Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey completed on January 10, 2024, DCI Wexford 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 unannounced onsite Medicare recertification survey completed January 10, 2024, DCI Wexford 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:
494.90(a)(1) STANDARD
POC-MANAGE VOLUME STATUS
Name - Component - 00
The plan of care must address, but not be limited to, the following:
(1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient's volume status;
Observations:
Based on medical record reviews (MR), facility policies/procedures, and interviews with staff (EMP), the facility did not ensure fluid removal was performed per the Plan of Care ' s prescribed Estimated Dry Weight (EDW) for three (3) of five (5) medical records reviewed. (MR 1-3)
A review of agency procedure titled Fluid Volume Management/Estimated Dry Weight (EDW) on 1/3/24 at approximately 12:00 pm revealed, " Purpose: Give guidance for providing the necessary care and services to manage the PD patient ' s volume status and establishing the estimated dry weight (EDW). ... Volume status is measured in terms of the dialysis patient ' s "target weight, " or estimated dry weight (EDW) ... "
MR1: Peritoneal Dialysis (PD)Training start date of 11/28/22. A review of documentation titled Effective Orders on 1/4/24 at approximately 1:00 pm revealed an ordered target weight of 100 kg between 9/29/2023 to 12/13/23. A review of agency documents titled Daily Home Automated Peritoneal Dialysis Record ...October ...2023 on 1/3/24 at approximately 11:00 am revealed a Target Weight of 87.5 kg. The target weights on the treatment record did not match the prescribed target weight of 100 kg.
MR2: Peritoneal Dialysis (PD) Training start date of 3/2/22. A review of documentation titled Effective Orders on 1/4/24 at approximately 1:00 pm revealed an ordered target weight of 73 kg on 9/29/23. A review of agency documents titled Daily Home Automated Peritoneal Dialysis Record ...October ...2023 on 1/3/24 at approximately 1:00 pm revealed a Target Weight of 59 kg. The target weights on the treatment record did not match the prescribed target weight of 73 kg.
A review of agency procedure titled Fluid Volume Management/Estimated Dry Weight (EDW) on 1/10/24 at approximately 3:00 pm revealed, " Purpose: Give guidance for providing the necessary care and services to manage the HHD patient ' s volume status and establishing the estimated dry weight (EDW). ...Volume status is measured in terms of the dialysis patient ' s "target weight, " or estimated dry weight (EDW) ...
MR3: Home Hemodialysis Training start date of 9/21/2020. A review of documentation titled Effective Orders on 1/4/23 at approximately 1:00 pm revealed a target weight of 67.5 kg on 11/10/23. A review of agency documents titled NxStage System One Hemodialysis Record revealed EDW or target weight of 69 kg on 12/5/23, 12/10/23, 12/12/23, 12/14/23, and 12/16/23. The target weights on the treatment record did not match the prescribed target weight of 67.5 kg.
The above findings were reviewed with EMP1, Clinical Manager, on 1/11/24 at approximately 3:00 pm.
Plan of Correction:Nurse Manager will educate all staff on the procedure for "Fluid Volume Management / Estimated Dry Weight (EDW)" with emphasis on verification of the correct target weight in the patient's home dialysis order entries.
Nurse Manager or her designee will review all patient medical records for correct EDW and make appropriate changes per MD order. Home Therapy Nurses will contact patients when target weight is changed by MD, within 2 days of order change.
Home Therapy Nurses will continue to review patient treatment records weekly to verify correct target weight in the patient's home dialysis order entries as well as other treatment parameters.
Beginning February 2024, Home Therapy Nurses will review fluid status with patients using the Nutrition Report Card, during monthly clinic visits.
Home Therapy Nurses will add a problem to each patient's care plan to ensure continuity of documentation for patient fluid status and EDW. This will include addressing issues and discrepancies (i.e. EDW change greater than 2.0 kg) noted throughout the month. Home therapy nurses will provide, and document phone follow up to address any issue noted.
