Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on May 4, 2021 through May 6, 2021, Fairmount Dialysis, was identified to have the following standard level deficiency that wwas determined to be in substantial compliance with the following 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:
494.62(d) STANDARD
EP Training and Testing
Name - Component - 00
§403.748(d), §416.54(d), §418.113(d), §441.184(d), §460.84(d), §482.15(d), §483.73(d), §483.475(d), §484.102(d), §485.68(d), §485.542(d), §485.625(d), §485.727(d), §485.920(d), §486.360(d), §491.12(d), §494.62(d).
*[For RNCHIs at §403.748, ASCs at §416.54, Hospice at §418.113, PRTFs at §441.184, PACE at §460.84, Hospitals at §482.15, HHAs at §484.102, CORFs at §485.68, REHs at §485.542, CAHs at §486.625, "Organizations" under 485.727, CMHCs at §485.920, OPOs at §486.360, and RHC/FHQs at §491.12:] (d) Training and testing. The [facility] must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years.
*[For LTC facilities at §483.73(d):] (d) Training and testing. The LTC facility must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least annually.
*[For ICF/IIDs at §483.475(d):] Training and testing. The ICF/IID must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training and testing program must be reviewed and updated at least every 2 years. The ICF/IID must meet the requirements for evacuation drills and training at §483.470(i).
*[For ESRD Facilities at §494.62(d):] Training, testing, and orientation. The dialysis facility must develop and maintain an emergency preparedness training, testing and patient orientation program that is based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, policies and procedures at paragraph (b) of this section, and the communication plan at paragraph (c) of this section. The training, testing and orientation program must be evaluated and updated at every 2 years.
Observations:
Based on a review of the facility emergency preparedness plan, facility policy and procedure, clinical records (CR), and an interview with Facility Administrator, it was determined the facility did not document training and testing of emergency preparedness training of patients for one (1) of seven (7) dialysis patients reviewed. (CR # 4)
Findings include:
Review of Policy: 5-01-21 titled, "Home Dialysis Monitoring and Ongoing Patient Education" on May 6, 2021 at approximately 12:30 pm states: "Purpose: To monitor and reinforce previously taught information, teach new procedures techniques, if applicable, and to observe patient aseptic technique...3. The following need to be reviewed at least quarterly: Emergency/disaster preparedness..."
1. Review of CR #4 (Peritoneal Dialysis) on May 6, 2021 at approximately 9:00 am revealed no documented quarterly emergency preparedness drill for the third quarter of 2020 or for the first quarter of 2021.
An interview with the Facility Administrator on May 6, 2021 at approximately 12:45 pm confirmed the above findings.
Plan of Correction:5/13/2021
POC
E 0036
The Facility Administrator (FA) will hold an in-service starting May 17, 2021 with the peritoneal dialysis (PD) clinical teammates to review Policy 5-01-21 Home Dialysis Monitoring and Ongoing Patient Education emphasizing the requirements of the facility to review emergency/disaster preparedness with each patient at least quarterly. Verification of attendance will be evidenced by teammate signature on in-service sheet. 100% of PD charts will be reviewed for evidence of quarterly emergency preparedness education. Any patient chart not in compliance with emergency preparedness education will be completed during the next clinic visit. In addition a tool was developed with due dates for quarterly emergency/disaster preparedness education to be completed. The PD RN will be responsible for the monitoring of this tool. Chart audits will be completed monthly until 100% compliance. Going forward, 10% of the charts will be reviewed during monthly medical record audits. The results of audit will be reviewed with the Medical Director during Facility Health Meetings (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of corrections.
Completion 05/05/2021
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on May 4, 2021 through May 6, 2021, Fairmount 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:
494.80(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 clinical records (CR), faciity policy and an interview with the administrator, the facility did not follow its policy regarding blood pressure management for three (3) of seven (7) CR's (CR #1, 2, and 5); did not follow its policy regarding vitals signs and treatment monitoring for one (1) of seven (7) CR's, (CR #2); and did not follow its policy regarding post treatment assessment for one (1) of seven (7) CR's, (CR #3).
