Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on 9/9/2022, US Renal Care Altoona Dialysis Center 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 9/9/2022, US Renal Care Altoona Dialysis Center was found to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.
Plan of Correction:
494.80(a)(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 and staff (EMP) interviews, the facility failed confirm the dialysis prescription and to communicate with physicians when blood flow rates (BFR) required adjustment beyond the current physicians' orders for three (3) of five (5) in-center hemodialysis medical records (MR) reviewed (MR1, MR3 and MR5).
Findings included:
Review of the agency policy and procedures on 9/12/2022 at approximately 2:00 PM revealed,
" POLICY: Initiation of Dialysis Treatment ...POLICY # C-TI-0010 ...14. Prior to walking away from patient ' s dialysis machine, verify all prescribed orders are followed. If unable to follow any part of the patient ' s prescription after trouble shooting, notify the charge nurse and document notification. Charge nurse will notify the physician if indicated and document any follow up or new orders. Prescription orders and safety measures include, but are not limited to the following:
a. Blood flow is at prescribed rate;
b. Heparin pump (if used) is turned on and delivering the correct dose;
c. Correct dialysate flow rate;
d. Dialysis machine temperature;
e. Bloodlines are secured;
f. Access, bloodline connections, and face are visible;
g. Fluid removal goal is programmed correctly ... "
MR #1 start of care 3/9/2021, was reviewed on 9/9/2022 at approximately 9:00 AM. A review of the patient ' s hemodialysis flowsheet dated 9/6/2022 through 8/23/2022 revealed the physician ordered a BFR of 450 ml/min and a DFR of 600. The date of the order was 8/30/2022. The BFR was delivered lower than prescribed on 9/6/2022 and 9/1/2022 at 400 ml/min. Three different staff members documented conducting checks during the treatment.
MR #3 start of care 8/18/2022, was reviewed on 9/9/2022 at approximately 9:48 AM. A review of the patient ' s hemodialysis flowsheet dated 9/6/2022 through 8/23/2022 revealed the physician ordered a BFR of 450 ml/min and a DFR of 600. The date of the order was 8/18/2022. The BFR was delivered lower than prescribed on 9/3/2022 at 250 ml/min from 11:02 AM to 2:32 AM. Four different staff members documented conducting checks during the treatment.
MR #5 start of care 1/28/2022, was reviewed on 9/9/2022 at approximately 10:25 AM. A review of the patient's hemodialysis flowsheet dated 9/2/2022 through 8/22/2022 revealed the physician ordered on 8/26/2022 for a BFR of 350 ml/min and a DFR of 600. The BFR was delivered lower than prescribed on 8/29/2022 at 270 ml/min from 1:32 PM to 3:31 PM. Three different staff members documented conducting checks during the treatment.
No documentation was available to confirm MR1, MR3 and MR5 was not able to achieve blood flow on the dates listed or a report was submitted to the physician.
An exit interview was conducted on 9/9/2022 at approximately 3:00 PM with the clinical specialist and charge nurse. Attending the meeting via conference call is as follows: area biomedical manager, biomedical technician, clinical coordinator, regional director, area manager and regional vice president which confirmed the above findings.
Plan of Correction:FA or Designee will educate staff on Policy C-TI-0010 Initiation of Dialysis Treatment focusing that all Prescription orders are to be adhered to in regard to Blood Flow Rates. All staff will follow patients prescribed blood flow rates and if that desired rate is not achieved the Physician will be notified and a Note will be placed on the patients chart to confirm this. FA and or Designee will audit 10% of all treatment sheets weekly for 4 weeks then Monthly for 2 months or until 100% accuracy is obtained. All findings will be reported in Monthly QAPI meetings and to the Governing Body to ensure continued compliance. Identified non-compliance will result in additional staff in-servicing and increased frequency of auditing.
494.80(a)(2) STANDARD
PA-ASSESS B/P, FLUID MANAGEMENT NEEDS
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
Blood pressure, and fluid management needs.
Observations:
Based on review of facility policy, medical records (MR) and interview with facility staff, the facility failed to assess and manage patient's blood pressure needs for one (1) of five (5) in center hemodialysis medical records reviewed (MR#5).
Findings Included:
Review of facility policy on 9/12/2022 at approximately 2:00 PM revealed, "POLICY: Intradialytic Monitoring of Patient ...POLICY #C-ID-0010 ...MONITORING: Direct patient care staff will monitor the following parameters during each dialysis treatment: PATIENT: 1. Must be in direct view of a staff member at all times; if leaving the treatment area for any reason, report off to another staff member and ensure observation of the assigned patients. 2. Vital signs: Obtained and documented at least every 30 minutes and reported to charge nurse if outside of standing orders and/or reportable parameters, refer to C-FORMS- 0081 Reportable Parameters to CN ...10. Comment regarding patient status and staff observation at least every 30 minutes.
DELIVERY SYSTEM:
1. Integrity of extracorporeal circuit: Pressure monitor readings (check arterial and venous drip chambers are filled with blood but are not backed up into the transducer filter protector, if applicable).
