Initial Comments:
Based on the findings of an unannounced Medicare complaint investigation survey conducted onsite October 1, 2024, and completed offsite October 3, 2024, Allegheny Valley Dialysis was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the 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:
494.180(b)(1) STANDARD
GOV-STAFF # & RATIO MEET PT NEEDS
Name - Component - 00
The governing body or designated person responsible must ensure that-
(1) An adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients;
Observations:
Based on review of facility schedule, medical records (MR), and employee interviews, the facility failed to ensure an adequate number of qualified personnel available to meets the needs of patients for seven (7) of twenty-two (22) MR reviewed (MR5, 8, 9, 11, 15, 19, & 20).
Findings included:
Review of facility schedule dated 9/1/24-9/28/24, on 10/1/24 at approximately 10:00am with facility administrator revealed dialysis treatments cancelled 9/14/24 due to inadequate staffing.
A review of medical records on 10/1/24 at approximately 11:00am revealed:
MR5, start of service (SOS) 12/23/20. Per late entry note dated 9/18/24, "due to staffing issues" facility administrator called patient 9/13/24. No return call documented. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24.
MR8, SOS 2/24/20. Per late entry note dated 9/18/24, "due to staffing issues" facility administrator called patient 9/13/24 to offer to reschedule to another unit either 9/13/24 or 9/14/24. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24.
MR9, SOS 4/30/24. Per late entry note dated 9/18/24, "due to staffing issues" facility administrator called patient 9/13/24 to offer to reschedule to another unit either 9/13/24 or 9/14/24. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24.
MR11, SOS 6/25/24. Per late entry note dated 9/18/24, "due to staffing issues" facility administrator called patient 9/13/24 to offer to reschedule to another unit either 9/13/24 or 9/14/24. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24.
MR15, SOS 8/10/24. Per late entry note dated 9/18/24, "due to staffing issues" facility administrator called patient 9/13/24. No return call documented. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24.
MR19, SOS 7/15/24. Per late entry note dated 9/18/24, "due to staffing issues" facility administrator called patient 9/13/24 to offer to offer treatment at a different location. Patient refused due to transportation. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24.
MR20, SOS 10/4/17. Per late entry note dated 9/18/24, "due to staffing issues" facility administrator called patient 9/13/24 to offer to reschedule to another unit either 9/13/24 or 9/14/24. Confirmed with administrator that patient did not receive dialysis treatment that was scheduled 9/14/24.
An interview conducted with Facility Administrator, Manager of Clinical Services, and Facility Administrators from 2 additional locations on 10/1/24 at approximately 2:00pm confirmed the above findings.
Plan of Correction:The Facility Administrator or designee will hold mandatory in-services for all clinical teammates starting on 10/21/24. Surveyor observations will be reviewed. Education to include a review of 1) Policy 8-02-01 Teammate Qualifications, Licensure and Adequate Teammate Staffing emphasizing an adequate number of qualified personnel are present whenever patients are undergoing dialysis so that the patient/staff ratio is appropriate to the level of dialysis care given and meets the needs of patients. 2) Policy 3-02-17 Progress Note Policy emphasizing that documentation needs to include treatment given or planned, patient encounters and the condition of the patient. Progress notes will capture communications related to patient's care that occur outside of the medical record (e.g. telephone, Secure Messaging, etc.). 3) Policy 4-07-01 Emergency Management emphasizing if emergency event requires additional staffing resources: the Facility Administrator or designee, will work with local leadership to determine availability of additional internal teammate resources within Region, Division, and Palmer Group. Verification of attendance at in-service is evidenced by teammate signature on in-service sheet.
The Facility Administrator or designee will audit 1) the staffing schedule daily for two (2) weeks then weekly for two (2) weeks then monthly for two (2) months to verify adequate staffing is scheduled. 2) Nursing progress notes monthly for three (3) months to verify progress notes are entered timely. Instances of noncompliance will be addressed immediately.
The results of the audits will be reviewed with the Medical Director during Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
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