Parameter reporting guidelines for patients and staff will be updated during the next monthly Governing Body Meeting scheduled for 1/25/2024.
Nurse Manager or her designee will perform chart audits 2x's per month, for 2 months and then transition to 1x per month going forward. All findings will be documented in the facility QAPI minutes.
494.100(a)(3) STANDARD
H-TRAIN CONTENT INCLUDES ER PREP HOME PTS
Name - Component - 00
The training must-
(3) Be conducted for each home dialysis patient and address the specific needs of the patient, in the following areas:
(i) The nature and management of ESRD.
(ii) The full range of techniques associated with the treatment modality selected, including effective use of dialysis supplies and equipment in achieving and delivering the physician's prescription of Kt/V or URR, and effective administration of erythropoiesis-stimulating agent(s) (if prescribed) to achieve and maintain a target level hemoglobin or hematocrit as written in patient's plan of care.
(iii) How to detect, report, and manage potential dialysis complications, including water treatment problems.
(iv) Availability of support resources and how to access and use resources.
(v) How to self-monitor health status and record and report health status information.
(vi) How to handle medical and non-medical emergencies.
(vii) Infection control precautions.
(viii) Proper waste storage and disposal procedures.
Observations:
Based on medical record reviews (MR), agency policy, and employee interviews EMP, the facility did not train dialysis patients to detect, report and manage potential dialysis complications or how to self-monitor health status and report health status information for one (1) of five (5) medical records reviewed (MR1).
Findings include:
A review of medical records (MR) was conducted between 1/3/24 and 1/4/24.
MR1: Peritoneal Dialysis (PD)Training start date of 11/28/22. Agency documentation titled, Daily Home Automated Peritoneal Dialysis Record dated between December 16-31, 2023, and November 16-31, 2023, noted systolic blood pressure (SBP) values of 75 on December 16, SBP = 85 on December 17 and SBP = 87 on November 16.
An interview with clinic nurse manager (EMP1) on 1/4/24 at approximately 3:00 pm revealed that the clinic did not teach home dialysis patients reportable parameters for low or high blood pressures. EMP1 explained that patients are taught to report if they have " symptoms " for low or high blood pressure. During an interview on 1/4/24 at approximately 3:00 pm with EMP2, staff nurse, it was also confirmed that patients were trained to contact staff based on symptoms of hypotension, not based on blood pressure parameters.
A review of agency documentation titled, " Parameter Reporting Guidelines " on 1/4/24 at approximately 11:00 am revealed, " Blood Pressure ...SBP [systolic blood pressure] ...RN Reports to Physician ...SBP <90 or >200 &/or patient is symptomatic ...DBP <50 or >105 &/or patient is symptomatic & if marked change from baseline ... "
MR1: A review of agency documents titled ...Homechoice Claria Treatment Summary Report on 1/4/24 at approximately 3:00 pm noted:
12/18/23: SBP = 85 and the report was reviewed on 12/20/23 by EMP2, RN.
12/17/23: SBP =75 and the report was reviewed on 12/19/23 by EMP2, RN.
11/16/23: SBP = 89 and the report was reviewed on 11/20/23 by EMP3, RN.
An interview with EMP1, RN Clinical Manager, and EMP2, staff RN, on 1/4/24 at approximately 3:00 pm confirmed that MD notification for the SBP recordings <90 was not documented.
The above finding was reviewed during an exit meeting on 1/4/24 at approximately 3:30 pm.
Plan of Correction:Nurse Manager will educate all the staff on the "Parameter Reporting Guideline", to include the patients blood pressure and symptoms.
Nurse Manager or her designee will educate all patients, and provide a copy of the Parameter Reporting Guidelines, including reporting blood pressure readings and current symptoms.
All RNs will document acknowledgement of any blood pressure readings outside of the parameters and notify the patient's physician.
Nurse Manager or her designee will perform chart audits 2x's per month, for 2 months and then 1x per month going forward. All findings will be documented in the facility QAPI minutes.
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