Initial Comments:
Based upon the findings of an unannounced onsite complaint survey conducted on September 7, 2023, Suburban Campus Dialysis was identified to have the following standard level deficiency that was determined to be in substantial compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage for End-Stage Renal Disease (ESRD) Facilities-Emergency Preparedness.
Plan of Correction:
494.62(b)(9) STANDARD
Dialysis Emergency Equipment
Name - Component - 00
§494.62(b)(9) Condition for Coverage:
[(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:]
(9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available.
Observations:
Based on review of agency policy, emergency AED cart log, and interview with facility administrator (FA), agency clinical staff failed to document completed daily AED equipment check in five (5) of twenty-six (26) calendar open clinic days. for one (1) of one (1) log reviewed. Log #1.
Findings include:
Review conducted of agency policy 1-02-08 Emergency Equipment Checks revealed: "3. The following equipment checks will be performed by a licenses nurse teammate to verify the designated equipment is available and functional: Daily -Check Status Indicator for green check for Zoll AED."
Review of Log #1 conducted on September 7, 2023, at approximately 10:00 AM, revealed: Missing AED checks by clinical staff on 8/10/23 (Thursday), 8/18/23 (Friday), 8/31/23 (Thursday), 9/5/23 (Tuesday), and 9/6/23 (Wednesday), with staff documentation error of two (2) days AED check for 9/7/23.
Interview conducted on September 7, 2023, at approximately 1:00 PM, with facility administrator confirmed above findings.
Plan of Correction:The Facility Administrator or designee heald mandatory in-services for all direct patient care teammates starting on 09/08/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-02-08 "Emergency Equipment Checks" with emphasis on but not limited to: 1) The following equipment checks will be performed by a license nurse teammate to verify the designated equipment is available and functional: Daily: Check Status Indicator for green check for Zoll AED, refer to Checking Status Indicator of Zoll Automated External Defibrillator (AED)... Verification of attendance at In-service will be evidenced by teammate's signature on the training/In-service form.
The Facility Administrator or designee will audit the emergency equipment log to verify the Zoll AED status indicator is documented as checked: Daily for two (2) weeks from 09/11/23 through 09/25/23, weekly for two (2) weeks 09/26/23 through 10/10/23, and monthly for two (2) months 10/11/23 through 12/11/23. Instances of non-compliance will be addressed immediately.
The Facility Administrator will review audit results with the Medical Director during the monthly Quality Assessment Performance Improvement meeting known as Facility Health Meeting, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
Initial Comments:
Based upon the findings of an unannounced onsite complaint survey conducted on September 7, 2023, Suburban Campus 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:
494.150(c)(2)(i) STANDARD
MD RESP-ENSURE ALL ADHERE TO P&P
Name - Component - 00
The medical director must-
(2) Ensure that-
(i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;
Observations:
Based on review of medical records (MR), agency policy, and interview with facility administrator, clinical staff failed to timely document required nursing pre-treatment patient assessments as per agency policy for six (6) of eighteen (18) records reviewed. (MRs #1-3).
Findings include:
Review conducted on September 7, 2023, between appropriately 1:00 PM and 2:30 PM, of MRs revealed:
MR#1 start of care (soc) 1/24/18, dialysis treatment (TX) report 8/28/23, TX initiated 11:22 AM, Registered Nurse (RN) documented pre-TX assessment at 12:53 PM, one (1) hour, thirty-one (31) minutes following the start of treatment.
TX report 9/4/23, TX initiated 11:22 AM, RN documented pre-TX assessment at 12:37 PM, one (1) hour, fifteen (15) minutes following the start of treatment.
MR#2 soc 8/3/23, dialysis TX report report 8/24/23, TX initiated 06:18 AM, RN documented pre-TX assessment at 7:30 AM, one (1) hour, twelve (12) minutes following the start of treatment.
MR#3 soc 11/18/23. dialysis TX report 8/25/23, TX initiated 3:53 PM, RN documented pre-TX assessment at 7:17 PM, three (3) hours, twenty-four (24) minutes minutes following the start of treatment.
TX report 8/30/23, TX initiated 3:44 PM, RN documented pre-TX assessment at 4:52 PM, one (1) hour, seven (7) minutes following the start of treatment;
TX report 9/6/23, TX initiated 3:41 PM, RN documented pre-TX assessment at 8:24 PM, five (5) hours, twenty-three (23) minutes following the start of treatment, .
Review conducted on September 7, 2023, at approximately 1:30 PM, of agency policy 1-03-08 CWOW-PRE-INTRA-POST TREATMENT DATA COLLECTION, MONITORING AND NURSING ASSESSMENT revealed: ... "2. The Nursing assessment will be performed and documented by a licensed nurse; specifically a Registered Nurse (RN) or ... a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). ... INTRADIALYTIC DATA COLLECTION/ASSESSMENT 8. The licensed nurse will round on these patients without reported abnormal findings and complete the nursing assessment within one hour of dialysis treatment initiation. "
Interview conducted on September 7, 2023, at approximately 3:00 PM, with facility administrator confirmed the above findings.
Plan of Correction:A Governing Body meeting was held on 09/27/23 with the Medical Director, Facility Administrator and Regional Operations Director to review the results of the survey ending on 09/07/23. The Governing Body reviewed Policy COMP-DD-017 "Medical Director Qualifications and Responsibilities" with the Medical Director, who acknowledges that he/she is responsible to ensure that all policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and non-physician providers. Plan of correction has been developed and initiated to correct identified deficiencies and to sustain compliance.
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/08/23. Surveyor observations were reviewed. Education included but was not limited to Policy 1-03-08 "CWOW - Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: 1) The Nursing assessment will be performed and documented by a licensed nurse; specifically a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). 2) The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. 3) The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation. Verification of attendance is evidenced by teammate's signature on the training/ in-service sheet.
The Facility Administrator or designee will conduct audits to verify the nurse assessment is completed on each patient within one (1) hour of treatment initiation: on twenty five percent (25%) of treatment records from 09/11/23 through 09/25/23: daily for two (2) weeks 09/26/23 through 10/10/23, then weekly for two (2) weeks 10/11/23 through 10/25/23. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.
The Medical Director will review progress of teammate education, results of all audits, and adherence to this plan of correction during monthly Quality Assessment Performance Improvement meetings known as the Facility Health Meeting. The Facility Administrator will report progress, as well as any barriers to maintaining compliance, with supporting documentation included in the meeting minutes. Action plans will be evaluated for effectiveness, new plans developed as applicable to achieve compliance with teammate adherence to policy and procedure. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.
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