Initial Comments:
Based on the findings of an onsite unannounced complaint investigation survey completed on April 4, 2023, Westtown Dialysis, was identified to have the following standard level deficiencies and 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:
494.100(c)(1)(ii) STANDARD
H-COORDINATION OF CARE BY MEMBER OF IDT
Name - Component - 00
Services include, but are not limited to, the following:
(ii) Coordination of the home patient's care by a member of the dialysis facility's interdisciplinary team.
Observations:
Based upon review of ESRD complaint log for 2023, interview with the Regional Manager of Clinical Services, Medical Record (MR) review, review of a fax from Vascular Surgeon #1 office, and faciliy policy and procedure review, it was determined the ESRD failed to ensure coordination of access cannulation training for one (1) out of three (3) MR's reviewed (MR#1).
Findings include:
A. Review of policy "Support Services" on 4/4/23 at approximately 12:30 PM states:
" ....1. A home dialysis training facility will furnish (either directly, under agreement, or by arrangement with another ESRD facility) home dialysis support services regardless of whether dialysis supplies are provided by the dialysis facility or a durable medical equipment company. Services include, but are not limited to, the following:
... ....? Coordination of the home patient ' s care by a member of the dialysis facility ' s interdisciplinary team
... ....? Patient consultation with members of the interdisciplinary team, as needed
....7. The home hemodialysis nurse, or designee, is responsible for scheduling appointments.
...12. Alternative support services may include any of the following:
... ...? Collaboration with other health care providers i.e., nursing homes, hospitals, visiting nurses
....? Addressing patient problems or complaints
13. All support services are documented in the patient ' s medical record. "
B. Review of a fax the ESRD received from Vascular Surgeon #1 on 4/3/23 at approximately 11:42 AM, revealed the following:
Vascular Surgery Office Visit Note dated 2/5/23: " post op suture removal R arm ...the fistula has not been cannulated for dialysis. I have given him a prescription stating that he can start to cannulate the fistula ... "
Review of MR#1 (Start of care: 8/1/18) on 4/3/23 from 10:00 AM-11:00 AM revealed the following:
" HHD encounter " completed by Medical Director on 2/17/23 states " ...has right upper arm AVF. Surgeon #1 angioplastied it in early February 2023. Sounds great ... " No further documentation of plans for access training.
" Nurse Monthly Progress Note " completed by HHD RN #2 on 2/17/2023 states " .... The patient would like to be retrained on self cannulation ... " No further documentation of scheduling for access training.
Review of Facility complaint log for 2023 revealed MR#1 to have sent a complaint letter to the ESRD CEO on 3/3/23, with the Regional Operations Director being forwarded the complaint letter on 3/6/23. It was not until complaint review by the Regional Operations Director that training was scheduled as a resolution.
An interview with the Facility Regional Manager of Clinical Services on 4/3/23 at approximately 1:30 PM confirmed the above findings. Confirmed there are two additional ESRD's owned by the same company in close proximity to have sent the patient for access training. Confirmed MR#1's revised access was cleared for cannulation training on 2/5/23 with no documentation of cannulation training from the ESRD until 3/27/23.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for the Home Hemodialysis (HHD) Nurse, starting on 04/24/22. Any new nurse supporting the program will be trained in this POC. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 12-01-03 "Services Provided", with emphasis on but not limited to: 1. Services Provided: 1) The interdisciplinary team oversees training and monitoring of the home dialysis patient, the designated caregiver, or self-dialysis patient before the initiation of home dialysis or self-dialysis and when the home dialysis caregiver or home dialysis modality changes.
Verification of attendance is evidenced by teammate's signature on the in-service sheet.
On 04/24/23, the Facility Administrator or designee will implement systemic approach to ensure coordination of access training, and that orders and instructions from Vascular Surgeons are incorporated into the patient's medical records, including but not limited to:
1. CWOW: 1) Through utilization of electronic Clinical System (CWOW), Home Dialysis Training Nurse to create a patient specific Care Activity for clinical intervention on a patient's access. a. Care Activity provides specific clinical intervention details, next steps, and their timing (specific dates). b. Care Activity includes: i. any orders and instructions needed/provided from the Vascular surgeon, as applicable; ii. Date to be sent; iii. Date received; iv. Date included into the patients' medical records. 2. Core team: 1) all access care activities to be reviewed weekly by the Core team to ensure timeliness of the activities, and follow through to completion of the specific activities as delineated in the care activity plan.
