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 012515 (X3) Date Survey Completed 04/20/2023
Name of Provider or Supplier Fresenius Medical Care Opelika Street Address, City, State 2609 Village Professional Drive, Suite 2, Opelika, 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 medical records (MR), facility policy and staff interview the interdisciplinary (IDT) team failed to adjust the plan of care to reflect the patient's current condition. This deficient practice affected Patient Identifier (PI) # 5 and PI # 7, two of two Peritoneal Dialysis (PD) records reviewed, and had the potential to affect all PD patients served by the facility. Findings include: Facility Policy: Comprehensive Interdisciplinary Assessment and Plan of Care (POC) Version Number: 5 Published Date: 4/24/19 Purpose: The purpose of this policy is to provide guidance on the requirements for the Comprehensive Interdisciplinary Assessment (CIA) and the patient POC. ...Comprehensive Assessment Participation...The following are recommendations that may be used for the interdisciplinary patient assessment, development, and review of the POC prior to implementation: ...Plan of care discussions may occur during rounds... Failure to Achieve POC Outcome If the patient specific expected outcome as determined by the attending physician, IDT, and patient for the POC is not achieved within the identified timeframe: The IDT must adjust the patient's POC, and document changes made to the POC. Implement the POC changes to address the identified issues... 1. PI # 5 was admitted to the facility on 2/3/22 with a diagnosis of End Stage Renal Disease (ESRD). Review of the OSR (Orders Summary Report) revealed an order for PD dated 11/29/22 with an Estimated Dry Weight (EDW) of 68 kg (kilograms). Review of the POC dated 12/13/22 revealed documentation of the following: a. A goal to maintain/achieve desired body weight with an intervention to monitor weight goal progress updated on 12/9/22 by the dietician. b. A goal to maintain the iPTH (Intact Parathyroid Hormone) between 160 and 720 pg/ml (picograms per milliliter) with interventions of monitoring the iPTH and continue Sensipar per physician orders updated on 12/9/23 by the dietician. Review of the Provider Round Note dated 12/13/22, 3/14/23 and 4/18/23 revealed documentation to decrease the DW (dry weight) from 68 kg to 66 kg. Review of the PD Treatment Summary dated from 2/19/23 to 4/17/23 revealed the following treatments and weights were documented: On 3/8/23, completed treatment with a weight of 60 kg. On 3/9/23, completed treatment with a weight of 61 kg. On 3/10/23, completed treatment with a weight of 58.9 kg, which was the lowest documented weight for PI # 5. On 3/11/23, completed treatment with a weight of 59.7 kg. On 3/12/23, completed treatment with a weight of 60 kg. On 4/1/23, completed treatment with a weight of 63.8 kg. On 4/2/23, completed treatment with a weight of 63.7 kg. On 4/3/23, completed treatment with a weight of 63.9 kg. On 4/4/23, completed treatment with a weight of 63.8 kg. On 4/5/23, completed treatment with a weight of 64 kg. On 4/6/23, completed treatment with a weight of 63.8 kg. On 4/7/23, completed treatment with a weight of 63.7 kg. On 4/8/23, completed treatment with a weight of 63.9 kg. On 4/9/23, completed treatment with a weight of 64.2 kg. On 4/10/23, completed treatment with a weight of 63.8 kg. On 4/11/23, completed treatment with a weight of 63.7 kg. On 4/12/23, completed treatment with a weight of 64.1 kg. On 4/13/23, completed treatment with a weight of 64.2 kg, which was the highest documented weight for PI # 5. On 4/14/23, completed treatment with a weight of 63.9 kg. On 4/15/23 and 4/16/23, completed treatment with a weight of 63.8 kg. On 4/17/23, completed treatment with a weight of 64 kg. Further review of the Provider Round Notes dated 3/14/23 and 4/18/23 revealed documentation to increase Sensipar to 60 mg (milligram) a day in response to an iPTH of 1235 on 3/9/23 and a iPTH of 1453 on 4/10/23. Review of the MR revealed no documentation PI # 5's POC was adjusted to reflect the provider's decrease of the DW from 68 kg to 66 kg and to increase Sensipar to 60 mg a day. In an interview conducted on 4/20/23 at 8:53 