Fkc Murrysville

“EP Testing Requirements CFR(s): §416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, “Organizations” under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility’s] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient’s home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice’s emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility’s] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility’s] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE’s response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE’s emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility’s emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID’s emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA’s response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA’s emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI’s and OPO’s] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI’s response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI’s emergency plan, as needed. This Standard is not met as evidenced by: 42178 Based on a review of the facility emergency preparedness program and an interview with facility administrator, the facility failed to conduct either a full-scale exercise that is community- based or when a community-based exercise is not accessible, an individual, facility-based exercise or a tabletop exercise that includes a group discussion that challenges an emergency plan at least annually. Findings included: A review of the facility emergency preparedness program was conducted on December 4, 2024, at approximately 12:15pm revealed no documentation of evidence that the facility participated in either a full-scale exercise that is community- based or when a community-based exercise is not accessible, an individual, facility-based exercise or a tabletop exercise that includes a group discussion that challenges an emergency plan for 2022 or 2023. An interview with the Regional Director and Center Manager on December 6, 2024, at approximately 1:30pm confirmed the above findings.”

“IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This Standard is not met as evidenced by: 42178 Based on review of facility policy, direct observation, and interview with staff (EMP), the facility failed to ensure staff emptied prime waste container for one (1) of two (2) observations and failed to fully reclined chair while cleaning for one (1) of two (2) observations for Cleaning and Disinfection of the Dialysis Station (Observation #1& #2). Findings included: Review of facility policy on December 6, 2024, at approximately 1:00pm revealed: “...Cleaning and Disinfecting the Dialysis Station ... Procedure 3. ...Place the chair in the Trendelenburg position and open side panels if chair has swing open side so all surfaces of the chair are accessible...” Observation #1 conducted on December 4, 2024, at approximately 9:55am at station #12. Patient Care Technician (PCT) failed to empty and wipe inside prime waste container. Surveyor observed approximately one inch of waste water remaining in prime waste contained from end of previous treatment and remained at start of next patient treatment. Observation #2 conducted on December 4, 2024, at approximately 10:30am at station #7. PCT failed to fully recline dialysis chair and sides of seat cushions. An interview with the Regional Director and Center Manager on December 6, 2024, at approximately 1:30pm confirmed the above findings.”

“POC-MANAGE VOLUME STATUS CFR(s): 494.90(a)(1) The plan of care must address, but not be limited to, the following: (1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient’s volume status; This Standard is not met as evidenced by: 42178 Based on a review of facility policies/procedure, medical records (MR), hemodialysis (HD) treatment records, and employee interviews, the facility failed to follow its’ policy for monitoring vital signs, reporting and/or documenting abnormal findings for three (3) of seven (7) MR reviewed (MR#3-#5, & #7). Findings included: Review of agency Policy on December 6, 2024, at approximately 1:00pm revealed: “Patient Assessment and Monitoring...Pre-Treatment...Blood Pressure, Record blood pressure. Verify: Systolic blood pressures greater than 180mm/Hg and/or diastolic blood pressures greater than 100mm/Hg, Systolic blood pressures less than or equal to 100mm/Hg systolic during treatment...During Treatment...Blood Pressure...Reposition electronic cuff or use a manual cuff for aberrant blood pressure readings. Report to nurse: Systolic blood pressures greater than 180mm/Hg, Diastolic blood pressures greater than 100mm/Hg, Blood pressures greater than or equal to 100mm/Hg systolic...Post-Treatment...Blood Pressure...Ensure vital signs and overall condition are stable or discharge...” A review of medical records took place on December 3, 2024, at approximately 1:00pm and revealed the following: MR #3, Start of Care at facility: 6/3/24, dates reviewed: 10/25/24-11/29/24. Treatment record dated 10/25/24: included blood pressure reading during treatment at 3:00pm of 201/75 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of blood pressure greater than 100mm/Hg diastolic. MR#5, Start of Care at facility: 9/18/24, dates reviewed: 11/13/24-8/27/24. Treatment record dated 11/18/24: included a blood pressure during treatment at 11:01am of 167/103 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of diastolic blood pressure greater than 100mm/Hg. Treatment record dated 11/22/24: included a blood pressure during treatment at 12:00pm of 175/102, at 12:30pm of 182/101, and at 2:53pm of 160/102 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of diastolic blood pressure greater than 100mm/Hg. MR#7, Start of Care at facility: 7/22/24, dates reviewed: 11/15/24-11/29/24. Treatment record dated 11/18/24: included a pre-treatment blood pressure reading at 6:00am of 231/111 sitting and 248/103 standing obtained by a patient care technician (PCT). Blood pressure recorded during treatment at 6:12am of 231/111, at 6:31am of 246/100, at 7:01am of 235/104, at 9:01am of 234/100 obtained by a patient care technician (PCT). No documentation of recheck or nurse notification of systolic blood pressure greater than or equal to 180mm/Hg and diastolic blood pressure greater than 100mm/Hg. An interview with the Regional Director and Center Manager on December 6, 2024, at approximately 1:30pm confirmed the above findings.”

