Initial Comments:
Based on the findings of an unannounced onsite Medicare recertification survey conducted January 30, 2024 through February 1, 2024, Thorn Run 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 unannounced onsite Medicare recertification survey conducted January 30, 2024 through February 1, 2024, Thorn Run 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:
494.90(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 review of facility policy, review of medical records (MR) and interview with the facility administrator, it was determined that the facility failed to assess and/or manage patient's blood pressure for one (3) three of five (5) hemodialysis patients reviewed (MR1, MR4, and MR6).
Findings include:
Review of facility policy completed on 2/1/24 at approximately 3:00 p.m. revealed: TITLE: Pre-intra-post Treatment Data Collection, Monitoring and Nursing Assessment. POLICY: ...Intradialytic Data Collection Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the patient care technician (PCT) or licensed nurse include: a. Vital signs and treatment monitoring, i For non-nocturnal treatments is completed at least every thirty (30) minutes ...b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures ...
Review of MR completed on 2/1/24 between approximately 10:00 a.m. and 12:00 p.m. revealed:
MR1- Admission date 10/30/19. Treatment sheets reviewed dated between 1/6/24- 1/30/24.
Treatment sheet dated 1/23/24 revealed patient was assessed at 12:03 p.m. Patient was not assessed again until 1:03 p.m. (60 minutes between assessments).
MR4- Admission date 11/8/22. Treatment sheets reviewed dated between 12/31/23-1/26/24.
Treatment sheet dated 1/10/24 revealed patient was assessed at 8:31 a.m. Patient was not assessed again until 9:31 a.m. (60 minutes between assessments).
MR6- Admission date 4/2/21. Treatment sheets reviewed dated between 1/12/24-1/29/24.
Treatment sheet dated 1/29/24 revealed patient was assessed at 10:33 a.m. Patient was not assessed again until 11:34 a.m. (61 minutes between assessments).
Interview completed on 2/1/24 at approximately 3:10 p.m. with the facility administrator confirmed the above findings.
Plan of Correction:The Facility Administrator or designee will hold mandatory in-services for all clinical teammates starting 02/26/24 to ensure all teammates are in attendance. Surveyor observations will be reviewed. Education will include but not be limited to a review of Policy 1-03-08 "Pre- Intra- Post treatment Data Collection Monitoring and Nursing Assessment" with emphasis on but not limited to: 1) Intra dialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes vital signs and treatment monitoring at least every 30 minutes. 2) ...b. At a minimum, obtain and document the following: i. Blood pressure; ii. Heart or pulse rate; iii. Blood and dialysate flows, arterial and venous pressures. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct treatment records audits to verify timely documentation of vital signs every thirty (30) minutes: on twenty five percent (25%) of the treatment records daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment 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.
494.90(a)(1) STANDARD
POC-ACHIEVE ADEQUATE CLEARANCE
Name - Component - 00
Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.
Observations:
Based on review of facility policy, review of medical records (MR) and interview with the facility administrator, it was determined that the facility failed to ensure blood flow rate (BFR) and/or dialysate flow rate (DFR) were delivered in accordance with the dialysis prescriptions ordered by the physician for two (2) of five (5) MRs reviewed (MR4 and MR6).
Findings include:
Review of facility policy completed on 2/1/24 at approximately 3:00 p.m. revealed: TITLE: Pre-intra-post Treatment Data Collection, Monitoring and Nursing Assessment. POLICY: ...Intradialytic Data Collection Assessment ...9. Intradialytic treatment monitoring and data collection which may be performed by the patient care technician (PCT) or licensed nurse include: a. Vital signs and treatment monitoring, i. For non-nocturnal treatments is completed at least every thirty (30) minutes ...b. At a minimum, obtain and document the following: i. Blood pressure ii. Heart or pulse rate iii. Blood and dialysate flows, arterial and venous pressures ...
Review of MR completed on 2/1/24 between approximately 10:00 a.m. and 12:00 p.m. revealed:
MR4-Admission date 11/8/22. Review of treatment sheets dated between 12/31/23-1/26/24. Review of patient orders dated 12/29/22: blood flow rate (BFR) 350 and dialysate flow rate (DFR) 800.
Treatment sheet dated- 1/12/24 DFR ran at 500 the entire treatment time.
Review of treatment sheets dated between 12/31/23-1/26/24. Review of patient orders dated 1/12/24 blood flow rate (BFR) 350 and dialysate flow rate (DFR) 800.
Treatment sheet dated- 1/12/24 DFR ran at 500 the entire treatment time.
MR6- Admission date 4/2/21. Review of treatment sheets dated between 1/12/24-1/29/24. Review of patient orders dated 12/18/23: blood flow rate (BFR) 450, dialysate flow rate (DFR) 600.
Treatment sheet dated-1/15/24 BFR ran at 400 the entire treatment time.
Interview completed on 2/1/24 at approximately 3:10 p.m. with the Facility administrator confirmed the above findings.
Plan of Correction:The Facility Administrator or designee will hold mandatory in-services for all clinical teammates starting 02/26/24 to ensure all teammates are in attendance. Surveyor observations will be reviewed. Education will include but not be limited to a review of Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: 1) Patient identity, prescription and machine settings are verified by teammates prior to initiation of treatment. Prescription components include but are not necessarily limited to ... Blood Flow rate, Dialysate flow rate ... 2) If the dialysis prescription is not being met [including dialysis flow rate or change to/inability to obtain prescribed blood flow rate] the reason will be documented and the licensed nurse informed. 3) Abnormal findings or findings outside of any patient specific physician ordered parameters will 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. 4) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 5) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct audits to verify teammate documentation of abnormal findings, notification given to the licensed nurse, and the appropriate response by the nurse to the findings: on twenty five percent (25%) of the flow sheets daily for two (2) weeks then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment 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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