS RX
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
(2) Evaluation of the appropriateness of the dialysis prescription,
Observations:
Based on a review of facility policies and procedures, medical records (MR) and staff (EMP) interviews, the facility failed to ensure the evaluation of the appropriateness of the dialysis prescription including dialysate flow rate (DFR) for one (1) of three (3) in-center hemodialysis medical records (MR) reviewed (MR2).
Findings included:
Review of the agency policy and procedures on 7/7/2023 at approximately 8:15 AM revealed, Policy "SUBJECT: HEMODIALYSIS TREATMENT READINGS...PURPOSE: To evaluate the effectiveness of the dialysis treatment and fluid removal and to provide for early detection of complications that may arise related to the treatment. RESOURCES: HCFA 494.90 Condition: Patient plan of care (a)(1) Dose of dialysis ...POLICY: While the patient is receiving a hemodialysis treatment, the nursing staff will perform routine monitoring (reading) of the patient's overall condition and the status of the treatment itself a minimum of every 30 minutes and more frequently if needed. Legible documentation on the hemodialysis flowsheet will be completed and will not exceed 30 minutes between each reading..."
A review of MR2 was conducted on 6/28/2023, at approximately 1:55 PM, the start of care date was 5/12/2023. The "EFFECTIVE ORDERS-Hemodialysis Treatment" was dated 5/10/2023. A review of the "HEMODIALYSIS FLOWSHEET" dated 6/14/2023 through 6/23/2022 revealed the physician ordered a DFR of 600 ml/min. DFR was delivered higher than prescribed on 6/16/2023 at 800 ml/min for the entire treatment. Documentation was completed on 6/16/2023 by three staff members.
An exit interview was conducted with the director, nurse manager, chief technician, and social worker on 6/30/2023 at approximately 12:20 PM which confirmed the above findings.
Plan of Correction:1. All clinical staff will be re-trained on the facility's "Hemodialysis Treatment Readings" policy by 7/24/23. Training will include the responsibility to evaluate ordered treatment parameters and ensure that patients are receiving their appropriate dialysis prescription.
2. All clinical staff will review and sign acknowledgement of understanding of policy. Acknowledgement will be placed in the facility's education manual and/or personnel file.
3. Charge Nurse will round and initial records to confirm treatment parameters are set per physician orders.
4. Initially, Nurse Manager and/or Designee will audit 50% of treatment flow sheets daily for one (1) week to ensure that staff is following the policy with emphasis on documentation of patient receiving their appropriate dialysis prescription. If standards are met, 50% of the treatment flow sheets will be audited weekly for four (4) weeks. If standards are met, 50% of the treatment flow sheets will be audited monthly for three (3) months. If standards are met, 50% of the treatment flow sheets will be audited semi-annually. The audit results will be reviewed at monthly QAPI meetings.
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 manage patient's blood pressure needs and notify appropriate staff for one (1) of five (5) patients medical records reviewed (MR1).
Findings Included:
Review of the agency policy and procedures on 7/7/2023 at approximately 8:15 AM revealed, Policy "SUBJECT: HEMODIALYSIS TREATMENT READINGS...PURPOSE: To evaluate the effectiveness of the dialysis treatment and fluid removal and to provide for early detection of complications that may arise related to the treatment. RESOURCES: HCFA 494.90 Condition ...PROCEDURE...2. Normal parameters for hemodialysis will be established by the Medial Director and will be posted and available for use by the nursing staff. Or each parameter, guidance will be given regarding actions to take if reading fall outside the established parameters as follows...b. The Physician will be notified of the following: Post Treatment Weight Loss if an extra treatment is needed Temperature>100.0 F, Heart Rate <50 BPM ior > 120 BPM or irregularity if symptomatic, Blood Pressure Pre Treatment Systolic <90 or > 200 Diastolic < 50 or > 120 if symptomatic, Blood Pressure Pre Treatment Systolic <90 or > 200 Diastolic > 120 if symptomatic, *Notify MD if post treatment , there are remaining signs of significant volume overload (decreased breath sounds, lung rales/crackles, SOB, severe hypertension, edema)..."
