Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012509	(X3) Date Survey Completed 03/30/2023
Name of Provider or Supplier North Alabama Nephrology Center	Street Address, City, State 1311 North Memorial Parkway #200, Huntsville, 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)

V0559

POC-OUTCOME NOT ACHIEVED-ADJUST POC
CFR(s): 494.90(b)(3)

If the expected outcome is not achieved, the interdisciplinary team must adjust the patient's plan of care to achieve the specified goals. When a patient is unable to achieve the desired outcomes, the team must- (i) Adjust the plan of care to reflect the patient's current condition; (ii) Document in the record the reasons why the patient was unable to achieve the goals; and (iii) Implement plan of care changes to address the issues identified in paragraph (b)(3)(ii) of this section.

This STANDARD is not met as evidenced by:
Based on review of the medical record (MR), the facility policy, and staff interviews, it was determined the IDT (Interdisciplinary Team) failed to ensure staff followed the facility policy for managing missed treatments due to non-adherence. This affected PI (Patient Identifier) # 4, in one of one record reviews with continued treatment non-adherence. Findings include: Facility Policy Title: Managing Missed Treatments due to Non-Adherence or Prolonged Hospitalization or Vacation Published: 07/05/2022 Reference Number: 45116 Version: 3 Purpose To provide guidance on managing missed treatments for patients who: Miss their scheduled treatment(s) without rescheduling... Non-Adherent to Treatment Schedule ...Patients who are non-adherent to their treatment schedule: May not be involuntarily discharged or removed from the regular schedule. Should be referred to the Social Worker (SW) for assessment of their psychosocial status and identification of root cause affecting adherence. ...2a. If the patient is located, offer to reschedule the missed treatment if a slot is available. 2b. If staff is unable to reach the patient or their emergency contact, notify the...nephrologist...inquire... if... the patient was admitted to the hospital. Staff may also...attempt to locate the patient and determine if they are safe...Check nearby hospitals...Contact the police to request...to go by the patient's home to check on the patient. 3. Document the missed treatment and all actions taken to locate the patient... 4. Refer the patient to the SW who can utilize the Root Cause Analysis (RCA) and Intervention Tool (IT) for Patients Not Meeting Quality Goals to assess reason for missed treatment and if there's a barrier that might contribute to more misses in the future. 5, SW reports assessment findings to Clinical Manager to determine a plan for preventing future missed treatments. Consult or notify attending nephrologist of any plan....identified. 6. Discuss the plan with the patient, update the plan of care if necessary...make any additional documentation in the MR. If the Patient...Continues to miss regularly scheduled treatments...1-2 dialysis treatments per week despite education, offers to reschedule and/or counseling efforts... 1. Refer the patient to SW for reassessment 2. Schedule an IDT meeting with the patient to discuss assessment findings and develop a plan to address barriers. Include...patient's goals/ideas for improving adherence. 3. Use the missed treatment focused intervention tools to determine barriers... 4. Re-educate the patient... Explore feasibility of other treatment modalities, including the option of no treatment... If the Patient...Has Missed 3 consecutive treatments...Does not contact the facility...efforts to locate...through emergency contacts...have been unsuccessful... 1. Notify the attending nephrologist. 2. Send Missed 3 Treatments letter via certified mail... 3. Notify the network of the situation... If the Patient has not contacted the...facility and has missed 6 consecutive treatments...Efforts to locate or communicate...unsuccessful... 1. Notify the attending nephrologist. 2. Notify the Network... 3. Send Missed 6 Treatments letter via certified mail... 1. PI # 4 was admitted to the facility on 2/25/22 with diagnoses including End Stage Renal Disease. Review of PI # 4's current plan of care (POC), a 6 month CIA (comprehensive interdisciplinary) assessment, approved by the IDT on 10/19/22, revealed the patient's status was stable. The SW documented "patient is very stable and compliant with treatment adherence". The IDT scheduled the next POC meeting for 4/17/23. MR review revealed an Orders Summary Report which included hemodialysis orders for 4 hour dialysis treatments on Monday, Wednesday, and Friday. Review of the Treatment Sheet (TS) dated 2/3/23 (Friday) revealed PI # 4 dialyzed 2 hours 7 minutes. Review of the facility report titled, Clinical Record View Report (CRVR), revealed the following documentation: 2/6/23 No Show-Patient Refused to Attend Treatment 2/8/23 No Show-Patient Refused to Attend Treatment There were no reasons documented why PI # 4 refused treatments and no documented attempts to reschedule the 2 missed treatments. Review of the TS dated 2/10/23 (Friday) revealed PI # 4 dialyzed 2 hours 30 minutes. Further review of the CRVR documentation revealed the following: 2/13/23 No Show-Patient Refused to Attend Treatment 2/15/23 No Show-Patient Refused to Attend Treatment 2/17/23 No Show-Patient Refused to Attend Treatment There were no reasons documented why PI # 4 refused treatments and no documented attempts to reschedule 3 missed treatments. There was no documentation the Missed 3 consecutive treatments letter was sent and no documentation the Network was notified. Review of the TS dated 2/20/23 (Monday) revealed PI # 4 dialyzed 1 hour 31 minutes. Further review of the CRVR documentation revealed the following: 2/22/23 No Show-Patient Refused to Attend Treatment 2/24/23 No Show-Patient Refused to Attend Treatment 2/27/23 No Show-Patient Refused to Attend Treatment There were no reasons documented why PI # 4 refused treatments, and no documented attempts to reschedule 3 missed treatments. There was no documentation the Missed 3 consecutive treatments letter was sent and no documentation the Network was notified. Review of the TS dated 3/1/23 (Wednesday) revealed PI # 4 dialyzed 1 hour 48 minutes. Further review of the CRVR documentation revealed the following: 3/3/23 No Show-Patient Refused to Attend Treatment 3/6/23 No Show-Patient Refused to Attend Treatment 3/8/23 No Show-Patient Refused to Attend Treatment Review of the TS dated 3/10/23 (Friday) revealed PI # 4 dialyzed 1 hour 58 minutes. Further review of the CRVR documentation, the Absence and Hospitalization Record, and Nurse Note dated 3/24/23 revealed the following documentation: 3/13/23 No Show-Patient Refused to Attend Treatment, pt (patient) refused reschedule 3/15/23 No Show-Patient Refused to Attend Treatment, pt refused reschedule 3/17/23 No Show-Patient Refused to Attend Treatment, pt refused reschedule 3/20/23 No Show-Gastrointestinal Upset 3/22/23 No Show-Patient Refused to Attend Treatment, reported hospitalized 3/24/23 No Show-Patient Refused to Attend Treatment, clothes not ironed There was no documentation the Missed 6 consecutive treatments letter was sent and no documentation the Network was notified. Review of the TS dated 3/27/23 (Monday) revealed PI # 4 dialyzed 1 hour 57 minutes. There was no documentation the SW completed an RCA to identify treatment adherence barriers and no documentation an IDT meeting with the patient to discuss assessment findings was conducted. There was no documentation the IDT developed a plan to address barriers and included the patient's goals/ideas for improving adherence. There was no documentation the Network was notified. In an interview conducted on 3/30/23 at 9:08 AM, Employee Identifier # 1, Facility Administrator, confirmed the IDT failed to ensure facility staff followed the facility treatment non-adherence policy.