Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 012505 (X3) Date Survey Completed 07/26/2018
Name of Provider or Supplier Physicians Choice Dialysis-Montgomery Street Address, City, State 1001 Forest Avenue, Montgomery, AL
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
V0544 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:
Based on the observation, review of medical records, facility policies and interviews, it was determined the facility failed to ensure staff: 1) Followed physician orders for BFR (blood flow rate). 2) Completed AMA (Against Medical Advice) forms for all dialysis treatments ending prior to physician ordered time. This affected 1 of 6 in-center hemodialysis patient records reviewed, including Patient Identifier (PI) # 6 and had the potential to negatively affect all patients who receive in-center hemodialysis treatments at this facility. Findings include: Facility Policy Title: Refusal of Care / Treatment Against Medical Advice Policy: 1-01-10 Purpose: To provide requirements for teammates to follow when a patient refuses care or treatment against medical advice. Policy: ... B. Completion of the Refusal of Care / Treatment Against Medical Advice Form 1. The RN (Registered Nurse) will verify that a patient signs the 1-01-01A Refusal of Care / Against Medical Advice form 0417 form if a patient: Refuses their entire dialysis treatment... ... 3. The RN will obtain the patient's signature on the Refusal of Care / Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient's signature prior to rinse-back, the RN will obtain the patient's signature on the form prior to the patient's departure from the facility. 4. The RN must countersign all Refusal of Care / Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 5. If the patient refuses to sign the Refusal of Care / Treatment Against Medical Advice form, the RN will document the patient's refusal with the words " patient refused" in the patient signature box along with the date. Under such circumstances, the RN will sign the form and will also obtain a witness' signature on the form... Facility Policy Title: Shortened / Early Termination of Treatment or Extended Treatment Policy: 1-01-09 Purpose: To provide requirements for teammates to follow when a patient's treatment is terminated early or extended... ... B. Shortened / Early Termination of Treatment 1. If shortened / early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient's attending nephrologist to discuss appropriate intervention (if any), including what additional medical orders may be necessary to address the patient's specific needs. NOTE: Shortened / Early Termination of the dialysis treatment included all reasons the prescribed dialysis time is not met by 30 or more minutes. This includes but is not limited to: the late initiation of treatment with termination at scheduled time, early termination at the end of treatment and interruptions of dialysis during the treatment i.e. machine or access problems or use of the bathroom by the patient... 3. If a patient's treatment is shortened / early terminated, the RN will document the event in the patient's medical record. Documentation will include, as appropriate: The amount of time by which the treatment was shortened; A description of why the treatment was shortened; Whether the patient's nephrologist was notified; A description of the follow-up medical orders provided by the patient's attending nephrologist (if any); A description of all other interventions planned to address the shortened treatment, including recommendations to the patient; and A copy of the Early Termination of Treatment Against Medical Advice form signed by the patient, if shortened voluntarily by patient... 4. Additionally, if the patients dialysis is terminated 30 or more minutes prior to the ordered treatment length, the reason and corresponding sub-reason must be documented in ChairSide Snappy or in Snappy while reconciling or late reconciling the treatment times... 5. The facility's FA (Facility Administrator) will verify that all shortened treatments are recorded and trended, and the FA shall verify that such records are reviewed and discussed at the Facility Health Meetings, (FHM) as appropriate... Medical Record Review: 1. PI # 6 was admitted to the facility on 7/7/14 with End Stage Renal Disease (ESRD) and was receiving in-center hemodialysis treatments three times a week. Review of the Hemo Treatment Orders dated 5/15/18 revealed the patient's treatment time was 225 minutes. Review of the Post Treatment Flowsheet dated 6/22/18 revealed the patient's treatment was 140 minutes, which was 85 minutes shortened. Further review of the Post Treatment Flowsheet dated 6/22/18 revealed, "... Patient rides with (ambulance name) and was 2 hours late for treatment..." There was no documentation of an Early Termination Against Medical Advice form, nor was there documentation the patient's attending nephrologist was notified of the shortened treatment. Review of the Post Treatment Flowsheet dated 6/25/18 revealed the patient's treatment was 194 minutes, which was 31 minutes shortened. Further review of the Post Treatment Flowsheet dated 6/25/18 revealed, "... Patient arrived late for treatment..." There was no documentation of an Early Termination Against Medical Advice form, nor was there documentation the patient's attending nephrologist was notified of the shortened treatment. An interview was conducted on 7/26/18 at 11:35 AM with Employee Identified (EI) # 1, Facility Administrator, who verified the above.