MR1, admission date 3/15/2023, primary diagnosis; Type 1 diabetes mellitus with diabetic chronic kidney disease. A review of hemodialysis flowsheets from 6/12/2023 to 6/23/2023, was conducted on 6/28/2023 at approximately 1:20 PM.
Per "HEMODIALYSIS FLOWSHEET" a medication order with a start date of "05/03/23 clonidine hcl-0.1 MG OP QHD-PRN P" was available. Within the "Procedures, Complications & Notes" section listed the following information: "...MED CLONIDINE HCL Was Effective: No note: BP 209/105 (3:19PM)...MED CLONIDINE HCL Was Effective: No note: bp 206/103 (2:19 PM)..."
The following hemodialysis flowsheet dated 6/12/2023 revealed the following:
12:50 PM BP 198/107
1:32 PM BP 196/98
2:00 PM BP 206/103
2:31 PM BP 206/103
2:33 PM BP 203/95
03:01 PM TX Complication: HYPERTENSION
03:32 PM BP 210/104
04:00 PM BP 220/109
04:26 PM 223/114
04:29 PM BP 203/99
Per EMP 1 confirmed no documentation was available a physician was notified.
An exit interview was conducted with the director, nurse manager, chief technician, and social worker on 6/30/2023 at approximately 12:20 PM which confirmed the above findings.
Plan of Correction:1. All clinical staff will be re-trained on the facility's "Hemodialysis Treatment Readings" policy by 7/24/23. Training will include the following: the responsibility for clinical staff to evaluate ordered treatment parameters and ensure that patients are receiving their appropriate dialysis prescription; notification to the Charge Nurse if readings fall out of the physician established parameters; and proper notification to the physician by the Charge Nurse.
2. All clinical staff will review and sign acknowledgement of understanding of policy. Acknowledgement will be placed in the facility's education manual and/or personnel file.
3. Charge Nurse will round and initial records to confirm treatment parameters are set per physician orders.
4. Initially, Nurse Manager and/or Designee will audit 50% of treatment flow sheets daily for one (1) week to ensure that staff is following the policy with emphasis on documentation of patient receiving their appropriate dialysis prescription and notification of Charge Nurse and Physician for any readings outside of established parameters. If standards are met, 50% of the treatment flow sheets will be audited weekly for four (4) weeks. If standards are met, 50% of the treatment flow sheets will be audited monthly for three (3) months. If standards are met, 50% of the treatment flow sheets will be audited semi-annually. The audit results will be reviewed at monthly QAPI meetings.
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 a review of facility policies and procedures, medical records and staff (EMP) interviews, the facility failed confirm the dialysis prescription and to communicate with physicians when dialysate flow rate (DFR) required adjustment beyond the current physicians' orders for two (2) of three (3) in-center hemodialysis medical records (MR) reviewed (MR2 and MR3).
Findings included:
Review of the agency policy and procedures on 7/7/2023 at approximately 8:15 AM revealed, Policy "SUBJECT: HEMODIALYSIS TREATMENT READINGS...PURPOSE: To evaluate the effectiveness of the dialysis treatment and fluid removal and to provide for early detection of complications that may arise related to the treatment. RESOURCES: HCFA 494.90 Condition: Patient plan of care (a)(1) Dose of dialysis...POLICY: While the patient is receiving a hemodialysis treatment, the nursing staff will perform routine monitoring (reading) of the patient's overall condition and the status of the treatment itself a minimum of every 30 minutes and more frequently if needed. Legible documentation on the hemodialysis flowsheet will be completed and will not exceed 30 minutes between each reading..."
A review of MR2 was conducted on 6/28/2023, at approximately 1:55 PM, the start of care date was 5/12/2023. The "EFFECTIVE ORDERS-Hemodialysis Treatment" was dated 5/10/2023. A review of the "HEMODIALYSIS FLOWSHEET" dated 6/14/2023 through 6/23/2022 revealed the physician ordered a DFR of 600 ml/min. The DFR was ran at 800 ml/min on 6/21/2023 from 1:02 PM until 2:02 PM.
A review of MR3 was conducted on 6/30/2023, at approximately 9:00 AM, the start of care date was 8/10/2020. The "EFFECTIVE ORDERS-Hemodialysis Treatment" was dated 12/30/2022. A review of the "HEMODIALYSIS FLOWSHEET" dated 6/7/2023 through 6/26/2022 revealed the physician ordered a DFR of 600 ml/min. The DFR was ran at 800 ml/min on 6/14/2023 from 10:00 AM until 10:31 AM.