The Facility Administrator or designee will audit Care Activities in CWOW to verify action plans, documentation and follow-up: daily for two (2) weeks and weekly for two (2) weeks. Ongoing compliance will be monitored in weekly Core Team meetings.
The Facility Administrator or designee will review audit results with the Medical Director during 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.
494.100(c)(2) STANDARD
H-RECORDKEEPING SYSTEM
Name - Component - 00
(2) The dialysis facility must maintain a recordkeeping system that ensures continuity of care and patient privacy. This includes items and services furnished by durable medical equipment (DME) suppliers referred to in §414.330(a)(2) of this chapter.
Observations:
Based upon policy and procedure review, interview with the HHD RN (Home Hemodialysis Registered Nurse) #1, and Medical Record (MR) review, it was determined the ESRD failed to ensure the Medical Record to contain orders and instructions from Vasculator Surgeon #1 for a post-op access revision for one (1) out of three (3) MR's reviewed (MR#1).
Findings include:
A. Review of policy "Medical Records Custodian and Maintenance" on 4/4/23 at approximately 1:00 PM states " ....1. At the discretion of the Facility Administrator, the nurse responsible for clinical care and/or designee is responsible for the supervision and authenticity of medical records services in consultation with DaVita ' s Corporate Health Information Management Department. The responsibilities of the Custodian of medical records include:
?Verifies that the medical records are complete, documented accurately, and maintained in accordance with accepted professional standards and practices.
B. Review of MR#1 (Start of care: 8/1/18) on 4/3/23 from 10:00 AM-11:00 AM revealed the following:
" HHD encounter " completed by Medical Director on 3/17/2023 states " ...has right upper arm AVF. Surgeon #1 angioplastied it in early February 2023. Sounds great. Wants to start cannulation training, discussed benefits of buttons holes vs sharps. Awaiting staff to schedule training ... "
" Patient Note " completed by HHD RN #1 on 3/27/23 states " Pt and wife came to unit today for the first day of cannulation training on an existing fistula......This HHD RN was able to cannulate arterial needle using 17g 1 " needle w/o issues, but venous needle was unsuccessful. Pt CVC venous line used for blood return....."
" Patient Note " completed by HHD RN #1 on 3/28/23 states " Pt and wife came in on 3/28/23 for second day of AVF cannulation with 17 g needles...."
The medical record did not contain documention of orders or instructions from Vascular Surgeon #1 in regards to cannulation of the revised access.
An interview with HHD RN #1 on 4/3/23 at approximately 11:00 AM confirmed MR#1 did not contain documention of orders or instructions from Vascular Surgeon #1 in regards to cannulation of the revised access.
Plan of Correction:The Facility Administrator or designee held mandatory in-services for the Home Hemodialysis (HHD) Nurse, starting on 04/24/22. Any new nurse supporting the program will be trained in this POC. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 12-01-03 "Services Provided", with emphasis on but not limited to: 1. Services Provided: 1) The interdisciplinary team oversees training and monitoring of the home dialysis patient, the designated caregiver, or self-dialysis patient before the initiation of home dialysis or self-dialysis and when the home dialysis caregiver or home dialysis modality changes.
Verification of attendance is evidenced by teammate's signature on the in-service sheet.
On 04/24/23, the Facility Administrator or designee will implement systemic approach to ensure coordination of access training, and that orders and instructions from Vascular Surgeons are incorporated into the patient's medical records, including but not limited to:
1. CWOW: 1) Through utilization of electronic Clinical System (CWOW), Home Dialysis Training Nurse to create a patient specific Care Activity for clinical intervention on a patient's access. a. Care Activity provides specific clinical intervention details, next steps, and their timing (specific dates). b. Care Activity includes: i. any orders and instructions needed/provided from the Vascular surgeon, as applicable; ii. Date to be sent; iii. Date received; iv. Date included into the patients' medical records. 2. Core team: 1) all access care activities to be reviewed weekly by the Core team to ensure timeliness of the activities, and follow through to completion of the specific activities as delineated in the care activity plan.
The Facility Administrator or designee will audit Care Activities in CWOW to verify action plans, documentation and follow-up: daily for two (2) weeks and weekly for two (2) weeks. Ongoing compliance will be monitored in weekly Core Team meetings.
The Facility Administrator or designee will review audit results with the Medical Director during 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.
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