Findings include:
A review of policy 1-03-08 "Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment" on May 6, 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 CR's was conducted on 5/6/2021 from approximately 11:30 am - 2:30 pm.
CR #1, Admission date: 10/6/2020. Review of treatment sheets revealed the following:
On 4/8/2021, Pre Treatment blood pressure was recorded as 173/103 by the PCT with no documentation that the licensed nurse was notified and no documentation was noted by licensed nurse. At 08:05 am, blood pressure was documented by the PCT with no documentation of licensed nurse notification and no documentation was noted by licensed nurse.
On 4/15/2021 at 11:05 am, blood pressure was documented at 92/51 with no documentation that the licensed nurse was notified and no documentation was noted by licensed nurse.
CR #2, Admission date: 11/18/19. Review of treatment sheets revealed the following:
On 4/8/2021, 07:28 am blood pressure 87/35 was documented by PCT with comment "pt bp low"; 07:30 am blood pressure 86/41 was documented by PCT; 09:13 am blood pressure 93/27 was documented by PCT; 09:29 am blood pressure 83/45 was documented by PCT. None of the above entries had documentation that the licensed nurse was notified and no documentation was noted by licensed nurse.
On 4/10/2021 at 0758 am, blood pressure was documented at 78/36 with no documentation that the licensed nurse was notified and no documentation was noted by licensed nurse.
On 4/13/2021 at 10:29 am, blood pressure was documented at 87/33 with no documentation that the licensed nurse was notified and no documentation was noted by licensed nurse.
On 4/15/2021, Vital sign documentation was noted for 6:30 am and not again until 8:30 am. No vital sign documentation was noted for 7:00 am; 7:30 am; and 8:00 am.
CR #3 Admission date: 3/3/2021. Review of treatment sheets revealed the following:
On 4/6/2021, no post treatment data collection/assessment was documented.
CR #5 Admission Date: 12/28/19. Review of treatment sheets revealed the following:
On 4/6/2021 at 06:25 am, blood pressure 215/114 was recorded by PCT with "nurse aware" documented. No licensed nurse documentation was noted.
An interview with the administrator on May 6, 2021 at approximately 12:45 pm confirmed the above findings.
Plan of Correction:5/13/2021
V 0504
The FA held an in-service for all patient care teammates starting on May 7, 2021 to review Policy 1-03-08 Pre-Intra-Post Treatment Data Collection, Monitoring and Nursing Assessment emphasizing but not limited to: 1) any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse. If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 2) Intradialytic treatment monitoring and data collection, which include vital signs and treatment monitoring, must be completed at least every thirty (30) minutes. 3) Abnormal findings or findings outside of any patient specific physician ordered will be documented and reported to the licensed nurse. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The licensed nurse notifies the physician as needed of changes in patient status. All findings, interventions and patient response will be documented in the patient's medical record. 4) The clinical teammate will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. If an abnormal finding is identified, the licensed nurse will assess the patient prior to discharge. Verification of attendance will be evidenced by teammate signature on in-service sheet. The FA or designee will perform flow sheet audits on 10% of all patient records weekly for four (4) weeks then on 10% monthly during medical record audits to verify timely treatment monitoring, documentation of abnormal findings, finding is reported to the licensed nurse, licensed nurse documents assessment and/or intervention, performs post treatment assessment and MD notification when needed.
Instances of non-compliance will be addressed immediately. The results of audits will be reviewed teammates during homeroom meetings and with the Medical Director during FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion 05/05/2021
494.80(d)(2) STANDARD
PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO
Name - Component - 00
In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted-
At least monthly for unstable patients including, but not limited to, patients with the following:
(i) Extended or frequent hospitalizations;
(ii) Marked deterioration in health status;
(iii) Significant change in psychosocial needs; or
(iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis.