NOTE: If transducer filter becomes wet, replace immediately. Inspect the side of the
protector that faces the machine. If fluid is visible, biomed technician will be
notified and machine taken out of service after dialysis treatment is completed.
2. Anticoagulant delivery
3. Blood flow rate
4. Dialysate flow rate
5. Alarm limits and/or conditions..."
Review of facility policy on 9/12/2022 at approximately 2:00 PM revealed, "POLICY: Reportable Parameters to CN ...POLICY #C-Forms-0081 ...NURSE MUST COMPETE ASSESSMENT BEFORE TREATMENT INITIATED IF ANY PARAMETERS NOT MET, PCT/CCHT/LPN B/P Systolic >160 or <90 Diastolic >110..."
MR #5 start of care 1/28/2022, was reviewed on 9/9/2022 at approximately 10:25 AM. A review of the patient's hemodialysis flowsheets dated 9/2/2022 through 8/22/2022 revealed, hemodialysis flowsheet dated 8/29/2022 data as followed:
11:27 AM BP 62/20
11:28 AM BP 78/36
11:31 AM BP 86/43
12:01 PM BP 68/33
12:04 PM BP 71/34
12:52 PM BP 86/23
12:57 PM BP 88/22
1:22 PM BP 141/121
1:56 PM BP 82/32
2:25 PM BP 86/34
2:55 PM BP 89/41
3:25 PM BP 68/41
3:30 PM BP 87/25
3:44 PM 85/66
Four different staff members documented conducting checks during the treatment. No documentation was available to confirm a report was submitted to the physician.
An exit interview was conducted on 9/9/2022 at approximately 3:00 PM with the clinical specialist and charge nurse. Attending the meeting via conference call was as follows: area biomedical manager, biomedical technician, clinical coordinator, regional director, area manager and regional vice president which confirmed the above findings.
Plan of Correction:FA or Designee will educate all staff on Policy C-ID-0010 Intradialytic Monitoring of Patient as well as C-Forms -0081 Reportable Parameters to CN. All staff will report any and all Blood Pressures outside the parameters of Systolic >160 Or <90 and Diastolic >110. Reportable Parameters have been posted on the treatment floor for all staff to reference. The FA and or designee will audit 10% of the treatment sheets weekly for 4 weeks and then monthly x 4. Audit findings will be reviewed in monthly QAPI meetings. The Governing Body will review QAPI meeting minutes to ensure continued compliance. Identified non-compliance will result in additional staff in-servicing and increased frequency of auditing.
494.80(a)(3) STANDARD
PA-IMMUNIZATION/MEDICATION HISTORY
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
Immunization history, and medication history.
Observations:
Based on a review of agency policy, medical record (MR) and staff (EMP) interview, it was determined that the agency failed to maintain an accurate medication profile of potential adverse effects, drug reactions, ineffective drug therapy, significant side effects, drug interactions and noncompliance for one (1) of seven (7) MR's reviewed (MR5).
Findings Included:
Review of the agency policy and procedures on 9/12/2022 at approximately12:00 PM revealed, " POLICY: GUIDELINES FOR ADMINISTRATION OF MEDICATION ...POLICY #C-MA-0010 ...PROCEDURE ...12. When administering a medication, the following steps will be followed:
? Check the physician ' s order to verify dosing specifications
? Verify that no allergy or adverse reaction exists to the ordered medication.
This information is available and can be checked from the patient ' s
electronic medical record under "allergy section" or allergy sticker on the
patient ' s physical chart, or patient kardex, if in use.
Review of MR5 on 9/9/2022 at approximately 10:25 AM revealed, start of care date of 1/28/2022. The patient's hemodialysis flowsheet dated 8/22/2022, listed under section "ALLERGY DESCRIPTION MEPERIDINE HCL, IV CONTRAST, ANTIHISTAMINES, TETANUS TOXOID, ABSORBED." The surveyor reviewed a chart documents which revealed "(Fax date 8/18/2022) Listed under the section "Allergies Tetanus toxoids [Swelling of limb, NOS]; IVP Contrast; tetanus toxoid; Benadryl; Demerol [Nausea and vomiting]; Keflex [joint pain] ... " The allergy listed on the documents did not match.
An exit interview was conducted on 9/9/2022 at approximately 3:00 PM with the clinical specialist and charge nurse. Attending the meeting via conference call is as follows: area biomedical manager, biomedical technician, clinical coordinator, regional director, area manager and regional vice president which confirmed the above findings.
Plan of Correction:FA and or Designee will educate all Nursing Staff on Policy C-MA-0010 Guidelines for Medication Administration. All Nursing staff will verify Allergies following hospital discharges on Patients chart as well as EMR. All Nursing staff will verify allergies prior to administering medications. FA and or designee will audit all Allergies of those hospitalized upon return weekly for 4 weeks then monthly for 2 months to ensure accurate transfer of documentation. All Audit findings will be reported monthly in QAPI meetings. The Governing body will review QAPI meeting minutes to ensure continued compliance. Identified non-compliance will result in additional staff in-servicing and increased frequency of auditing.
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