Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey conducted February 6, 2024 through February 7, 2024, Children's Hospital of Pittsburgh of the Upmc Health System 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 conducted February 6, 2024 through February 7, 2024, Children's Hospital of Pittsburgh of the Upmc Health System 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(d)(1) STANDARD
PA-FREQUENCY REASSESSMENT-STABLE 1X/YR
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-
(1) At least annually for stable patients;
Observations:
Based on review of medical records (MR), review of facility documentation and interview with the Ambulatory Manager the facility failed to ensure an annual comprehensive assessment was completed for one (1) of four (4) medical records reviewed (MR3).
Findings include:
MR3- admit date: 4/8/21 contained documentation of an annual comprehensive assessment completed 7/2022. No documentation within MR3 of an annual assessment being completed for 7/2023.
An interview with the Ambulatory Manager and the Director of Nursing on 2/7/24 at approximately 4:00 p.m. confirmed the above findings.
Plan of Correction:The Clinical Director of dialysis in association with the Manager will oversee the compliance for documentation on the annual comprehensive assessment of all dialysis patients. The CMS requirement (494.80 d) for comprehensive assessments states an assessment must be completed on each patient annually on stable patients. Education sessions will be provided by the Manager to all the dialysis staff the week of March 4-8, 2024. This education is mandatory for all staff and staff will sign a log to document the education. This education will be completed by March 8, 2024. The manager will continue to audit all dialysis patients records to ensure a comprehensive assessment is completed annually.
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), facility documents, and employee interviews, the facility did not ensure that training for home therapies included information on how to self-monitor health status and report health status information for one (1) out of four (4) medical records reviewed. (MR4)
Findings include:
A review of facility document titled " Your Personal Peritoneal Dialysis Training Manual " on 2/7/24 revealed, " [Page 24] Blood Pressure ...The physician will give you specific guidelines to follow for your child. The physician will tell you what your child ' s normal vital signs should be. Notify the Dialysis Unit if your child ' s vital signs are out of their acceptable range. ... "
A review of patient teaching material on 2/7/24 revealed, " Vital Signs ...Blood Pressure ...Normal Blood Pressure ...Adolescents ...[systolic]94-140 ...[diastolic] 62-88... The physician will give you specific guidelines to follow for your child. Many times the blood pressure medication is adjusted based on your child ' s blood pressure ... "
A review of medical records (MR 1 - 4) was conducted on 2/7/24.
MR4 adolescent. Admission: 11/1/22, Peritoneal Dialysis (PD) patient. Facility documentation titled, Homechoice Claria Prescribed ...Report, with treatment dates between 7/17/23 - 8/15/23 listed the following abnormal blood pressures (BP):
7/25/23: BP 150/116. Systolic and Diastolic BP were above normal range for adolescent.
8/7/23: BP 88/70. Systolic BP was below normal range for adolescent.
8/9/23: BP 93/43. Systolic BP and Diastolic BP were below normal range for adolescent.
During an interview on 2/7/24 with (EMP6) Home PD nurse and (EMP1) Ambulatory Manager, the abnormal blood pressures were reviewed and it was determined that no specific BP reporting guidelines for MR4 were in place. Also unable to be determined if the patient/caregiver reported the abnormal blood pressures to the facility staff.
The findings were reviewed with EMP1 (Ambulatory Manager) and EMP3 (Director of Nursing) during an exit interview on 2/7/24 at approximately 4:00 pm.
Plan of Correction:The Clinical Director of Dialysis in association with the Manger of dialysis will oversee the compliance with Peritoneal Dialysis Home training for monitoring of blood pressures and when to contact the physician. Policy D401- Dialysis-Patient Home Record Keeping will be revised and under section V: Procedure: b-Record pretreatment VS (blood pressure, pulse and temperature) added will be "the physician will provide specific guidelines to follow for your child. The physician will tell you what your child's normal VS should be and will advise when to contact the physician if your child's VS are out of acceptable range". The BP guidelines will be discussed with the parent at each PD clinic visit and documented on the Monthly Peritoneal Dialysis Assessment and Plan of Care, under the Blood Pressure and Fluid Management Section. This form is signed by the physician and the parent at each monthly clinic visit. The dialysis manager will provide education, which is mandatory for all dialysis staff and will document education on a log. The education will be conducted the week of March 4-8, 2024 and will be completed March 8th. The manager will audit all dialysis patient records to ensure patient education on blood pressure monitoring acceptable ranges is completed.
|