Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on July 6, 2021 through July 7, 2021, Girard Estates 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 conducted on July 6, 2021 through July 7, 2021, Girard Estates 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:
494.40(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 observation of the treatment area, interview with the Facility Administrator, and review of policy and procedure, it was determined the facility failed to manually check the conductivity and/or the pH of dialysate for three (3) of three (3) hemodialysis machines prior to treatment. (Dialysis station #'s 4, 13, and 20).
Findings include:
Observations were made in the in patient treatment area on July 6, 2021 between the hours of 10:00 AM and 12:30 PM .
Review of policy and procedure: 1-03-02 titled,"Testing and Documenting pH, Conductivity and Temperature of Proportioned Dialysate" on July 7, 2021 at approximately 1:00 PM., states, " Purpose: To provide guidance for testing and documenting pH, conductivity and temperature of proportioned dialysate. Policy: 1. Trained teammates will test pH and conductivity of final dialysate utilizing appropriate test strips and/or meters prior to each patient treatment. . . 3. Document results in the treatment record when testing is complete..."
1. At approximately 11:15 AM on July 6, 2021 at station #13, observation of conductivity and/or pH was not verified with an independent meter prior to the initiation of treatment by patient care technician (PCT) #3.
2. At approximately 11:40 AM on July 6, 2021 at station #6, observation of conductivity and/or pH was not verified with an independent meter prior to the initiation of treatment by PCT #1.
3. At approximately 12:00 PM on July 6, 2021 at station #4, observation of conductivity and/or pH was not verified with an independent meter prior to the initiation of treatment by RN #1.
An interview with the facility administrator on July 7, 2021 at approximately 1:20 PM confirmed the above findings.
Plan of Correction:V TAG 0250
494.40(a) STANDARD
DIALYS PROPORT-MONITOR PH/CONDUCTIVITY:
The Facility Administrator (FA) held mandatory in-service(s) starting on 07/08/21 for all clinical teammates to review Policy 1-03-02 Testing and Documenting pH, Conductivity and Temperature of Proportioned Dialysate emphasizing teammates will test pH and conductivity of final dialysate utilizing appropriate test strips and/or meters prior to each patient treatment and document the results in the treatment record when testing is complete. Verification of attendance is evidenced by teammate signature on in-serviced form. The FA or designee will complete daily audits for two (2) weeks, if satisfactory, then weekly for four (4) weeks until sustained compliance in achieved. The results of the audits will be reviewed with the teammates during homeroom meetings and with the Medical Director during monthly Facility Health Meetings (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion date-08/06/21
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 medical records (MR), facility policy, and an interview with the administrator, the facility did not follow its policy regarding blood pressure management for two (2) of seven (7) MR's (MR #2, and 7).
Findings include:
A review of policy 1-03-08 "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" on July 7, 2021 at approximately 12:00 pm states: "1. Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily limited to: ii. Measurement of Blood Pressure (BP) 1. Sitting and standing BP measurement required pre and post treatment...2. Intradialytic BP in the sitting/reclined or supine position...Intradialytic Data Collection/Assessment: 9. Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: a. Vital signs and treatment monitoring i. For non-nocturnal treatments is completed at least every thirty (30) minutes...Post Treatment Data Collection/Assessment: 15. The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings...Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record...Blood pressure: Pre Dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/HG. Diastolic greater than or equal to 100 mm/Hg. Intradialytic: Difference of 20 mm/Hg increase of decrease from patient's last intradialytic treatment BP reading...Post Treatment: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg. Standing diastolic greater than 90 mm/Hg or less than 50 mm/Hg...Sitting Bp for patient's that cannot stand: 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..."
A review of MR's was conducted on 7/7/2021 from approximately 8:30 am through 11:00 am.
MR #2, Admission date: 10/7/2020. Review of treatment sheets revealed the following:
On 6/7/2021, at 08:31 am, blood pressure 176/109 was documented by the PCT with no documentation of licensed nurse notification. At 9:01 am, blood pressure 189/105 was was documented by the PCT with no documentation of licensed nurse notification. At 9:32 am, blood pressure 187/117 was documented by the PCT with no documentation of licensed nurse notification.