AM, Employee Identifier (EI) # 2, Director of Operations, Sister Facility, confirmed there was no documentation PI # 5's POC was adjusted to reflect the provider's decrease of the DW from 68 kg to 66 kg and to increase Sensipar to 60 mg a day. 2. PI # 7 was admitted to the facility on 2/14/22 with a diagnosis of ESRD. Review of the OSR revealed an order for PD dated 7/16/22 for CCPD (Continuous Cyclic Peritoneal Dialysis, which requires the use of a Cycler) seven days a week, five exchanges in which four would be with 2000 ml (milliliters) and the last exchange would be with 1000 ml. The average dwell time ordered at one hour and 40 minutes and the cyclic therapy time of eight hours and 30 minutes with an EDW of 71.5 kg. Further review of the OSR revealed no documentation of a physician's order for CAPD (Continuous Ambulatory Peritoneal Dialysis, which does not require the use of a cycler and is a "manual" PD) Review of the Provider Round Note dated 12/13/22, 3/21/23 and 4/11/23 revealed documentation to decrease the DW to 70 kg. Review of PI # 7's POC dated 2/14/23 revealed documentation of the following: a. A goal to maintain/achieve desired body weight with an intervention to monitor weight goal progress updated on 1/31/23 by the dietician. b. A goal to improve treatment adherence with an intervention to continue to monitor the patient since the "patient is adherent to treatment..." Review of the PD Treatment Summary dated from 2/19/23 to 4/2/23 revealed the following treatments and weights were documented: On 2/19/23, completed CAPD treatment with a weight of 73.83 kg. On 2/20/23, completed CAPD treatment with a weight of 73.06 kg. On 2/21/23, 2/22/23, 2/23/23 and 2/24/23, completed CAPD treatment with a weight of 72.11 kg. On 2/25/23, completed CAPD treatment with a weight of 71.38 kg. On 2/26/23, completed CAPD treatment with a weight of 72.11 kg. On 2/27/23 and 2/28/23, completed CAPD treatment with a weight of 73.2 kg. On 3/1/23, completed CAPD treatment with a weight of 73.56 kg. On 3/2/23, completed CAPD treatment with a weight of 73.65 kg. On 3/3/23, completed CAPD treatment with a weight of 74.06 kg. On 3/4/23, completed CAPD treatment with a weight of 72.56 kg. On 3/5/23, completed CAPD treatment with a weight of 71.66 kg. On 3/6/23 and 3/7/23, completed CAPD treatment with a weight of 71.11 kg. On 3/8/23, completed CAPD treatment with a weight of 70.29 kg. On 3/9/23, completed CAPD treatment with a weight of 69.93 kg, which was the lowest documented weight for PI # 7. On 3/10/23, completed CAPD treatment with a weight of 70.07 kg. On 3/11/23 and 3/12/23, completed CAPD treatment with a weight of 70.75 kg. On 3/13/23 and 3/14/23, completed CAPD treatment with a weight of 72.02 kg. On 3/15/23, completed CCPD treatment with a weight of 72.56 kg, which was the only date a CCPD treatment was completed. On 3/16/23, completed CAPD treatment with a weight of 72.29 kg. On 3/17/23 and 3/18/23, completed CAPD treatment with a weight of 72.74 kg. On 3/19/23, completed CAPD treatment with a weight of 73.02 kg. On 3/20/23 and 3/21/23, completed CAPD treatment with a weight of 74.2 kg. On 3/22/23, completed CAPD treatment with a weight of 74.06 kg. On 3/23/23 and 3/24/23, completed CAPD treatment with a weight of 78.0 kg, which was the highest documented weight for PI # 7. On 3/25/23, completed CAPD treatment with a weight of 77.1 kg. On 3/26/23, 3/27/23 and 3/28/23, completed CAPD treatment with a weight of 76.37 kg. On 3/29/23 and 3/30/23, completed CAPD treatment with a weight of 76.01 kg. On 3/31/23, completed CAPD treatment with a weight of 75.28 kg. On 4/1/23, completed CAPD treatment with a weight of 75.33 kg. On 4/2/23, completed CAPD treatment with a weight of 75.74 kg. Review of the MR revealed no documentation PI # 7's POC was adjusted to reflect the provider's decrease of the DW to 70 kg and the patient's nonadherence with the physician ordered CCPD treatments. In an interview conducted on 4/20/23 at 8:45 AM, EI # 2 confirmed there was no documentation PI # 7's POC was adjusted to reflect the provider's decrease of the DW to 70 kg, the patient's nonadherence with the physician ordered CCPD treatments and staff failed to adjust the POC to reflect the patient's current condition.