Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on May 12, 2025 through May 14, 2025, Duke Street Dialysis 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 May 12, 2025, through May 14, 2025, Duke St. 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:
494.170 STANDARD
MR-COMPLETE, ACCURATE, ACCESSIBLE
Name - Component - 00
The dialysis facility must maintain complete, accurate, and accessible records on all patients, including home patients who elect to receive dialysis supplies and equipment from a supplier that is not a provider of ESRD services and all other home dialysis patients whose care is under the supervision of the facility.
Observations:
Based on review of policy/procedure, medical records (MR) and interview with the facility Administrator the clinic failed to ensure documentation was completed with signatures and/or dates for two (2) of five (5) records reviewed. MR #2 & MR #4.
Findings include:
Review of policy/procedure completed May 14, 2025 at approximately 1:00PM revealed: Policy: 1-01-10; Refusal of Care/ Treatment Against Medical Advice; Purpose: "To provide requirements for teammates to follow when a patient refuses care or treatment against medical advice." Policy: A. Refusal of Care: 2. "If a patient refuses care/treatment , the RN will document the event in the patient's medical record. Documentation will include... A copy of the Refusal of Care/Treatment Against Medical Advice form signed by the patient". B. Completion of the Refusal of Care/Treatment Against Medical Advice Form; 1. "The RN will verify that a patient signs... 4. A RN must countersign all Refusal of Care/Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form."
Review of medical records completed May 14, 2025 between approximately 10:00AM and 12:00PM revealed the following:
MR#2, Admit Date: 4/21/23; contained two (2) Early Termination of Treatment Against Medical Advice Forms. Both forms contained the "Pt unable to sign" in the section under Patient signature, the RN section was signed. Neither form was dated by either the patient or RN.
MR#3, Admit Date: 4/13/16; contained three (3) Early Termination of Treatment Against Medical Advice Forms. Three (3) forms contained patients signature, One (1) form contained a RN signature, one (1) form contained a witness signature. No form contained a date.
Interview with Facility Administrator completed May 14, 2025 at approximately 2:30PM confirmed policy/procedure to be current and above findings.
Plan of Correction:FA Pamela Carl addressed concerns with the clinical team and held an in-service on 5/14/25 to re-educate team on importance of complete documentation.
The facility admin assistant is responsible for auditing daily x1 week, then weekly for one month, and then ongoing auditing for complete documentation.
FA Michaela Mauk will review auditing on a weekly basis to ensure complete documentation. Findings will be shared with the facility medical director during monthly meetings. FA is responsible for compliance of the plan of correction.
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