Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012505	(X3) Date Survey Completed 07/21/2022
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)

V0599

H-RECORDKEEPING SYSTEM
CFR(s): 494.100(c)(2)

(2) The dialysis facility must maintain a recordkeeping system that ensures continuity of care and patient privacy. This includes items and services furnished by durable medical equipment (DME) suppliers referred to in §414.330(a)(2) of this chapter.

This STANDARD is not met as evidenced by:
Based on review of facility policy, medical records, and interview, it was determined the facility failed to ensure the home treatment records were accurate and complete for: 1. Intraperitoneal (IP) antibiotic administration in one of one home peritoneal dialysis (PD) records reviewed with physician ordered IP antibiotics. 2. Dietician monthly progress notes in two of two home PD records. This affected Patient Identifier (PI) # 6 and PI # 7 and had the potential to negatively affect all patients who perform home PD with this facility. Findings include: Facility Policy Title: CWOW (Clinic Without Walls)-Medical Record Quality Assurance Policy:3-02-07 Revision Date: April 2021 Purpose....medical records...provide continuity of care in a cohesive and linear manner... Policy: Documentation Requirements: Nurse: 14. As needed, provides documentation related to monitoring the patient condition, events, or occurrences before, during, or after treatments as well as general status review... Dietician: 19. Dieticians are required to record patient progress notes at least monthly for patients...All progress notes and plan of care follow-up notes are...dated...signed at the time they are written or entered electronically... 1. PI # 6 was admitted to the facility 2/2/18 with End Stage Renal Disease (ESRD) and PI # 6 performed home PD seven days a week. MR review revealed a PD Encounter Note dated 6/23/22 in which the physician documented, infection comments, "will continue vancomycin one (1) gm (gram) every 5 days times (x) 4 (four) doses, if worsens may need catheter removal." Further review of the 6/23/22 PD Encounter Note documentation revealed Nutrition Alb (Albumin) 3.3 low 060622 below. Review of the Patient Note documentation dated 6/23/22 at 2:24 PM completed by the PD Registered Nurse (RN) revealed the following: "...into the clinic see Dr. (doctor)...started Vancomycin 1 gm (gram) IP x (for) 4 (four) doses. Epo (epoetin) 38,000 units given at 1:00 PM...Tolerated well." Written questions provided to the facility on 7/21/22 at 7:55 AM requested documentation that PI # 6 received Vancomycin 1 gm at the clinic or home on 6/23/22, 6/28/22, 7/3/22 and 7/8/22 and for monthly dietician progress for past 60 days. In an interview conducted on 7/21/22 at 11:26 AM, EI (Employee Identifier) # 2, Regional Home Manager, provided documentation which confirmed PI # 6 started Vancomycin on 6/27/22, which was 4 days after the 6/23/22 PD encounter and received doses on 7/2/22, on 7/7/22 and on 7/12/22. EI # 6 reported PI # 6 left the clinic on 6/23/22 before starting the IP Vancomycin. EI # 2 confirmed the documentation did not reveal a delay in implementation of the 6/23/22 physician order for peritonitis treatment. In addition, EI # 2 confirmed no monthly dietician progress note was completed for June. 2. PI # 7 was admitted to the facility 3/31/2020 with ESRD and PI # 7 performed home PD seven days a week. Record review revealed a Plan Of Care Follow Up Note dated 4/1/22 completed by the dietician which revealed the following: low albumin 3.7- no change which was less than goal of greater than equal to four (4), ONS (oral nutritional supplement) initiate/continued-tolerating supplement. Further review of the MR revealed a physician PD Encounter Note dated 5/27/22 which revealed documentation, 5/5/22-albumin 3.3 low, below. There was no monthly dietician progress note documentation for May. Written questions were provided the facility on 7/20/22 at 3:55 PM requesting monthly dietician progress documentation. An interview was conducted on 7/21/22 at 11:10 AM with EI # 2 who confirmed there was no documentation the dietician completed a monthly progress note during May 2022 which addressed the albumin decrease.