UPMC Children’s Hospital of Pittsburgh

“PA-FREQUENCY REASSESSMENT-STABLE 1X/YR CFR(s): 494.80(d)(1) 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- (1) At least annually for stable patients; This Standard is not met as evidenced by: 38039 Based on review of medical records (MR), review of facility documentation and interview with the Ambulatory Manager the facility failed to ensure an annual comprehensive assessment was completed for one (1) of four (4) medical records reviewed (MR3). Findings include: MR3- admit date: 4/8/21 contained documentation of an annual comprehensive assessment completed 7/2022. No documentation within MR3 of an annual assessment being completed for 7/2023. An interview with the Ambulatory Manager and the Director of Nursing on 2/7/24 at approximately 4:00 p.m. confirmed the above findings.”

“H-TRAIN CONTENT INCLUDES ER PREP HOME PTS CFR(s): 494.100(a)(3) The training must- (3) Be conducted for each home dialysis patient and address the specific needs of the patient, in the following areas: (i) The nature and management of ESRD. (ii) The full range of techniques associated with the treatment modality selected, including effective use of dialysis supplies and equipment in achieving and delivering the physician’s prescription of Kt/V or URR, and effective administration of erythropoiesis-stimulating agent(s) (if prescribed) to achieve and maintain a target level hemoglobin or hematocrit as written in patient’s plan of care. (iii) How to detect, report, and manage potential dialysis complications, including water treatment problems. (iv) Availability of support resources and how to access and use resources. (v) How to self-monitor health status and record and report health status information. (vi) How to handle medical and non-medical emergencies. (vii) Infection control precautions. (viii) Proper waste storage and disposal procedures. This Standard is not met as evidenced by: 46886 Based on medical record reviews (MR), facility documents, and employee interviews, the facility did not ensure that training for home therapies included information on how to self-monitor health status and report health status information for one (1) out of four (4) medical records reviewed. (MR4) Findings include: A review of facility document titled “ Your Personal Peritoneal Dialysis Training Manual “ on 2/7/24 revealed, “ [Page 24] Blood Pressure ...The physician will give you specific guidelines to follow for your child. The physician will tell you what your child ’ s normal vital signs should be. Notify the Dialysis Unit if your child ’ s vital signs are out of their acceptable range. ... “ A review of patient teaching material on 2/7/24 revealed, “ Vital Signs ...Blood Pressure ...Normal Blood Pressure ...Adolescents ...[systolic]94-140 ...[diastolic] 62-88... The physician will give you specific guidelines to follow for your child. Many times the blood pressure medication is adjusted based on your child ’ s blood pressure ... “ A review of medical records (MR 1 - 4) was conducted on 2/7/24. MR4 adolescent. Admission: 11/1/22, Peritoneal Dialysis (PD) patient. Facility documentation titled, Homechoice Claria Prescribed ...Report, with treatment dates between 7/17/23 - 8/15/23 listed the following abnormal blood pressures (BP): 7/25/23: BP 150/116. Systolic and Diastolic BP were above normal range for adolescent. 8/7/23: BP 88/70. Systolic BP was below normal range for adolescent. 8/9/23: BP 93/43. Systolic BP and Diastolic BP were below normal range for adolescent. During an interview on 2/7/24 with (EMP6) Home PD nurse and (EMP1) Ambulatory Manager, the abnormal blood pressures were reviewed and it was determined that no specific BP reporting guidelines for MR4 were in place. Also unable to be determined if the patient/caregiver reported the abnormal blood pressures to the facility staff. The findings were reviewed with EMP1 (Ambulatory Manager) and EMP3 (Director of Nursing) during an exit interview on 2/7/24 at approximately 4:00 pm.”