Volume 2025 | No. 2
SURVEYOR
RENAL DIALYSIS
■ The SNF reported to the dialysis facility the patient’s Hgb results ranging from 6.3g/dl - 6.8g/ dl between July and October, which resulted in the SNF sending the patient to the hospital for transfusions on five occasions. Interview with the CNM revealed that the patient has a diagnosis of Alport syndrome which can lead to hemolytic anemia, however this has not been documented as a reason for not meeting the anemia goal on the plan of care. There is no evidence that the IDT conducted an evaluation of the patient's comorbidities in order to identify a reason/diagnosis for consistently low hemoglobin levels. There is no note in the physician or nursing monthly progress notes related to the unmanaged anemia, requiring five blood transfusions in a five month period. The nursing and physician portion of the plan of care addressed only the ESA dose and stated “continue with anemia management” on the initial start of care assessment and again on the 90- day follow up assessment. There is no evidence of plan of care revisions after the follow up.
RD5-P.01 Frequency of the citation: 33%
Overview of the requirement: Storage, handling, labeling, and administration of drugs and biologicals is in accordance with written policies and procedures. Comment on deficiencies: Compliance is evaluated by direct observation, response to interviews, and document review. Surveyors frequently noted missing or insufficient policies for disposal of expired drugs and the presence of expired medications. Examples of ACHC Surveyor findings: ■ The facility did not have a policy regarding appropriate administration, storage, handling, labeling, and dispensing of drugs and biologicals. ■ Policy states that multi-dose vials will be labeled with the date that they are first opened. An opened multi-dose vial of heparin was not labeled with its open date. ■ The facility did not have a process for recall of drugs and biologicals or current drug references and antidote information available onsite. ■ The dialysis supply closet stored multiple packs of lab tubes with expiration dates ranging from 1/2022 - 1/2025. ■ The facility did not dispose of expired drugs. A vial of heparin (10,000 units) with an expiration date of 10/2023 was present. Compliance tips for:
Compliance tips for:
Patient needs identified by the comprehensive assessment are used to develop and implement an individualized plan of care. The plan includes measurable and expected outcomes and estimated time frames to achieve them. Required elements of the plan are defined in the standard. Monthly progress notes reflect that a physician, nurse practitioner, clinical nurse specialist, or physician’s assistant providing ESRD care sees the patient at least monthly.
Nerd Newbies (understand the requirement)
■ Audit care notes:
Nerd Apprentices (audit for excellence)
ٝ against orders to ensure consistency and alignment with organizational policies. ٝ for inclusion of all required elements. ٝ for evidence that a qualified clinical professional has seen the patient/ reviewed the plan of care at least monthly. ■ Create templates to ensure all required measurements are captured. ■ Educate staff on the importance of individualized plans of care. A standardized approach increases the risk of patient-specific needs being overlooked.
Nerd Trailblazers (prepare the path for others)
Policies related to medication management are designed to ensure safety for patients and compliance with laws and regulations for dispensing scheduled drugs. ■ Audit storage areas and rotate dated medications and supplies to ensure that those closest to expiration are used first.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Dispose of expired drugs. ■ Monitor for drug recalls.
■ Review policies to ensure that all required elements are included. ■ Conduct staff training related to storage, labeling, and administration, and disposal of medications.
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 9
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