Initial Comments:
Based on the findings of an on-site, unannounced Medicare recertification survey conducted October 18, 2022 - October 19, 2022, Freedom Center of Central Pennsylvania, 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 October 18, 2022 through October 19, 2022, Freedom Center of Central Pennsylvania, 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:
494.100(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), and Director of Operations (DOO) it was determined the facility failed to determine if patients are following their treatment plans and/or having problems with their dialysis at home for one (1) of five (5) MRs reviewed (MR #2).
Findings:
Review was conducted of facility policy on October 19, 2022 at approximately 12:00 p.m. Policy 'Home Therapies Patient Treatment Record Keeping' 'Policy' states "...Electronically transmitted data will be reviewed by the home therapies nurse or appropriate staff member on a routine and ongoing basis between clinic visits....Home treatment records will be reviewed by the home therapy registered nurse during patient monthly clinic visits to identify trends, error or omissions, and other issues or concerns to be addressed with the patient and/or care partner..."
Review of MRs was conducted on October 18, 2022 between approximately 10:00 a.m. - 3:00 p.m. and on October 19, 2022 between approximately 9:45 a.m. to 11:00 a.m. revealed the following:
MR #2, Date of Admission: 9/19/2017: Patient Peritoneal Dialysis Treatment orders dated 8/17/2022. Medication included: Heparin 3,000 units bolus at the beginning of every treatment. Treatment flowsheets reviewed from 9/19/2022-10/8/2022.
No documentation of patient administering Heparin 3,000 units bolus at the beginning of every treatment for the date range reviewed.
No documentation provided of monitoring the patient's Heparin treatment compliance to determine if the patient is following the individualized treatment plan. No documentation provided of registered nurse providing education to reinforce the need to administer Heparin dosage and record daily Heparin dosage on flowsheet.
Interview with the DOO on October 19, 2022 at approximately 1:00 p.m. confirmed the policy above as current and above findings.
Plan of Correction:V 587
To ensure compliance the Clinic Manager (CM), Home Therapy Clinical Manager (HTCM) or designee will in-service the Home Therapy (HT) RNs on the following policy:
- Home Therapies Patient Treatment Record Keeping
The in-service will provide re-education on ensuring that the HT patients flowsheets are reviewed on a routine and ongoing basis between clinic visits with documentation of the review. This includes verification of the proper administration and documentation of the prescribed heparin dosage. The documentation will also include re-education if the flowsheet review indicates a lack of treatment compliance with heparin dosing.
The training will be completed by October 26, 2022, with documentation on file at the facility.
The CM or designee will perform audits for the next four (4) months to ensure an assessments were completed timely per policy. At that time, if compliance is sustained, the audits will then follow the monthly Quality Assessment and Performance Improvement (QAPI) schedule. A plan of correction (POC) audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audit results and report the findings to the QAPI Committee at the monthly meeting. Sustained compliance and oversight will be monitored by the QAPI committee.
Completion Date: November 25, 2022
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