No documentation was available in the MR's to confirm that the physician was notified of the inability to achieve the prescribed blood flow or that the physician had ordered changes to the DFR.
An exit interview was conducted with the director, nurse manager, chief technician, and social worker on 6/30/2023 at approximately 12:20 PM which confirmed the above findings.
Plan of Correction:1. All clinical staff will be re-trained on the facility's "Hemodialysis Treatment Readings" policy by 7/24/23. Training will include the following: the responsibility for clinical staff to evaluate ordered treatment parameters and ensure that patients are receiving their appropriate dialysis prescription; notification to the Charge Nurse if readings fall out of the physician established parameters; and proper notification to the physician by the Charge Nurse.
2. All clinical staff will review and sign acknowledgement of understanding of policy. Acknowledgement will be placed in the facility's education manual and/or personnel file.
3. Initially, Nurse Manager and/or Designee will audit 50% of treatment flow sheets daily for one (1) week to ensure that staff is following the policy with emphasis on documentation of patient receiving their appropriate dialysis prescription and notification of Charge Nurse and Physician for any readings outside of established parameters. If standards are met, 50% of the treatment flow sheets will be audited weekly for four (4) weeks. If standards are met, 50% of the treatment flow sheets will be audited monthly for three (3) months. If standards are met, 50% of the treatment flow sheets will be audited semi-annually. The audit results will be reviewed at monthly QAPI meetings.
494.100(c)(1)(i) STANDARD
H-MONITOR HOME ADAPT;HOME VISIT=POC
Name - Component - 00
Services include, but are not limited to, the following:
(i) Periodic monitoring of the patient's home adaptation, including visits to the patient's home by facility personnel in accordance with the patient's plan of care.
Observations:
Based on review of facility policy, review of medical records, and an staff (EMP) interview the facility failed to ensure an initial home visit was conducted upon initiation of home therapy treatment for one (1) of two (2) peritoneal dialysis (PD) patient medical records reviewed (MR4).
Findings included:
Review of the agency policy on 6/30/2023 at approximately 10:05 AM revealed, Policy "Ongoing Patient Education and Retraining, PURPOSE: Provide guidelines to reinforce previously taught information, teach new procedures and techniques and to observe patient technique. SUPPORTIVE DATA ...Retraining must be provided whenever there is a change in home dialysis helper, treatment modality, home dialysis equipment, dialysis setting (location), and when there is a change in the patient's medical condition that may affect his/her ability to perform dialysis safely..."
A review of MR4 was conducted on 6/30/2023 at approximately 9:40 AM, date of admission 4/5/2023: During an interview with EMP2 on 6/30/2023 at approximately 11:50 AM the surveyor requested date of home visit for MR4. EMP2 confirmed EMP9 was onsite 5/8/2023 but the patient did not permit entry into the residence. The surveyor requested documentation of the visit. No documentation was provided by the facility of initial home visit being conducted.
An exit interview was conducted with the director, nurse manager, chief technician, and social worker on 6/30/2023 at approximately 12:20 PM which confirmed the above findings.
Plan of Correction:1. The Home Training Nurse will complete an initial home visit for patient currently out of compliance by 7/28/2023.
2. Home Training Nurse will be re-trained on the facility's "Ongoing Patient Education and Retraining" policy by 7/24/23. Training will include the following: the responsibility for Home Training Nurse to provide education and/or re-training for home patients per policy; and to conduct an initial home visit for patients upon initiation of home therapy treatment; proper documentation of education, re-training, and/or home visit in the patients' medical record.
3. Home Training Nurse will review and sign acknowledgement of understanding of policy. Acknowledgement will be placed in the facility's education manual and/or personnel file.
4. Initially, Home Nurse Manager and/or Designee will audit all home patient medical records monthly for three (3) months to ensure that Home Training Nurse is following the policy. If standards are met, all home patient medical records will be audited quarterly for six (6) months. If standards are met, all home patient medical records will be audited yearly. The audit results will be reviewed at monthly QAPI meetings.
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