Initial Comments:
Based on the findings of an on-site, unannounced Medicare recertification survey conducted OCtober 5, 2020 through October 6, 2020, Robinson Home Training, 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 on-site, unannounced Medicare recertification survey conducted October 5, 2020 through October 6, 2020, Robinson Home Training, was found not to be in 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. As a result of the Medicare recertification survey three (3) standard level deficiencies were cited.
Plan of Correction:
494.90(a)(6) STANDARD
POC-P/S COUNSELING/REFERRALS/HRQOL TOOL
Name - Component - 00
The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis.
Observations:
Based on review of facility policy, review of medical records (MRs), and interview with the Facility Administrator (FA) and Social Worker (SW), it was determined the facility failed to ensure that the standardized mental and physical Assessment tool (KDQOL-36) was administered by the time of the first reassessment (i.e., within 4 months of initiating treatment) for two (2) of five (5) MRs reviewed (MR #4 and MR# 5)' and failed to ensure that the standardized mental and physical assessment tool (KDQOL-36) was administered and repeated at least annually for three (3) of five (5) MRs reviewed (MR #1, MR #2, and MR #3).
Findings:
Interview with SW on October 5, 2020 at approximately 12:21 p.m. revealed, "I wasn't aware of the time frame from when the initial was done. I was not told about the policy."
A review was conducted of facility policy on October 6, 2020 at approximately 11:00 a.m. Policy 3-01-10 'Quality of Life Assessment Survey' 'policy' section 1 states " The Quality of Life (QOL) assessment survey is to be administered by the Social Worker to patients within the first four (4) months of initiating treatment, on an as needed basis, and repeated at least annually thereafter". Section 2 states "If a patient refuses to complete the KDQOL-36 at any time, the Social Worker needs to have the patient sign the Refusal of Permission to Survey to document the refusal".
Review of MRs was conducted on October 6, 2020 between approximately 10:00 a.m. - 3:00 p.m. revealed the following:
MR #1 Date of admission: 6/25/2014: No documentation of the 2018, 2019 and 2020 annual KDQOL-36 being administered. No exemption to completing the KDQOL-36 was documented in the medical record.
MR #2 Date of admission: 12/20/2018: No documentation of the 2019 and 2020 annual KDQOL-36 being administered. No exemption to completing the KDQOL-36 was documented in the medical record.
MR #3 Date of admission: 10/5/2017: No documentation of the 2018, 2019 and 2020 annual KDQOL-36 being administered. No exemption to completing the KDQOL-36 was documented in the medical record.
MR #4 Date of admission: 1/2/2020: No documentation of the 2020 initial KDQOL-36 being administered. No exemption to completing the KDQOL-36 was documented in the medical record.
MR #5 Date of admission: 3/28/2018: No documentation of the 2018 initial KDQOL-36 being administered. No exemption to completing the KDQOL-36 was documented in the medical record.
Interview with the FA on October 6, 2020 at approximately 3:00 p.m. confirmed the policy above as current and above findings.
Plan of Correction:V0552
The FA in-serviced teammates on 10/14/2020 on Policy #3-01-10: Quality of Life Assessment Survey.
The social worker was instructed to administer the survey within four months of initiating treatment, and repeated at least annually. If the patient refuses to complete the Qualify of Life survey at any time, the social worker needs to document the refusal in the electronic medical record. Teammate in-services are evidenced by in-service signature sheet. The FA/AA will conduct medical chart audits monthly using the medical record chart audit form. 10% of the charts will be audited monthly. The results of the audits will be reviewed with the Medical Director and interdisciplinary team during monthly Facility Health Meeting with an Improvement Plan developed if needed. The FA is responsible for compliance.
494.100(b)(2),(3) STANDARD
H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS
Name - Component - 00
The dialysis facility must -
(2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and
(3) Maintain this information in the patient ' s medical record.
Observations:
Based on review of facility policy, review of medical records (MRs), and interview with Facility Administrator (FA), it was determined the facility failed to review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months and/or determining if patients are following their treatment plans and/or having problems with their dialysis at home for three (3) of five (5) MRs reviewed (MR #1, MR #2 and MR #5).
Findings:
Review was conducted of facility policy on October 6, 2020 at approximately 2:00 p.m. Policy 12-01-28 'Home dialysis Monitoring and Ongoing Patient Education' 'Purpose' states "To monitor and reinforce previously taught information and teach new procedures and techniques, if applicable ........". 'Policy' section 1 states, "The home hemodialysis facility will: ............ Retrieve and review self monitoring data and other information from home hemodialysis and/or self-care patients or their designated caregivers at least every two (2) months". Section 2 states "The facility interdisciplinary team monitors the patients status to determine if the patient is following the individualized treatment plan". Policy 5-01-29 'Daily Home Treatment Record' states "Each peritoneal dialysis patient will be instructed to complete documentation of each treatment procedure on the Daily Home Treatment Record .... 7...In the absence of Home Records, the licensed nurse teammate will review importance of home records, the patient's responsibility to provide them and issue new record sheets. All of the above will be documented. In addition, the patient's plan of care should address any problems with adherence to this requirement..."
Review of MRs was conducted on October 6, 2020 between approximately 10:00 a.m. - 3:00 p.m. revealed the following:
MR #1, Date of Admission: 6/25/2014: Patient Peritoneal Dialysis Treatment orders dated 7/15/2020. Target weight ordered: 157 lbs (pounds) on 7/15/2020. Last documented registered nurse review of patient self monitoring data was dated 9/6/2020. Treatment flowsheets reviewed from 6/21/2020-9/6/2020..
