Fkc Rehoboth

“PE-EQUIPMENT MAINTENANCE-MANUFACTURER’S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer’s recommendations. This Standard is not met as evidenced by: 22676 Based on review of glucometer logs, interview, review of glucometer policy, and manufacturer’s instructions, the facility failed to ensure the glucometer was in the control range and follow manufacturer’s instructions for one of one glucometer used in the facility. This deficient practice had the potential to provide incorrect blood glucose results and could result in inaccurate glucose level results to all 67 patients receiving care at the facility. Findings include: Review of electronic “Blood Glucose Logs” for the Isolation station and the treatment unit, from 12/01/23 through 01/31/24 revealed the following: Review of the meter for the treatment unit labeled “Meter v2 58013” for December revealed: On 12/18/23, the recorded acceptable low control range was 92-124, the recorded low control was 127. On 12/22/23, the recorded acceptable low control range was 92-124, the recorded low control was 138. Review of “Meter v2 58013” for January revealed: On 01/17/24, the acceptable control was 92-124, the recorded control was documented as being 175. On 01/20/24, the acceptable control was 92-124, the recorded control was documented as being 127. On 01/24/24, the acceptable control was 92-124, the recorded control was documented as being 126. During an interview on 02/13/24 at 1:15 PM, Biomedical Technician confirmed the findings and agreed the staff did not repeat the low-level and high-level control as required by the manufacturer’s instruction. Review of the facility’s policy titled, “Blood Glucose Monitoring Device,” dated 11/06/23, revealed, under “Policy Training” section revealed, “Calibration and control testing shall be performed each operating day ...” Review of the “Embrace Pro” blood glucose monitoring system manufactures instruction revision date 09/2020 revealed, “... if the test fall outside the range printed on the test strip vial, repeat the test ...””

“PA-APPROPRIATENESS OF DIALYSIS RX CFR(s): 494.80(a)(2) The patient’s comprehensive assessment must include, but is not limited to, the following: (2) Evaluation of the appropriateness of the dialysis prescription, This Standard is not met as evidenced by: 22676 Based on record reviews, interview, and policy review, the facility failed to follow the individualized dialysis (an artificial means of kidney function that removes the waste and excess fluid from the blood by passing through a filter) prescription as determined by the medical provider for 5 of 7 sampled in-center patients (Patient (P) 1, P2, P4, P6, and P7). Failure to follow the medical providers’ dialysis prescription has the potential to negatively impact the effectiveness of the prescribed dialysis treatments for the all 67 patients receiving in-center dialysis treatments at this facility. Findings include: 1. Review of P1s electronic medical record (EMR) revealed a prescribed dialysate flow rate (DFR) of 800 milliliters per minute (ml/min). Review of one of six “Post Treatment” flowsheets from 01/30/24 through 02/10/24 in the EMR indicated the following: On 02/10/2024, the DFR was documented at 500 ml/min from 12:01 PM through the end of treatment at 2:10 PM. There was no documented rationale for the change to the prescribed DFR. 2. Review of P2s EMR revealed a prescribed DFR of 600 ml/min. Review of one of six “Post Treatment” flowsheets from 01/31/24 through 02/12/24, in the EMR indicated the following: On 02/05/24, the DFR was documented at 500 ml/min from 7:09 AM through the end of treatment at 11:15 AM. There was no documented rationale for the change to the prescribed DFR. 3. Review of P4s EMR revealed a prescribed DFR of 500 ml/min. Review of two of six “Post Treatment” flowsheets from 01/29/24 through 02/09/24, in the EMR indicated the following: On 01/31/24, the DFR was documented at 800 ml/min from 3:40 PM through the end of treatment at 7:32 PM. On 02/07/24, the DFR was documented at 800 ml/min from 11:35 AM through 1:32 PM. There was no documented rationale for the change to the prescribed DFR. 4. Review of P6s EMR revealed a prescribed DFR of 800 ml/min. Review of one of six “Post Treatment” flowsheets from 01/29/24 through 02/09/24, in the EMR indicated the following: On 01/31/24, the DFR was documented at 500 ml/min from 11:39 AM through the end of treatment at 2:43 PM. There was no documented rationale for the change to the prescribed DFR. 5. Review of P7s EMR revealed a prescribed Blood flow rate (BFR) of 450 ml/min. Review of two of six “Post Treatment” flowsheets from 01/29/24 through 02/09/24, in the EMR indicated the following: On 01/31/24, the BFR was documented at 400 ml/min from 2:01 PM through the end of treatment at 6:32 PM. On 02/05/24, the BFR was documented at 400 ml/min from 2:19 PM through the end of treatment at 7:38 PM. There was no documented rationale for the change to the prescribed DFR. During an interview on 02/13/24 at 10:15 AM, the Administrator and Clinic Manager 2, confirmed the above findings and confirmed that staff did not follow the facility’s policy. Review of the facility’s policy titled, “Patient Assessment and Monitoring,” dated 05/01/23, revealed, “Check the prescribed blood flow rate is being achieved or the reason is documented in the medical record if unable to meet prescribed flow rate. Check dialysate flow rate setting is correct, and the correct prescribed flow is being ...””

“POC-COMPLETED/SIGNED BY IDT & PT CFR(s): 494.90(b)(1) The patient’s plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient’s designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided. This Standard is not met as evidenced by: 22676 Based on record review, interviews, and review of the facility’s policy, the facility failed to ensure that 4 of 7 patients (Patient (P) 1, P2, P5, and P6) reviewed, participated in the plan of care (POC), or received the information within a timely manner. Failure to ensure the patients reviewed the POC and understand the goals set has the potential to negatively impact the effectiveness of the dialysis treatments for the 67 patients receiving dialysis treatments at this facility. Findings include: 1. Review of P1’s annual POC, in the electronic medical record (EMR) under the “Plan of Care” section, dated 01/15/23, revealed the facility failed to ensure the patients were provided the POC information in a timely manner. As of 02/14/24 the POC form was not signed by the patient and there was no documentation that the information had been provided to the patient. 2. Review of P2’s 30-day POC, in the EMR under the “Plan of Care” section, dated 11/14/23, revealed the facility failed to document evidence P2 was provided the POC information until 12/06/23. 3. Review of P5’s annual POC in the EMR under the “Plan of Care” section, dated 10/25/23 revealed there was no evidence documented the POC information was provided to P5 until 12/09/23. 4. Review of P6’s annual POC in the EMR under the “Plan of Care” section, dated 09/12/23 revealed, there was no evidence documented the POC information was provided to P5 until 10/13/23. During an interview on 02/13/24 at 10:15 AM, the Administrator 2 and Clinic Manager 3 confirmed the facility failed to show the POC information was provided to the patients in a timely manner for P1 P2, P5, and P6. Review of the facility’s form titled, “Comprehensive Interdisciplinary Assessment and Plan of Care” stated “ ...the form required a patient signature and date when the plan was reviewed, and the patient understood the plan...” Review of the facility’s policy titled, “Comprehensive Interdisciplinary Assessment and Plan of Care,” dated 7/03/23, indicated, “. . .An interdisciplinary Comprehensive Assessment and Plan of care must be completed by the interdisciplinary team members, per the frequency outlined in the Condition for Coverage ...The patient’s plan of care will be signed by all members of the IDT (sic) (Interdisciplinary Team).””