HospitalInspections.org

Based on document review, staff/patient interviews and observations it was determined the hospital failed to develop and implement policies and procedures for outpatients who have diagnosis of acute renal failure to receive dialysis treatment in the acute dialysis unit. Additionally, the hospital failed to develop acute outpatient dialysis policies in conjunction with the medical staff and approval of the governing body. Failure to have policies and procedures in place for the provision of care to all categories of dialysis patients can result in services being provided to patients who are not qualified for this service resulting in possible negative outcomes.

Findings include:

The acute dialysis unit log was reviewed from 1/1/14 to 4/28/14. The log had one (1) patient (patient #1 on the identifier list), with an acute renal failure diagnosis who is being dialyzed as an outpatient three (3) times a week. Patient #1 has received outpatient dialysis treatments on 4/18/14, 4/21/14, 4/23/14, 4/25/14 and 4/28/14.

Review of the medical record for patient #1 revealed the patient is a fifty-seven (57) year old white female who was admitted to the hospital on 4/5/14 with an admitting diagnosis that included acute renal failure, diabetes, chronic obstructive pulmonary disease and chronic anemia. A Nepgrology consult was ordered.

Documentation in a progress note made by the consulting nephrologist on 4/14/14 reported the patient has an acute kidney injury due to acute tubular necrosis (proven by biopsy). Will keep on hemodialysis until patient recovers.

In another progress note by the consulting nephrologist on 4/15/14 documented the patient was denied admission to chronic outpatient dialysis services due to medicare issues (acute renal diagnosis). Will discharge and dialyze three (3) times a week until recovery.

The patient was discharged on 4/16/14 to receive acute dialysis treatments in the acute hospital unit.

Review of the policies and procedures for the acute dialysis unit revealed the hospital provides dialysis to patients without distinction to inpatient or outpatient status.

There were no policies for the dialysis unit which address providing outpatient dialysis services to patients with acute renal failure diagnosis who are not hospitalized or in an observation category. Also, there were no time frames addressing how long acute renal failure outpatients may dialyze in this status prior to making a final determining if the patient has chronic end stage disease. Additionally, the medical staff and governing body have not approved any policies and procedures for the acute unit that includes dialyzing acute renal failure outpatients.

The Vice President of Patient Services was interviewed on 4/29/14 at 1200 hours. He was questioned about the patient#1 receiving acute outpatient dialysis. He asserted they have been providing dialysis to patients with either acute or chronic renal failure for years for patients who are classified as either inpatients or outpatient observation. He stated patient #1 was the first patient they had provided acute dialysis services who is not an inpatient or observation patient. The Vice President referred to a CMS publication 100-04 Medicare Claims which indicates they can bill for a patient who does not have an ESRD diagnosis and is dialyzed in their hospital unit. When asked if they have policies and procedures for the provision of dialysis to acute renal failure outpatients, he stated they have not developed any polices.

Review of the CMS publication 100-04 Medicare Claims revealed the following in part: "Questions have arisen regarding how hospitals should report dialysis for outpatients who do not have ESRD but who need hemodialysis treatment, so we are clarifying how those services should be billed." The section that identified the ability of the hospital to bill for these services was under subpart:
I. General Information and under Section B. 2 which states "A hospital outpatient that does not have ESRD and is receiving hemodialysis in the hospital outpatient department. This services is reported on a type of bill 13X or type of bill85X.