Greenfield Hs - Eastpointe

“Policies/Procedures for Sheltering in Place CFR(s): §403.748(b)(4), §416.54(b)(3), §418.113(b)(6)(i), §441.184(b)(4), §460.84(b)(5), §482.15(b)(4), §483.73(b)(4), §483.475(b)(4), §485.68(b)(2), §485.542(b)(4), §485.625(b)(4), §485.727(b)(2), §485.920(b)(3), §491.12(b)(2), §494.62(b)(3). (b) Policies and procedures. The [facilities] 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 [annually for LTC facilities]. At a minimum, the policies and procedures must address the following:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice. This Standard is not met as evidenced by: 22960 Based upon interview and record review, the facility failed to develop a plan demonstrating a means to shelter in place for patients and staff who may remain in the facility in the event of an emergency, potentially effecting 24 patients receiving hemodialysis treatment and the staff, resulting in an increased potential for harm. Findings include: On 02/21/24 at 11:00 AM, the surveyor requested all policies and procedures regarding emergency preparedness for dialysis treatment and its response to an emergency from Clinical Manager “A”. On 02/21/24 at 11:45 AM, record review of the Emergency Preparedness binder revealed that policies and procedures for sheltering in place in the event of an emergency were not present in the binder. On 02/21/24 at 12:10 PM, when queried about a policy/procedure for sheltering in place, Biotech Leader “D” stated the facility did not have a policy specific to this.”

“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: 22960 Based on on observation, interview, and record review, the facility failed to repair 3 non-functional backflow prevention devices in a timely manner, resulting in the increased potential for contamination of the water supply. Findings include: On 2/21/24 at 10:30 AM, during an observation of the facility’s water treatment room with Biotech Staff “C”, there were 2, Watts 919 backflow prevention devices for the water supply to the Reverse Osmosis (RO) system that were observed with red tags which both noted “failed.” In addition, the Febco 850 backflow prevention device for the water supply to the fire suppression system was also observed to have a red tag that noted, “failed”. When queried, Biotech Staff “C” confirmed that the devices had been tested on 10/2023 and had failed testing. Biotech Staff “C” stated Biotech Leader “D” would have more information regarding the status of replacement/repair for these faulty backflow devices. On 2/21/24 at 11:00 AM, Biotech Leader “D” stated that a quote for repair/replacement for the backflow devices had been obtained on 10/27/23. Biotech Leader “D” stated that they needed to obtain 2 quotes before any work could be completed. Biotech Leader “D” stated that the facility was still waiting on a written quote from a second company. On 2/21/24 at 4:41 PM, a second quote from repair company was provided. The second quote for replacement/repair of the faulty backflow devices was dated 2/21/24.”

