Davita Sampson County Home Training

“PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO CFR(s): 494.80(d)(2) In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. This Standard is not met as evidenced by: 38766 Based on policy review, medical record reviews and staff interview, the facility staff failed to ensure a plan of care was performed within 30 days for unstable patients in 1 of 6 medical records reviewed. (Patient #3) Findings included: A review on 01/11/2024 of the facility policy titled, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” revised October 2020 revealed, “...ASSESSMENT: ...7. A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: ...At least monthly for unstable patients ...Monthly (unstable patients) - Monthly until patient is determined by interdisciplinary team to be stable...” An open medical record review on 01/11/2024 of Pt (Patient) #3 revealed a 59-year-old female was admitted to the facility for PD on 01/16/2023. The review revealed the patient was identified as unstable due to psychosocial needs on 02/23/2023 during a plan of care meeting. The review revealed no documentation was found that any monthly reassessments or revisions by the IDT was conducted to determine if the patient would remain unstable or deemed stable. An interview on 01/11/2024 at 1420 with the Regional Home Manager revealed if a patient was deemed unstable by the physician, a plan of care should be done monthly until the patient was deemed stable. The interview confirmed that the plan of care had not been performed and it was an oversight.”

“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: 38766 Based on policies and procedures, medical record review, and staff interview, the facility failed to ensure the patient plan of care was signed by all members of the IDT including the patient for 1 of 6 patient records sampled (Patient #3). Findings included: A review on 01/11/2024 of the facility policy titled, “INTERDISCIPLINARY TEAM (IDT) PATIENT ASSESSMENT AND PLAN OF CARE” revised October 2020 revealed, “...Plan of Care: ...14. The patient’s plan of care will be completed by the facility’s interdisciplinary team, including patient or personal representative and the signed by team members including the patient or the patient’s representative. If the patient chooses not to sign the plan of care, this choice will be documented on the plan of care, along with the reason the signature was not provided...” An open medical record review on 01/11/2024 of Pt (Patient) #3 revealed a 59-year-old female was admitted to the facility for PD on 01/16/2023. Review of the patient’s initial plan of care revealed a care plan meeting was held 02/02/2023. Review of the “Interdisciplinary Team Signatures” revealed that the plan of care did not include the signature of the physician, nurse, dietitian, nor the patient. An interview on 01/11/2024 at 1420 with the Regional Home Manager revealed the patient plan of care should be signed by the interdisciplinary team on the day of the plan of care meeting. The interview revealed if a team member attended the meeting remotely, the plan of care should be signed by the team member before the patient’s next clinic visit and obtain the patient’s signature during the next visit to the clinic.”