Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on February 14, 2024 through February 16, 2018, Fresenius Kidney Care of Huntingdon 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 February 14, 2024 through February 16, 2024, Fresenius Kidney Care of Huntingdon, 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 policies and procedures,medical records (MR), and interviews with facility clinical manager and facility administrator, it was determined that the facility failed to adequately monitor blood pressures and pulses during treatment for three (3) of three (3) MR reviewed. (MR # 1- # 3)
Findings include:
Review of Fresenius Kidney Care Clinical services patient assessment and monitoring on 2/16/24 at approximately 1:25 PM revealed: " Pre-treatment assessment and data collection: Direct patient care staff may collect pre-treatment weight, blood pressure (BP), access, and complaints reported by the patient. Monitoring During Treatment: Obtain blood pressure and pulse rate every thirty (30) minutes or more as needed but not to exceed forty-five (45) minutes or per state regulations ... " ; " Document machine parameters and safety checks every thirty (30) minutes or more often as needed but not to exceed forty-five (45) minutes or per state regulations ... " ; " General observation/mental status: " Note: When leaving the treatment room, report off to another staff member to ensure patient observation and monitoring during the dialysis treatment. "
Review of medical records (MR) on 2/16/24 between 11:20 AM-1:15 PM revealed:
MR # 1: Start of care (SOC): 7/24/23; Review of treatment flow sheets from 1/29/24-2/14/24 revealed:
a.Treatment flow sheet from 1/29/24: Blood pressure: 136/88; pulse: 103 at 11:07 AM; next blood pressure and pulse check were completed at 12:00 PM and were Blood pressure: 130/82 and pulse: 117. (fifty-three (53) minutes between checks)
b.Treatment flow sheet from 2/14/24: Blood pressure: 125/52; pulse: 54 at 10:32 AM; next blood pressure and pulse check were completed at 12:06 PM and were Blood pressure: 116/77 and pulse: 113. (One (1) hour and thirty-four (34) minutes between checks)
MR # 2: Start of care (SOC):10/4/21; Review of treatment flow sheets from 1/29/24-2/14/24 revealed:
a.Treatment flow sheet from 2/5/24: Blood pressure: 133/49; pulse: 76 at 9:03 AM; next blood pressure and pulse check were completed at 10:02 AM and were blood pressure: 141/59 and pulse: 81. (fifty-nine (59) minutes between checks)
MR # 3: Start of care (SOC): 6/2/21; Review of treatment flow sheets from 1/29/24-2/14/24 revealed:
a. Treatment flow sheet from 2/9/24: Blood pressure: 94/57; pulse: 64 at 10:31 AM next blood pressure and pulse check were completed at 11:33 AM and were blood pressure: 124/57 and pulse: 68. (one (1) hour and two (2) minutes between checks)
An interview with the Facility Administrator and clinical manager on 2/16/24 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:V 504
To ensure compliance the Clinic Manager (CM) or designee will in-service all direct patient care (DPC) staff on policy:
- Patient Assessment and Monitoring
Emphasis will be placed on ensuring that patient vital signs (VS), including blood pressure (BP) and pulse, and machine parameters are assessed and documented every thirty (30) minutes, and not exceeding forty-five (45) minutes, per policy, while the patient is receiving treatment.
Inservicing will be completed by March 5, 2024. All training documentation is on file at the facility.
The CM or designee will perform daily audits of twenty percent (20%) of flowsheets for two (2) weeks. At that time, if improved compliance is observed the audits will then be completed 2 times/week for 2 weeks. If 100% compliance is maintained after the 2 weeks, the audits will be completed monthly following the Quality Assessment and Performance Improvement (QAPI) program. A plan of correction (POC) specific auditing 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 audits and report the findings to the QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.
Staff found to be non-compliant will be re-educated and referred for counseling.
Completion Date: March 29, 2024
494.90(a)(1) STANDARD
POC-ACHIEVE ADEQUATE CLEARANCE
Name - Component - 00
Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.
Observations:
Based on review of policies and procedures, medical records (MR), and interviews with facility clinical manager and facility administrator, it was determined that the facility failed to adequately monitor prescribed blood flow during treatment in one (1) of three (3) MR reviewed. (MR # 1)
Findings include:
Review of Fresenius Kidney Care Clinical services patient assessment and monitoring on 2/16/24 at approximately 1:25 PM revealed: " Document machine parameters and safety checks every thirty (30) minutes or more often as needed but not to exceed forty-five (45) minutes or per state regulations ... " Machine parameters and extracorporeal circuit: " Check machine settings and measurements: check prescribed blood flow is being achieved or reason is documented in medical record if unable to meet prescribed blood flow".
Review of medical records (MR) on 2/16/24 between 11:20 AM-1:15 PM revealed:
MR # 1: Start of care (SOC): 7/24/23; Review of treatment flow sheets from 1/29/24-2/14/24 revealed:
a.Treatment flow sheet from 2/12/24: Prescribed Blood flow rate (BFR) four hundred fifty (450); BFR from 10:11 AM through 12:17 PM: three hundred (300) with no documentation for the lower BFR (two (2) hours and six (6) minutes between checks); BFR from 12:17 PM through 12:30 PM: four hundred (400) (thirteen (13) minutes) with no documentation for the lower BFR.
An interview with the Facility Administrator and clinical manager on 2/16/24 at approximately 1:30 PM confirmed the above findings.
Plan of Correction:V 544
To ensure compliance the CM or designee will in-service all DPC staff on policy:
- Patient Assessment and Monitoring
Emphasis will be placed on ensuring that any machine parameters not within the physician prescribed limits must be reported to the RN for evaluation, intervention and documentation. These parameters include the blood flow rate (BFR). The reason the BFR is not being achieved must be documented. The staff will be instructed that there must be documentation of the registered nurse (RN) notification by the patient care technician (PCT). The RN must document the evaluation for the BFR. The meeting also reinforced that the safety checks and monitoring must be completed and documented every 30 minutes and not to exceed 45 minutes.
Inservicing will be completed by March 5, 2024. All training documentation will be on file at the facility.
The CM or designee will perform daily audits of 20% of flowsheets for 2 weeks. At that time, if improved compliance is observed the audits will then be completed 2 times/week for 2 weeks. If 100% compliance is maintained after the 2 weeks, the audits will be completed monthly following the QAPI program. A POC specific auditing 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 audits and report the findings to the QAPI Committee at the monthly meeting. Sustained compliance will be monitored by the QAPI committee.
Completion Date: March 29, 2024
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