Fmc Birmingham Home

“H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ’ s medical record. This Standard is not met as evidenced by: 50873 Based on record review, interview, and facility policy review, the facility failed to demonstrate retrieval and review of self-monitoring data for 1 (Patient #4) of 15 sampled patients. Findings included: A facility policy titled, “Home Therapies Patient Non-Adherence,” dated 11/04/2024, indicated, “Patient adherence to the prescribed home dialysis treatment plan will be reviewed as part of the IDT [Interdisciplinary Team] clinical assessment and should include evaluation of the patient’s demonstrated behaviors in the following components: - Completing the prescribed frequency and duration of dialysis treatments. - Submitting complete and accurate documentation of dialysis treatments.” The policy also stated, “When simple non-adherence is identified, IDT member(s) shall engage the patient (and care partner as applicable) to discuss the identified concern(s) with actions that include: - Reviewing the importance of adherence and any potential safety implications” and “- Providing education, focused interventions, counseling, or additional support, as needed.” The policy revealed the section titled, “Documentation,” indicated, “Discussions, interventions, and actions implemented to address treatment related non-adherence shall be documented in the patient’s medical record.” Patient #4’s “KNX [an electronic health record application used by the clinic] Treatment Summary: PD [peritoneal dialysis]” for the timeframe from 10/01/2025 through 10/31/2025 revealed an order dated 07/25/2025 for continuous cycling PD seven times a week. The treatment summary revealed treatment data including dates, times, and ultrafiltration volume. Further review revealed no data was documented for the patient’s blood pressure, heart rate, or weight for each treatment. A printed copy of Patient #4’s “KNX Treatment Summary: PD” for the timeframe from 10/01/2025 through 10/31/2025 was located in the patient’s paper medical record. The copy revealed a handwritten note that indicated the patient stated they completed all treatments and that the doctor was made aware. The copy revealed there was no evidence staff made efforts to obtain treatment data including blood pressure, weights, or heart rates or of educating the patient to submit them to the clinic. Patient #4’s “KNX Treatment Summary: PD” for the timeframe from 11/01/2025 through 11/30/2025 revealed an order dated 07/25/2025 for continuous cycling PD seven times a week. The treatment summary revealed treatment data including dates, times, and ultrafiltration volume. Further review revealed no data was documented for the patient’s blood pressure, heart rate, or weight for each treatment. A printed copy of Patient #4’s “KNX Treatment Summary: PD” for the timeframe from 11/01/2025 through 11/30/2025 was located in the patient’s paper medical record. The copy revealed a handwritten note that indicated the patient did not bring in a flowsheet. The copy revealed no documentation that staff made efforts to obtain the flowsheets or provided reeducation to the patient. On 01/16/2026 at 11:58 AM, Registered Nurse (RN) #8 stated that Patient #4 kept their treatment information in a binder but failed to bring their binder in (to the clinic). RN #8 stated that during the patient’s visit to the clinic that week, the patient informed her that they had lost their binder. RN #8 stated she was unsure if she put a note in (the patient’s medical record) regarding the lost binder but admitted she should have. On 01/16/2026 at 4:10 PM, the Clinic Manager confirmed there was missing treatment data including vital signs and weights for Patient #4. The Clinic Manger stated that there was no evidence that the missing information was being addressed by the RN. The Clinic Manger stated the facility expectation was that there would be evidence of the RN making attempts to collect the information from the patient.”

“QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This Standard is not met as evidenced by: 50873 Based on interview, facility document review, and facility policy review, the facility failed to analyze data for all required benchmarks and potentially contributing factors in their Quality Assessment and Performance Improvement (QAPI) program. This deficient practice had the potential to affect all patients who received care at the facility. Findings included: A facility policy titled, “Quality Assessment and Performance Improvement [QAPI] Program,” dated 11/04/2024, indicated, “An effective and successful review of the QAPI meeting and program activities will include: - Analysis of the QAPI trending tools.” A facility document titled “Trends: Crude Mortality Rate” for the timeframe from December 2024 through November 2025 revealed a total of 21 patient deaths. The document revealed potential contributing factors were documented and included that 18 of the 21 patient deaths had a hospital stay in the 30 days prior to death. The document revealed there was no evidence of mortality analysis, other than review of individual patient deaths. The document revealed there was no evidence of analysis of potential contributing factors for mortality. On 01/16/2026 at 9:00 AM, the Clinic Manager (CM) confirmed that the facility failed to analyze potential contributing factors related to mortality and to identify any trends for mortality. The CM stated that the 18 out of 21 patients having hospitalizations 30 days prior to death could be a potential trend. The CM stated that QAPI review of mortality included in depth review of each individual death but did not include a review comparing deaths and potential contributing factors.”