“POC-ACHIEVE ADEQUATE CLEARANCE CFR(s): 494.90(a)(1) Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis. This Standard is not met as evidenced by: 42178 Based on a review of facility policies/procedure, medical records (MR), hemodialysis (HD) treatment records, and employee interviews, the facility failed to ensure the blood flow rate (BFR) and/or the dialysate flow rate (DFR) was administered per physician order for one (1) of five (5) incenter hemodialysis patient MRs reviewed. (MR #5). Findings included: Review of agency Policy on December 6, 2024, at approximately 1:00pm revealed: “Patient Assessment and Monitoring ... During Treatment ... Machine Parameters and Extracorporeal Circuit, Check machine settings and measurements: Check prescribed blood flow is being achieved or reason is documented in the medical record if unable to meet prescribed blood flow. Check dialysate flow rate setting is correct, and the prescribed flow is being delivered ...” A review of medical records took place on December 3, 2024, at approximately 1:00pm and revealed the following: MR#5, Start of Care at facility: 9/18/24, dates reviewed: 11/13/24-8/27/24. Order reads in part the following: Blood Flow Rate (BFR): 400mL/min; Dialysate Flow Rate (DFR): Manual 600mL/min. Special attentions included “...may +/- 50 BFR from prescribed rate...” Review of Dialysis Treatment Details Reports revealed the BFR and DFR was not administered at prescribed rates on the following dates: On 11/13/24, at 11:08am the BFR was recorded to be administered at 375mL/min. From 12:02pm to 2:32pm the BFR was recorded to be administered at 300mL/min. At 3:03pm the BFR was recorded to be administered at 250mL/min. At 3:11pm the BFR was recorded to be administered at 200mL/min. The entire treatment the DFR was administered at 500mL/min. On 11/18/24, at 12:32pm and through the remainder of treatment the BFR was recorded to be administered at 300mL/min. On 11/20/24, at 10:37am and 2:32pm the BFR was recorded to be administered at 250mL/min. At 10:57am the BFR was recorded to be administered at 325mL/min. At 11:01am, 11:39am, 1:01pm, and 1:31pm the BFR was recorded to be administered at 300mL/min. At 12:03pm, and 2:01pm the BFR was recorded to be administered at 275mL/min. At 12:32pm the BFR was recorded to be administered at 320mL/min. At 3:00pm the BFR was recorded to be administered at 200mL/min. On 11/22/24, at 1:02pm and 2:02pm the BFR was recorded to be administered at 275mL/min. At 1:32pm the BFR was recorded to be administered at 300mL/min. At 2:34pm the BFR was recorded to be administered at 200mL/min. On 11/25/24, at 11:36am through 1:21pm the BFR was recorded to be administered at 300mL/min. At 2:08pm the BFR was recorded to be administered at 280mL/min. At 2:34pm the BFR was recorded to be administered at 0mL/min. At 2:55pm the BFR was recorded to be administered at 250mL/min. On 11/27/24, from 11:03am through 2:02pm the BFR was recorded to be administered at 250mL/min. At 2:40pm the BFR was recorded to be administered at 225mL/min. There was no documentation in the medical record that the hemodialysis staff had obtained a physician order to allow the BFR to be administered at a rate different from the prescribed amount for any of the above dates and there was no documentation of a reason why the BFR was administered at a rate different from the prescribed amount for any of the above dates. An interview with the Regional Director and Center Manager on December 6, 2024, at approximately 1:30pm confirmed the above findings.”

“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: 42178 Based on a review of facility policies/procedure, medical records (MR), and employee interviews, the facility failed to follow its’ policy for managing treatment adherence for one (1) of seven (7) MR reviewed (MR#3). Findings included: Review of agency Policy on December 6, 2024, at approximately 1:00pm revealed: “Managing Treatment Adherence or Prolonged Hospitalizations or Vacation ... Managing Treatment Adherence ... Patients who are non-adherent to their treatment schedule: ... Should be referred to the Social Worker who can utilize the Root Cause Analysis and interventions Tool for Patients Not Meeting Quality Goals to assess the reason for the missed treatment and if there’s a barrier that might contribute to more misses in the future. Notify the attending nephrologist when a patient misses a scheduled treatment(s)...Complex Non-Adherence, Continues to miss regularly scheduled treatments... Routinely misses treatment and is risking health concerns or potential hospitalization... 1. Notify the attending nephrologist. 2. Schedule an interdisciplinary team meeting with the patient to discuss assessment findings and develop a plan to address barriers. Include the patient’s goals/ideas for improving adherence. 3. Re-educate the patient about the impact missed treatments has on risk of hospitalization and death. Explore feasibility of other treatment modalities, including the option of no treatment with the patient. 4. Use root cause analysis and intervention tool to determine new or additional barriers affecting the patient’s adherence. 5. Utilize Letter of Concern-English Letter of Concern-Spanish to supplement interventions and ensure proper follow-up...” A review of medical records took place on December 3, 2024, at approximately 1:00pm and revealed the following: MR #3, Start of Care at facility: 6/3/24, dates reviewed: 10/25/24-11/29/24. MR revealed patient hospitalized 11/1/24-11/19/24. Documentation revealed patient no show to treatment 11/22/24. No notification to physician of missed treatment. Documentation revealed patient no show to treatment 11/27/24. Physician rounding note dated 10/28/24 included documentation “Skips [referring to the patient] more treatments than what she makes it to...” Physician rounding note dated 11/20/24 included documentation TREATMENT ASSESSMENT... Has edema as she has been missing treatment...” Interview with Center Manager on December 6, 2024, at approximately 12:30pm revealed patient chronically misses treatments and refuses to reschedule. No documentation of an interdisciplinary team meeting with the patient to discuss assessment findings and develop a plan to address barriers or the patient’s goals/ideas for improving adherence. No documentation of re-education to the patient about the impact missed treatments has or risk of hospitalization and death. No documentation of exploration of other treatment modalities, including the option of no treatment with the patient. No documentation of root cause analysis and intervention tool to determine new or additional barriers affecting the patient’s adherence. No evidence of letter of concern to supplement interventions and ensure proper follow-up. An interview with the Regional Director and Center Manager on December 6, 2024, at approximately 1:30pm confirmed the above findings.”