No current weight documented on flowsheets from 6/21/2020-9/6/2020 to reflect the patient's daily weight. Patient documented the exact weight: 173.6 for all dates with no variation revealing weight was not accurate.
No documentation provided of monitoring the patient's weight to determine if the patient is following the individualized treatment plan. No documentation provided of registered nurse providing education to reinforce the need to take and record daily weight on flowsheet.
No flowsheets provided for dates of: 7/10/2020-7/15/2020.
No documentation provided of registered nurse requesting or inquiring about missing flowsheet records for the dates of: 7/10/2020-7/15/2020.
MR #2, Date of Admission: 12/20/2018: Patient Peritoneal Dialysis Treatment orders dated 7/28/2020. Last documented registered nurse review of patient self monitoring data was dated 9/6/2020. Treatment flowsheets reviewed from 6/21/2020-9/6/2020.
6/26/2020: No documentation of post blood pressure and post pulse.
7/2/2020: No documentation of post weight, post blood pressure and post pulse.
7/6/2020: No documentation of post weight, post blood pressure and post pulse.
7/22/2020: No documentation of post weight, post blood pressure and post pulse.
8/3/2020: No documentation of post weight, post blood pressure and post pulse.
8/19/2020: No documentation of post weight, post blood pressure and post pulse.
8/21/2020: No documentation of post weight, post blood pressure and post pulse.
8/30/2020: No documentation of post weight, post blood pressure and post pulse.
No documentation provided of registered nurse providing education to reinforce completing every section on the flowsheet.
MR #5, Date of Admission: 3/29/2018: Patient Home Hemodialysis Treatment orders dated 7/14/2020. Last documented registered nurse review of patient self monitoring data was dated 7/14/2020. Treatment flowsheets reviewed from 8/31/2020-9/2/2020. Medication orders included: Epogen (medication used to treat a lower than normal number of red blood cells) 20,000 units IV (intravenous) push 2x qw (two times a week) and Venofer/Iron Sucrose 100 mg (milligrams) IV push qw.
Interview was conducted with FA on 10/6/2020 at approximately 1:00 p.m. Surveyor asked FA if the patient gives their own medication injections at home. FA replied, "Yes, he does."
No documentation of patient injecting ordered Epogen medication and Iron medication (i.e. completing flowsheet sections, "Dose, Route Time and Initial") for dates of: 8/31/2020-9/2/2020.
No documenation provided of registered nurse inquiring whether patient is following individualized medication prescription orders and providing education how to properly complete the flowsheet.
Interview with the FA on October 6, 2020 at approximately 3:00 p.m. confirmed the policy above as current and above findings.
Plan of Correction:V0587
The FA in-serviced teammates on 10/14/2020 on Policy #3-02-23: Peritoneal Dialysis daily/monthly reconciliation, audit, and close process and Policy #3-02-24: Home Hemodialysis daily/monthly reconciliation, audit, and close process.
The registered nurse was instructed to review the patients' flow sheets for completeness and accuracy. If any outliers, discrepancies/clarifications, the registered nurse will address with the patient and document in the electronic medical record each time. Teammate in-services are evidence by in-service signature sheet. The FA/AA will conduct monthly chart audits using the medical record chart audit form. 10% of the charts will be audited monthly. The results of the audits will be reviewed with the Medical Director and interdisciplinary team during monthly Facility Health Meeting with an improvement plan developed if needed. The FA is responsible for the compliance.
494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P
Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;
Observations:
Based on review of facility policy, review of medical records (MRs), and interview with the Facility Administrator (FA), it was determined the facility failed to ensure patients had a minimal evaluation completed by a registered nurse (RN), prior to initiating treatment for immediate needs which contained the minimal elements of nursing standards of care for two (2) of five (5) MRs reviewed. (MR #2 and MR #4)
Findings:
Review was conducted of facility policy on October 6, 2020 at approximately 2:00 p.m. Policy 5-02-28 'New Patient Pre-Treatment Evaluation' states "POLICY: A registered nurse (RN) as required by federal regulation will perform an initial pre-treatment evaluation of all new peritoneal dialysis (PD) patients prior to the initiation of their first treatment/training at the facility ...4. This pre-treatment evaluation will be documented on the New Patient Pre-Treatment Initial Nurse Assessment found in eP&P ... "
Review of MRs was conducted on October 6, 2020 between approximately 10:00 a.m. - 3:00 p.m. revealed the following:
MR #2 Date of admission: 12/20/2018: Initial treatment was on 12/20/2018. No time stamp of when treatment began. Documentation provided of registered nurse performing initial assessment. There is no time stamp on this initial assessment form which would show the assessment was completed prior to the patient's first dialysis treatment.
MR #4 Date of admission: 1/2/2020: Initial treatment was on 1/2/2020. No time stamp of when treatment began. No documentation provided of registered nurse performing initial assessment prior to the patient's first dialysis treatment.
Interview with the FA on October 6, 2020 at approximately 3:00 p.m. confirmed the policy above as current and above findings.
Plan of Correction:V0715
The FA in-serviced teammates on 10/14/2020 on Policy #5-02-28: New Patient Pre-treatment Evaluation and Policy #12-03-03: New Home Hemodialysis Patient Pre-treatment Evaluation.
The registered nurse will perform an initial pre-treatment evaluation of all new PD/HHD patients prior to the initiation of the first treatment. Teammates in-services are evidence by in-service signature sheet. The FA/AA will conduct monthly chart audits using the medical record chart audit form. 10% of the charts will be audited monthly. The results of the audits will be reviewed with the Medical Director and interdisciplinary team during monthly Facility Health Meetings with an improvement plan developed if needed. The FA is responsible for the compliance.
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