QA Investigation Results

Pennsylvania Department of Health
ALLEGHENY VALLEY DIALYSIS
Health Inspection Results
ALLEGHENY VALLEY DIALYSIS
Health Inspection Results For:


There are  8 surveys for this facility. Please select a date to view the survey results.

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 Medicare recertification survey completed on August 21, 2020, Allegheny Valley 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 completed August 21, 2020, Allegheny Valley Dialysis 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)(1) STANDARD
PA-ASSESS CURRENT HEALTH STATUS/COMORBIDS

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

(1) Evaluation of current health status and medical condition, including co-morbid conditions.




Observations:


Based on review of facility policy, medical records (MR) and interview with facility staff, the facility failed to ensure an evaluation of a patient medical condition was in accordance with the physician order and/or facility policy for one (1) of five (5) in center hemodialysis patient medical records reviewed (MR3).

Findings included:

Review of facility policy on 8/21/2020 at approximately 2:30 PM revealed: "Policy: 1-03-08...POST TREATMENT...16. If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse...17. Licensed nurse will use...clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician...is necessary prior to discharge...from the facility..."

Review of MR3 on 8/20/2020 at approximately 1:55 PM: Admission 10/6/2010. "...Primary Diagnosis...End stage renal disease...Comorbidities...Type 1 diabetes mellitus with hyperglycemia..." Physician PRN (as needed) order, start date 10/5/2010: "...Hypoglycemia...Dextrose 50% [ml] 50.00 ml (milliliter) IV (intravenous) Push Administer 25 grams for blood sugar <50. Recheck blood sugar after 5 minutes. May repeat X1 if blood sugar remains low and notify MD..." Review of hemodialysis treatment flow sheets from 8/3/2020 to 8/17/2020 revealed:
8/12/2020, "Treatment terminated 10:01 AM...Medications and Ancillaries Administered...Blood Glucose Testing (In-House) - Result: 31...10:33 AM...EMP9, RN (registered nurse)...Dextrose 50% [ml] 50 ml IVP (intravenous push)...Given...10:35 AM...EMP9, RN...Post Treatment Data Collection & Assessment...Assessment EMP9, RN, at 10:50 AM...Resp (Respiratory): Clear...Cardiac: Regular rate and rhythm...Mental: Oriented x 3...Other: Blood sugar rechecked 207 PT (patient) instructed to eat at home..."
There was no documented evidence of patient MR3 symptoms or assessment that precipitated the intervention for blood sugar testing. The patient blood sugar recheck was documented at 10:50 AM, 15 minutes after the Dextrose medication was documented administered. There was no documented evidence of physician notification of patient MR3 low blood sugar result.
There was no documented evidence the interventions provided for the patient blood sugar result of <50 was in accordance with the physician order and/or facility policy noted in MR3 hemodialysis treatment record for the aforementioned treatment date.

An exit conference was conducted on 8/21/2020 at approximately 1:15 PM with the facility Administrator, Regional Operations Director and Manager of Clinical Services. Above findings were reviewed.







Plan of Correction:

Plan of Correction for DaVita Allegheny Valley Dialysis Survey completed August 21, 2020.
V0502 / V0504:
DaVita Allegheny Valley takes the conditions of coverage very seriously; the Facility Administrator will review flow sheets for proper documentation as outlined in Policy: 1-03-08, PRE-INTRA-POST TREATMENT DATA COLLECTION MONITORING AND NURSING ASSESSMENT.
1. Facility Administrator (FA) held clinical teammate in-service on Monday August 31, 2020 to review the Policy: 1-03-08: PRE-INTRA-POST TREATMENT DATA COLLECTION MONITORING AND NURSING ASSESMENT, with special emphasis that abnormal findings or findings outside of any patient specific physician ordered parameters must be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary including utilizing PRN orders. Licensed nurse notifies the physician (or AHP if applicable) as needed of changes in patient status. All findings, interventions and patient response must be documented in the patient's medical record. Review of abnormal findings including Blood Pressure difference of 20 mm/Hg increase or decrease from patient's last intradialytic treatment Blood Pressure reading during the 30 minute checks during treatment. In-service will also review the deficiencies sited by the surveyor with examples of documentation trends.
2. In-service on August 31, 2020, reviewing the: Nurse News: Writing Right, parts one and two; review of effective documentation.
3. Flow sheets: Audits of flow sheets will be as follows:
- 5 flow sheets from each shift will be randomly pulled and audited daily for one week beginning August 31, 2020 through September 5, 2020. FA or Clinical Coordinator (CC) will audit flow sheets and review with teammates the findings.
- 5 flow sheets from each day will be pulled randomly and audited each week for 2 weeks, beginning September 7, 2020 through September 19, 2020.
- 10 flow sheets will be randomly pulled and audited for each week for 2 weeks.
- Thereafter 10% of medical records will be audited monthly
4. Results and documentation of the audits will be reviewed with the teammates and education provided for missed documentation.
5. Results of the audits will be reviewed with the Medical Director in the Monthly Facility Health Meeting (FHR/QAPI). Documentation of the findings will be entered into the FHR minutes.
6. Results of the audits will be reviewed with the Medical Director and the Regional Operations Director during the monthly Governing Body Meeting.