Observations:
Based on a review of facility policy, clinical record (CR), and an interview with the Facility Administrator, it was determined that the facility failed to follow its policy pertaining to completing a monthly comprehensive reassessment of an unstable patient for one (1) of two (2) active unstable patients reviewed (CR #6)
Finding include:
A review of the Facility Policy 1-14-01 titled "Interdisciplinary Team (IDT) Patient Assessment and Plan of Care" conducted on May 6, 2021 at approximately 12:20 pm states, "Purpose: To provide guidance for the development of patient assessment and plan of care for IDT teammates. Policy: Assessment: . . . 7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: . . . At least monthly for unstable patients . . . Plan of Care: Monthly (unstable patients) Assessment: Monthly until patient is determined by interdisciplinary team to be stable . . "
A review of CR's was conducted on May 6, 2021, at approximately 9:15 am.
CR #6, admission date: 2/18/2020. Care Plan dated 1/14/20201, lists the patient as "Unstable". There is no documentation of a comprehensive assessment/plan of care for the month of February 2021. The next documented comprehensive assessment/plan of care is on 3/11/2021, which the patient is listed as "Unstable".
An interview conducted with the facility administrator on May 6, 2021 at approximately 12:45 pm confirmed the above identified findings.
Plan of Correction:5/13/2021
V 0520
The FA will hold an in-service for all Interdisciplinary (IDT) teammates starting on May 18, 2021 to review Policy 1-14-01 Interdisciplinary Team (IDT) Patient Assessment and Plan of Care emphasizing a comprehensive re-assessment of each patient and a revision in the plan of care will be conducted at least monthly for unstable patients until the patient is determined by the IDT to be stable. Verification of attendance will be evidenced by teammate signature on in-service sheet. The charge nurse will be responsible for the monitoring of completion of all "unstable "care plans. The FA or designee will audit all unstable care plans monthly for three (3) months to verify compliance. The results of the audits will be reviewed with the Medical Director during FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion 05/05/2021
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 a review of facility policy, clinical records (CR), and an interview with the facility administrator, the facility did not follow its policy regarding retrieval and reviewing home treatment records at least weekly and maintain this information in the patient's clinical record (CR) for two (2) of two (3) CR's of peritoneal dialysis home patients. CR #4 and 7.
Findings include:
A review of facility policy "05-01-21 Home Dialysis Monitoring and Ongoing Patient Education" was completed on May 6, 2021 at approximately 12:35 pm. Policy states, "Policy: 1. The Peritoneal Dialysis facility will:...c. Retrieve and review home treatment records at least weekly. d. Maintain information in the patient's medical record..."
A review of MRs was conducted on May 6, 2021 at approximately 10:00 am.
CR #4, admission date: 5/6/2020; did not contain any home treatment records for treatments performed by the patient for peritoneal dialysis at home for the months of February 2021, March 2021, or April 2021. Facility did contact patient for records at time of this survey. The records were incomplete and not signed by a nurse to document review of records.
CR #7, admission date: 4/12/2021; did not contain any home treatment records for treatments performed by the patient for peritoneal dialysis at home since the start of home treatment. Facility did contact patient for records at time of this survey. The records were incomplete and not signed by a nurse to document review of records.
An interview with the facility administrator on May 6, 2021 at approximately 12:45 pm confirmed the above findings.
Plan of Correction:5/13/2021
V0587
The FA held an in-service with the PD teammates starting May 17, 2021 to review Policy 05-01-21 Home Dialysis Monitoring and Ongoing Patient Education and Policy 5-01-29 Daily Home Treatment Record emphasizing but not limited to: 1) The PD facility will retrieve and review complete self-monitoring data and other information from Peritoneal Dialysis patients or their designated caregivers at least every two (2) months and maintain information in the patient's medical record. 2) Each PD patient will be instructed to complete documentation of each treatment procedure on the Daily Home Treatment Record, also referred to as a flowsheet. 3) The patient will bring all completed flowsheet to the facility for each clinic visit. 4) The PD nurse will review the completed flow sheets to assist in evaluating the patient's progress and self-care decision-making process. This review will be verified by the home training nurse documenting the review in the medical record. Verification of attendance will be evidenced by teammate signature on in-service sheet. The FA or designee will audit five (5) clinic visits monthly to verify flowsheets are being retrieved, reviewed and documentation is present. Instances of non-compliance will be addressed immediately. The results of audits will be reviewed with the PD teammates and with the Medical Director during FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.
Completion 05/05/2021
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