On 6/9/2021, at 9:02 am, blood pressure 213/127 was documented was documented by the PCT with no documentation of licensed nurse notification. At 9:04 am, blood pressure195/115 was documented by the PCT with no documentation of licensed nurse notification. At 10:03 am, blood pressure 209/119 was documented by the PCT with no documentation of licensed nurse notification. At 10:31 am, blood pressure 220/119 was documented by the PCT with no documentation of licensed nurse notification. At 11:03 am, blood pressure of 223/121 was documented by the PCT with no documentation of licensed nurse notification. At 11:33 am, blood pressure of 219/128 was documented by the PCT with no documentation of licensed nurse notification.
On 6/11/2021, at 8:31 am, blood pressure 195/111 was documented by the PCT with no documentation of licensed nurse notification. At 9:01 am, blood pressure 205/109 was documented by the PCT with no documentation of licensed nurse notification. At 10:01 am, blood pressure 168/102 was documented by the PCT with no documentation of licensed nurse notification. At 10:31 am, blood pressure 191/115 was documented by the PCT with no documentation of licensed nurse notification. At 11:01 am, blood pressure 188/104 was documented by the PCT with no documentation of licensed nurse notification.
On 6/14/2021, at 7:31 am, blood pressure 168/101 was documented by the PCT with no documentation of licensed nurse notification. At 8:01 am, blood pressure 172/105 was documented by the PCT with no documentation of licensed nurse notification. At 8:31 am, blood pressure 178/105 was documented by the PCT with no documentation of licensed nurse notification. At 9:01 am, blood pressure 159/108 was documented by the PCT with no documentation of licensed nurse notification. At 9:32 am, blood pressure 161/105 was documented by the PCT with no documentation of licensed nurse notification. At 10:04 am, blood pressure 171/104 was documented by the PCT with no documentation of licensed nurse notification.
On 6/28/2021, at 8:31 am, blood pressure 159/103 was documented by the PCT with no documentation of licensed nurse notification. At 9:31 am blood pressure 170/105 was documented by the PCT with no documentation of licensed nurse notification, At 10:31 am, blood pressure 178/102 was documented by the PCT with no documentation of licensed nurse notification.
MR #7, Admission date: 8/6/2020. Review of treatment sheets revealed the following:
On 6/26/2021, 11:02 am blood pressure 180/101 was documented by the PCT with no documentation of licensed nurse notification.
An interview with the facility administrator on July 7, 2021 at approximately 1:20 pm confirmed the above findings.
Plan of Correction:VTAG 0504
494.80(a)(2) STANDARD
PA-ASSESS B/P, FLUID MANAGEMENT NEEDS:
The FA held mandatory in-service(s) starting on 07/21/21 for all clinical teammates to review of Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment emphasizing 1) Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. 2) Data collection includes but is not necessarily limited to measurement of Blood Pressure (BP). Sitting and standing BP measurement are required pre and post treatment. 3) Intradialytic BP in the sitting/reclined or supine position will be monitored at least every thirty (30) minutes. 4) Post treatment data collection will obtain and documented on each patient post dialysis and compare to pre dialysis findings. 5) Abnormal findings will be documented and reported to the licensed nurse. The following parameters have been established by the Governing Body and are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record...Blood pressure: Pre Dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/HG. Diastolic greater than or equal to 100 mm/Hg. Intradialytic: Difference of 20 mm/Hg increase of decrease from patient's last intradialytic treatment BP reading...Post Treatment: Standing systolic BP greater than 180 mm/Hg or less than 90 mm/Hg. Standing diastolic greater than 100 mm/Hg or less than 50 mm/Hg...Sitting BP for patient's that cannot stand: Sitting systolic BP greater than 180 mm/Hg or less than 90 mm/Hg. Sitting diastolic BP greater than 100 mm/Hg or less than 50 mm/Hg. Teammates were instructed that despite pre-assessment of documentation that showed licensed nurse was aware of the abnormal BP, all PCTs must document and notify the licensed nurse of each abnormal BPs. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician is necessary. Verification of attendance is evidenced by teammate signature on in-service form. The FA or designee will conduct flow sheet audits on twenty five percent (25%) of the patients daily for two (2) weeks. If satisfactory, will audit ten percent (10%) weekly for four (4) weeks then ten percent (10%) monthly going forward during medical record review audits. The results of the audits will be reviewed with the teammates during homeroom meetings and with the Medical Director during monthly FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion date 08/06/21
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