“MD RESP-ENSURE ALL ADHERE TO P&P CFR(s): 494.150(c)(2)(i) 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; This Standard is not met as evidenced by: 45246 Based on observation, interview and record review, the facility’s medical director failed to ensure staff adhered to policy and procedure regarding 1) blood flow rates and/or dialysate flow rates running as prescribed by the physician for 3 (P-1, 2, and 3) of 7 in-center patients reviewed and 2) post-treatment nursing assessments are performed and documented after dialysis treatment for 4 (P-1, 2, 3, and 4) of 7 in-center patients reviewed, resulting in the potential for adverse patient outcomes. Findings include: Interview with Staff J, Registered nurse, was conducted on 2/22/24 at 0950 regarding patients’ treatment orders. Staff J explained that each patient has personalized dialysis treatment orders that prescribed by practitioner. There are standard orders and unique orders that indicate a range for BFR (blood flow rate) and DFR (dialysate flow rate). Nurse explained that any rate outside those parameters has to be confirmed with practitioner and reflect patient’s physical condition during treatment. On 02/21/24 at 1600 during review of records for 4 patients of 7 randomly sampled patients revealed the following documentation. P-1’s treatment orders dated 01/06/24 indicated: duration- 195 min, BFR (blood flow rate)- 450, DFR (dialysate flow rate)- 800. Unique orders dated 9/02/23 had the following: BFR range from 350 to 450, DFR 2x (twice) BFR to 800 max. P-1’s treatment dated 02/08/24 started at 0532 and was done at 0854. At 0532 BFR was recorded 0 (zero) and DFR was 300. At 0601 BFR was changed to 150 and DFR was changed to 500. At 0631 BFR was changed to 450 and DFR to 800. No nursing progress/treatment note was found with explanation of BFR and DFR being outside the provider’s order and no record of provider’s notification was found for that treatment day. On 2/10/24 treatment flowsheet for P-1 indicated dialysis began at 0535 and was done at 0856. At 0535 BFR was documented as 0 (zero), DFR as 300. At 0544 BFR was changed to 450 and DFR to 800. No nursing progress/treatment note was found with explanation of BFR and DFR being outside the provider’s order and no record of provider’s notification was found for that treatment day. On 2/13/24 treatment flowsheet for P-1 indicated dialysis began at 0527 and was done at 0851. At 0527 BFR was documented as 450, DFR as 300. At 0531 BFR was changed to 0 (zero) and DFR continued at 300. At 0601 BFR was changed to 350 and DFR to 700. No nursing progress/treatment note was found with explanation of BFR and DFR being outside the provider’s order and no record of provider’s notification was found for that treatment day. Review of P-2 treatment flowsheets revealed the following documentation. Treatment dated 02/01/24: treatment order- BFR 450, DFR -800, duration 210 minutes. Unique orders were documented as: BFR range from 350 to 450, DFR 2x BFR to 800 max. Treatment was initiated at 1052 and completed at 1425. At 1052 BFR was documented as 0 (zero) and DFR at 500. At 1101 BFR was changed to 450 and DFR to 800. No nursing progress/treatment note was found with explanation of BFR and DFR being outside the provider’s order and no record of provider’s notification was found for that treatment day. Review of P-3 treatment flowsheets revealed the following. Treatment dated 02/09/24: treatment order- BFR 500, DFR -800, duration 210 minutes. Unique orders were documented as: BFR range from 350 to 500, DFR 2x BFR to 800 max. Treatment was initiated at 0936 and completed at 1309. At 0936 BFR was documented as 0 (zero) and DFR at 300. At 0959 BFR was changed to 500 and DFR to 800. Treatment dated 02/12/24: treatment order- BFR 500, DFR -800, duration 210 minutes. Unique orders were documented as: BFR range from 350 to 500, DFR 2x BFR to 800 max. Treatment was initiated at 0924 and completed at 1258. At 0924 BFR was documented as 305 and DFR at 600. At 0946 BFR was changed to 500 and DFR to 800. No nursing progress/treatment notes were found for both treatment days with explanation of BFR and DFR being outside the provider’s order and no notification of the provider was found on record. On 2/22/24 at 1325 interview with Clinical Manager Staff A was conducted. During interview Staff A stated that nursing staff follows prescribed treatment orders and has to notify provider if BFR or DFR are outside prescribed range. She also indicated that BFR set at 0 (zero) is puzzling to see in patient’s record. On 2/21/24 at 1630 further review of patients’ records revealed the following documentation. Treatment flowsheet for P-1 dated 02/13/24 revealed dialysis treatment was started at 0527 and completed at 0851. Nursing post-treatment assessment was documented as done at 0836 (prior to treatment completion). Treatment flowsheet for P-1 dated 02/15/24 revealed dialysis treatment was started at 0529 and completed at 0853. Nursing post-treatment assessment was documented as done at 0832 (prior to treatment completion). Treatment flowsheet for P-1 dated 02/17/24 revealed dialysis treatment was started at 0530 and completed at 0843. Nursing post-treatment assessment was documented as done at 0828 (prior to treatment completion). Treatment flowsheet for P-1 dated 02/20/24 revealed dialysis treatment was started at 0525 and completed at 0843. Nursing post-treatment assessment was documented as done at 0751 (52 minutes prior to treatment completion). Review of the P-2’s treatment sheet dated 02/20/24 had dialysis treatment start documented at 1024 and completion of treatment at 1359. Nursing post-treatment assessment was documented as done at 1355. P-3’s treatment sheet dated 02/12/24 revealed dialysis treatment was started at 0924 and completed at 1258. Nursing post-treatment assessment was documented as done at 1227 (prior to treatment completion). P-3’s treatment sheet dated 02/16/24 revealed dialysis treatment was started at 0941 and completed at 1316. Nursing post-treatment assessment was documented as done at 1250 (prior to treatment completion). P-3’s treatment sheet dated 02/19/24 revealed dialysis treatment was started at 0918 and completed at 1256. Nursing post-treatment assessment was documented as done at 1228 (prior to treatment completion). Furthermore, Review of the P-4’s treatment sheet dated 02/16/24 had dialysis treatment start documented at 1036 and completion of treatment at 1421. Nursing post-treatment assessment was documented as done at 1350 (31 minutes prior to treatment completion). On 2/23/24 at 10am during interview with facility’s Medical Director, Staff I, he confirmed that staff need to adhere to facility’s policies and procedures and follow providers’ orders for patients’ treatments. Also, nursing post-treatment assessment has be completed after dialysis treatment is done. Facility’s Policy for Patient monitoring was requested and reviewed on 2/22/24. Patient Monitoring Guidelines approved 12/08 and revised 05/18/23 indicated: Changes in treatment status and/or adverse side effects are continually monitored/assessed, communicated and documented in a timely fashion. Interventions and responses are recorded as necessary. Interventions may include but are not limited to adjustment of blood flow based on arterial and venous pressures, ultrafiltration rate, adjustment of needle placement, and initiation of sodium modeling/variation when applicable. The appropriateness of the intervention will directly affect the patient’s outcome and is based on a thorough assessment, which assures that the main goals of patient safety and adequacy of dialysis are achieved. The attending physician or designee is notified of any unusual problems in a timely manner. Post-dialysis monitoring is conducted to evaluate the patient’s response to therapy and effectiveness in achieving planned goals. The data is documented in the post-dialysis note areas of the hemodialysis flowsheet. A patient assessment is performed post-treatment based on collected data, patient complaints, and/or observations.”