FA is responsible for compliance with this plan of correction

Completion Date: 9/21/2020



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 facility policy, medical records (MR) and interview with facility staff, the facility failed to assess and manage patient's blood pressure and/or fluid management needs for three (3) of five (5) in center hemodialysis patient medical records reviewed (MR2 - MR4).

Findings Included:

Review of facility policy on 8/21/2020 at approximately 2:30 PM revealed: "Policy: 1-03-08 ...1. Patient data will be obtained and documented by the patient care technician (PCT or a licensed nurse...a...i...temperature ii...blood pressure (BP) 1. sitting and standing BP...required pre and post treatment...iii. pulse rate...INTRADIALYTIC DATA COLLECTION/ASSESSMENT...9...a...i..at least every thirty (30) minutes...b. At a minimum...i. BP...ii..pulse...11 Abnormal findings...will be reported to the licensed nurse immediately...The licensed nurse will use...clinical judgement...to determine if any clinical interventions are necessary. 12. The licensed nurse notifies the physician...as needed of changes in patient status...ABNORMAL FINDINGS...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...Blood pressure Intradialytic...Difference of 20 mm/Hg increase or decrease from patient's last Intradialytic treatment BP reading...Blood pressure post treatment...sitting...systolic greater than 140 mm/Hg or less than 90 mm/Hg,..diastolic greater than 90 mm/Hg or less than 50 mm/Hg...Heart or Pulse Rate Pre/Intra/Post...Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat..."

Review of MR2 on 8/20/2020 at approximately 1:05 PM: Admission 6/13/2017. Physician PRN (as needed) order, start date 9/5/2018: "...HYPOTENSION...IF BP (blood pressure) < 90 BEFORE TREATMENT OR DROPS 20 POINTS DURING 30 MINUTE CHECKS DECREASE MACHINE TEMP TO 35.5 DEGREES CENTGRADE AND ADMINISTER nss (normal saline solution) IN 100ML INCREMENTS UP TO 1 LITER IF PATIENT SYMPTOMATIC..." Review of hemodialysis treatment flow sheets from 8/3/2020 to 8/17/2020 revealed:
8/5/2020, Intradialytics: 6:32 AM BP 140/69, 7:02 AM BP 117/61 (drop of 23 points between 30 minute checks).
8/7/2020, Intradialytics: 5:37 AM BP 163/77, 6:02 AM BP 133/65 (drop of 30 points between 30 minute checks), 7:32 AM BP 148/68, 8:02 AM BP 117/53 (drop of 31 points between 30 minute checks).
There was no documented evidence of intervention/re-assessment provided for patient blood pressures below parameters per physician orders and/or facility policy noted in MR2 hemodialysis treatment records for aforementioned treatment dates.

Review of MR3 on 8/20/2020 at approximately 1:55 PM: Admission 10/6/2010. Physician PRN (as needed) order, start date 9/5/2018: "...HYPOTENSION...IF BP (blood pressure) < 90 BEFORE TREATMENT OR DROPS 20 POINTS DURING 30 MINUTE CHECKS DECREASE MACHINE TEMP TO 35.5 DEGREES CENTGRADE AND ADMINISTER nss (normal saline solution) IN 100ML INCREMENTS UP TO 1 LITER IF PATIENT SYMPTOMATIC..." Review of hemodialysis treatment flow sheets from 8/3/2020 to 8/17/2020 revealed:
8/3/2020, Intradialytics: 7:02 AM BP 170/104, 7:32 AM BP 135/88 (drop of 35 points between 30 minute checks), 9:02 AM BP 156/94, 9:32 AM BP 130/83 (drop of 26 points between 30 minute checks).
There was no documented evidence of intervention/re-assessment provided for patient blood pressures below parameters per physician orders and/or facility policy noted in MR3 hemodialysis treatment records for aforementioned treatment dates.

