Initial Comments:
Based on the findings of an onsite unannounced Medicare complaint survey conducted onsite June 13, 2024 and off site June 17, 2024, June 20, 2024, June 24, 2024, July 1, 2024 and July 5, 2024. Brown Dialysis was identified to have the following standard level deficiency that 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:
494.90(a)(4) STANDARD
POC-MANAGE ANEMIA/H/H MEASURED Q MO
Name - Component - 00
The interdisciplinary team must provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level.
The patient's hemoglobin/hematocrit must be measured at least monthly. The dialysis facility must conduct an evaluation of the patient's anemia management needs.
Observations:
Based on a review of medical records (MR), and an interview with the facility administrator, the facility did not provide the necessary care and services to achieve and sustain the clinically appropriate hemoglobin/hematocrit level for one (1) of one (1) MR. MR#1.
Findings include:
A review of MRs was conducted on June 13, 2024 at approximately 8:37 AM.
MR # 1 Admission date: 12/9/2024.
Limited Encounter dated 5/23/24 Nurse Practitioner, Assessment and Plan : Anemia, Monitor Hemoglobin weekly.Comprehensive Encounter by Medical Director on 6/4/24 Assessment and Plan : Anemia, Goal for hemoglobin will be 10-12: waste blood for hemoglobin > 12. Check hemoglobin weekly.
A review of lab results on June 13, 2024 at approximatley 9:54 a.m. revealed the following: . There was no hemoglobin result for the week of 5/5/25- 5/11/24.
An interview with the facility administrator conducted on July 1, 2024 at 2:20 pm confirmed the above findings.
Plan of Correction:V547
The Facility Administrator or designee held mandatory in-services for all clinical teammates including the Interdisciplinary Team, starting on 07/09/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-02-03 "Physician Orders" and Policy 1-14-01 "Interdisciplinary Team Patient Assessment and Plan of Care" with emphasis on but not limited to: A. Physician Orders: 1) Purpose: To verify that orders are properly documented, transcribed, verified and implemented in a timely manner for patient care in DaVita facilities and meet all DaVita, federal and applicable state regulations. B. Patient Assessment and Plan of Care: 1) Assessment criteria will include, but not be limited to, evaluation of... Laboratory results... Factors associated with anemia and potential treatment plans for anemia, including administration of erythropoiesis-stimulating agent. 2) Plan of Care will address but not be limited to the following: ... Anemia which addresses the necessary care and services to achieve and sustain the clinically appropriate hemoglobin level. The patient's hemoglobin will be measured at least monthly. Verification of attendance is evidenced by a signature sheet.
The Facility Administrator or designee immediately completed a one hundred percent (100%) audit of all patient's medical records to verify physician orders for hemoglobin labs are documented, transcribed, verified and implemented as prescribed. Any corrections needed were made immediately. The Facility Administrator or designee will audit one hundred percent (100%) of hemoglobin lab values completed to verify labs are drawn per physician orders: monthly for two (2) months. Ongoing compliance will be monitored with the 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 Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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