QA Investigation Results

Pennsylvania Department of Health
AVONWORTH DIALYSIS LLC
Health Inspection Results
AVONWORTH DIALYSIS LLC
Health Inspection Results For:

This is the only survey for this facility

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.



Initial Comments:


Based on the findings of an onsite unannounced initial Medicare certification survey completed on 4/26/2019, Avonworth Dialysis LLC 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 initial Medicare certification survey completed 4/26/2019, Avonworth Dialysis LLC was found 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-APPROPRIATENESS OF DIALYSIS RX

Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:

(2) Evaluation of the appropriateness of the dialysis prescription,




Observations:


Based on a review of facility policies and procedures, medical records and staff (EMP) interviews, the facility failed to communicate with physicians when blood flow rates (BFR) required adjustment beyond the current physicians' orders for two (2) of three (3) in-center hemodialysis medical records (MR) reviewed (MR1 and MR3).

Findings included:

Review of facility policies conducted on 4/26/2019 at approximately 3:10 PM revealed:
"Policy: 1-04-05 TITLE: BLOOD FLOW PROBLEMS, NOTES: All nurses must be licensed by the state in which they are practicing and perform duties within their scope of practice ...PURPOSE: To achieve and maintain prescribed blood flow...2. If blood flow problem remains unresolved, notify licensed nurse. 3. The licensed nurse will assess the patient, their vascular access and extracorporeal circuit for the above and include the following: Assess the effectiveness of above interventions, Determine the need to reduce blood flow and extend treatment time, Notify nephrologist for further evaluation and/or interventions, 4. Document findings and interventions in patient's medical record..."

MR #1 admit date 2/22/2019, was reviewed on 4/26/2019, at approximately 2:05 PM. A review of the physician orders dated 4/10/2019, and Post Treatment sheets dated 4/1/2019 to 4/22/2019 revealed the physician ordered a BFR of 300 ml/min. The BFR was not delivered per physician's orders on the following dates:

4/10/2019 at 350 ml/min
4/12/2019 at 400 ml/min
4/17/2019 at 350 ml/min
4/19/2019 at 350 ml/min
4/22/2019 at 350 ml/min

No documentation was available to confirm that the patient was unable to achieve/maintain blood flow or any reported was made the physician.

MR #3 admit date 1/30/2019, was reviewed on 4/26/2019, at approximately 3:00 PM. A review of the physician orders dated 2/1/2019 was conducted. Post treatment sheets dated 1/30/2019 to 2/8/2019 were reviewed and revealed the physician ordered for BFR of 400 ml/min. The BFR was not delivered per physician's orders on the following date 2/4/2019. The BFR was changed from 400 ml/min at 10:30 AM to 300 ml/min at 11:00 AM. No documentation was available to confirm that the patient was unable to achieve/maintain blood flow or any report was made to the physician.

An exit interview with the regional operations director, facility administrator, clinical service specialist and charge nurse on 4/26/2019 at approximately 3:30 PM confirmed the above information.








Plan of Correction:

Direct patient care teammates (TMs) will be in-serviced 04/29/2019 by the Group Facility Administrator (GFA) and/or the Clinical Service Specialist (CSS) on Policy 1-03-08 Pre-Intra-Post Data Collection, Monitoring and Nursing Assessment and Policy 1-04-05 Blood Flow Problems with emphasis on but not limited to: Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment. 2) If blood flow problem remains unresolved, notify licensed nurse. 3) The licensed nurse will assess the patient, their vascular access and extracorporeal circuit for the above and assess the effectiveness of interventions, determine the need to reduce blood flow and extend treatment time, and notify nephrologist for further evaluation and/or interventions, 4) Documentation of findings and interventions will be entered in the patient's medical record. Verification of attendance is evidenced by TM signature on training form. The FA or designee will audits one hundred percent (100%) of the flow daily for two weeks then weekly for four (4) weeks to verify compliance. Audit results will be shared with the TMs during homeroom meetings and with the Medical Director monthly during Facility Health Meetings (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.


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 a review of facility policy, medical records (MR) and staff (EMP) interviews, it was determined that the facility failed to ensure patients received dialysis treatment as prescribed by the physician for one (1) of three (3) in-center dialysis MR reviewed (MR1).

Findings included:

Review of facility policies conducted on 4/26/2019 at approximately 3:10 PM revealed:
"Procedure: 1-03-08F TITLE: TREATMETN INITIATION UTILIZING FRESENIUS 2008 SERIES DIALYSIS DELIVERY SYSTEMS WITH ALL SINGLE USE DIALYZER TYPES AND STREAMLINE OR COMBISET OR NIPRO BLOOD LINES ...2. Verify patient prescription ..."

MR #1 admit date 2/22/2019, was reviewed on 4/26/2019, at approximately 2:05 PM. A review of the physician orders dated 4/10/2019, and post treatment sheets dated 4/1/2019 to 4//22/2019 revealed the physician ordered a BFR of 300 ml/min.
The BFR was not delivered per physician ' s orders on the following dates:

4/12/2019 at 400 ml/min
4/17/2019 at 350 ml/min
4/19/2019 at 350 ml/min

No documentation was available to confirm that the patient was unable to achieve/maintain blood flow or any report was made to the physician. The BFR was set and remained at these rates for the remainder of the treatment. There were two (2) staff that completed patient checks during the treatments.

An exit interview with the regional operations director, facility administrator, clinical service specialist and charge nurse on 4/26/2019 at approximately 3:30 PM confirmed the above information.







Plan of Correction:

Direct patient care TMs will be in-serviced by 04/29/19 by the GFA and/or the CSS on Policy 1-03-08 Pre-Intra-Post Data Collection, Monitoring and Nursing Assessment emphasis on but not limited to: Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment. 2) If blood flow problem remains unresolved, notify licensed nurse. 3) The licensed nurse will assess the patient, their vascular access and extracorporeal circuit for the above and assess the effectiveness of interventions, determine the need to reduce blood flow and extend treatment time, and notify nephrologist for further evaluation and/or interventions, 4) Documentation of findings and interventions will be entered in the patient's medical record. Verification of attendance is evidenced by TM signature on training form. The FA or designee will audits one hundred percent (100%) of the flow daily for two weeks then weekly for four (4) weeks to verify compliance. Audit results will be shared with the TMs during homeroom meetings and with the Medical Director monthly during Facility Health Meetings (FHM-QAPI) with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.