Review of MR4 on 8/21/2020 at approximately 9:30 AM: Admission 7/4/2015. Physician PRN (as needed) order, start date 9/5/2018: "...HYPERTENSION...BP (blood pressure) >180/90. IF PATIENT TOOK MORNING MEDICATION (IF NOT HAVE PATIENT TAKE MEDICATION), INITIATE TREATMENT AND RECHECK bp IN ONE HOUR. IF BP STILL NOT WITHIN RANGE OF < 180/90 RECHECK WITH MANUAL CUFF, IF MANUAL IS ELEVATED, THEN ADMINISTER CLONIDINE 0.1 MG-1 TABLET PO (by mouth). RECHECK BP AFTER 30 MINUTES, IF BP REMAINS > 180/90 NOTIFY md FOR FURTHER ORDERS..." Review of hemodialysis treatment flow sheets from 8/3/2020 to 8/17/2020 revealed:
8/3/2020, Pre-Treatment: Blood Pressure Sit: 193/127, Blood Pressure Stand: 186/115...Intradialytics...7:31 PM BP 185/109, 7:49 PM 186/113...Post-Treatment Blood Pressure Sit: 175/133, Blood Pressure Stand: 175/100, Pulse: 102.
8/5/2020, Pre-Treatment: Blood Pressure Sit: 180/117, Blood Pressure Stand: 185/110...Pulse: 108...Intradialytics...4:44 PM BP 171/105, 5:01 PM 176/107...5:31 PM BP 160/115...7:32 PM BP 191/95...7:46 PM BP 146/130...Post-Treatment Blood Pressure Sit: 164/94, Blood Pressure Stand: 166/107.
8/10/2020, Pre-Treatment: Blood Pressure Sit: 182/112, Blood Pressure Stand: 181/105...Intradialytics...4:04 PM BP 174/100, 4:31 PM 157/102...7:01 PM BP 172/101...7:34 PM BP 188/104...Post-Treatment Blood Pressure Sit: 186/107, Blood Pressure Stand: 197/118.
8/14/2020, Pre-Treatment: Blood Pressure Sit: 192/118, Blood Pressure Stand: 193/120...Pulse: 105...Intradialytics...4:01 PM BP 189/116, 4:33 PM 194/113...5:00 PM BP 176/115...5:30 PM BP 180/115...6:00 PM BP 177/110...6:30 PM BP 176/114...7:00 PM BP 171/118...7:30 PM BP 187/121...Post-Treatment Blood Pressure Sit: 190/116, Blood Pressure Stand: 166/103.
There was no documented evidence of intervention(s) provided for patient blood pressures/heart rates above parameters per physician orders and/or facility policy noted in MR4 hemodialysis treatment records for aforementioned treatment dates.

An exit conference was conducted on 8/21/2020 at approximately 1:15 PM with the facility Administrator, Regional Operations Director and Manager of Clinical Services. Above findings were reviewed.
























Plan of Correction:

Plan of Correction for DaVita Allegheny Valley Dialysis Survey completed August 21, 2020.
V0502 / V0504:
DaVita Allegheny Valley takes the conditions of coverage very seriously; the Facility Administrator will review flow sheets for proper documentation as outlined in Policy: 1-03-08, PRE-INTRA-POST TREATMENT DATA COLLECTION MONITORING AND NURSING ASSESSMENT.
1. Facility Administrator (FA) held clinical teammate in-service on Monday August 31, 2020 to review the Policy: 1-03-08: PRE-INTRA-POST TREATMENT DATA COLLECTION MONITORING AND NURSING ASSESMENT, with special emphasis that abnormal findings or findings outside of any patient specific physician ordered parameters must be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary including utilizing PRN orders. Licensed nurse notifies the physician (or AHP if applicable) as needed of changes in patient status. All findings, interventions and patient response must be documented in the patient's medical record. Review of abnormal findings including Blood Pressure difference of 20 mm/Hg increase or decrease from patient's last intradialytic treatment Blood Pressure reading during the 30 minute checks during treatment. In-service will also review the deficiencies sited by the surveyor with examples of documentation trends.
2. In-service on August 31, 2020, reviewing the: Nurse News: Writing Right, parts one and two; review of effective documentation.
3. Flow sheets: Audits of flow sheets will be as follows:
- 5 flow sheets from each shift will be randomly pulled and audited daily for one week beginning August 31, 2020 through September 5, 2020. FA or Clinical Coordinator (CC) will audit flow sheets and review with teammates the findings.
- 5 flow sheets from each day will be pulled randomly and audited each week for 2 weeks, beginning September 7, 2020 through September 19, 2020.
- 10 flow sheets will be randomly pulled and audited for each week for 2 weeks.
- Thereafter 10% of medical records will be audited monthly
4. Results and documentation of the audits will be reviewed with the teammates and education provided for missed documentation.
5. Results of the audits will be reviewed with the Medical Director in the Monthly Facility Health Meeting (FHR/QAPI). Documentation of the findings will be entered into the FHR minutes.
6. Results of the audits will be reviewed with the Medical Director and the Regional Operations Director during the monthly Governing Body Meeting.

FA is responsible for compliance with this plan of correction

Completion Date: 9/21/2020