Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey completed on September 21, 2022, Hamarville Dialysis 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 on September 21, 2022, Hamarville Dialysis 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:
494.80(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 for one (1) of five (5) patient medical records reviewed (MR2).
Findings Included:
Review of facility policy on 9/21/22 revealed: "Policy: 1-03-08...Incenter Hemodialysis Policies & Procedures...1. Patient data will be obtained and documented by the patient care technician (PCT or a licensed nurse..blood pressure (BP) 1. sitting and standing BP...required pre and post treatment...Intradialitic...Assessment...11 Abnormal findings...will be reported to the licensed nurse immediately...The licensed nurse will use...clinical judgement...to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician...as needed of changes in patient status...Abnormal Findings...post treatment...sitting...systolic BP greater than 140 mm/Hg or less than 90 mm/Hg,..diastolic greater than 90 mm/Hg or less than 50 mm/Hg..."
Review of MR2 on 9/20/22 at approximately 10:45 AM: Admission 7/28/21. Physician order start date 6/26/2022: "Clonidine...0.1 Milligram Tablet...Administer for SBP (systolic blood pressure) greater than 180 or DBP (diastolic blood pressure) greater than 90, repeat BP in 1 hour, if exceeds parameters, administer x 2 doses and notify MD if BP remains out of parameters....Frequency, every hour as needed..."
Review of hemodialysis treatment flow sheets from 8/31/22 to 9/19/22 revealed:
9/2/22: Intradialytic DBP remained above parameter (greater than 90) throughout entire treatment from 11:09 AM to 2:35 PM; Post-Treatment Vitals: Sitting Blood Pressure 171/101.
9/5/22: Intradialytic DBP remained above parameter (greater than 90) during treatment from from 12:31 PM to 1:41 PM; Post-Treatment Vitals: Sitting Blood Pressure 167/103.
9/9/22: Intradialytic DBP remained above parameter (greater than 90) during treatment from 11:30 AM to 2:30 PM. Post-Treatment Vitals: Sitting Blood Pressure 175/107.
There was no documented evidence of intervention(s) provided for patient blood pressures above parameters per physician orders and/or facility policy noted in MR2 hemodialysis treatment records for aforementioned treatment dates.
An exit conference was conducted on 9/21/22 at approximately 1:45 PM with facility administrator (EMP2), alternate administrator (EMP1), and manager of clinical services (EMP9). Above findings were reviewed.
Plan of Correction:The Facility Administrator or designee held mandatory in-service for all clinical teammates starting on 09/23/22. 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" with emphasis on but not limited to: 1) Patient data will be obtained and documented by the patient care technician or licensed nurse. Data collection includes: Measurement of blood pressure, sitting and standing and intradialytic BP in the sitting/reclined or supine position. 2) Abnormal findings or findings outside of any patient specific physician ordered parameters will be documented and reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 3) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 4) Abnormal Findings: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg; Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. 5) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet. The Facility Administrator or designee will conduct audits to verify complete and accurate documentation, with notification of and response by the licensed nurse, per policy: on twenty five percent (25%) of the flow sheets daily on treatment days for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review 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)(5) STANDARD
POC-VA MONITOR/PREVENT FAILURE/STENOSIS
Name - Component - 00
The patient's vascular access must be monitored to prevent access failure, including monitoring of arteriovenous grafts and fistulae for symptoms of stenosis.
Observations:
Based on review of facility policy, observations (OBS), and interview with staff (EMP), the facility failed to ensure the patient (PT) access was monitored in accordance with facility policy for one (1) of two (2) in-center dialysis treatment floor observations conducted (OBS2-PT6).
Findings included:
Review of facility policy on 9/21/22 revealed: "Policy: 1-03-08...Incenter Hemodialysis Policies & Procedures...Intradialytic...Assessment...9. Intradialytic treatment monitoring...which may be performed by the PCT (Patient Care Technician) or licensed nurse includes: b. At a minimum...Vascular access visible and line connections intact...The vascular access site, blood line connections and the patient's face should be visible throughout the dialysis treatment..."
OBS2 conducted on 9/21/22 between approximately 9:15 AM and 11:30 AM revealed the following: Surveyor observed patient (PT6) receiving treatment at station 2 access site covered with blanket (not visible) from 9:20 AM to 9:55 AM (time staff removed blanket to visualize access site). Treament floor Charge RN (registered nurse, EMP4) confirmed to surveyor access site should be visible at all times.
An exit conference was conducted on 9/21/22 at approximately 1:45 PM with facility administrator (EMP2), alternate administrator (EMP1), and manager of clinical services (EMP9). Above finding was reviewed.
Plan of Correction:The Facility Administrator or designee held mandatory in-service for all clinical teammates starting on 09/23/22. 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" with emphasis on but not limited to: 1) Intradialytic Data Collection Assessment: Vital signs and treatment monitoring is completed at least every thirty (30) minutes. At a minimum, obtain and document the following: Vascular access visible and line connections intact. 2) The vascular access site, blood line connections and the patient's face should be visible throughout the dialysis treatment. Verification of attendance is evidenced by teammate signature on in-service sheet. The Facility Administrator or designee will conduct observational and flowsheet audits to verify access checks (visible vascular access site, blood line connections intact and patient's face visible) are completed and documented per policy: observations and twenty five percent (25%) flowsheets audited daily each treatment day for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. 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 Assurance 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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