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V 715
A Governing Body meeting was held on 10/27/23 with the Medical Director, Facility Administrator and Regional Operations Director to review the results of the survey ending on 10/13/23. The Governing Body reviewed Policy COMP-DD-017 "Medical Director Qualifications and Responsibilities" with the Medical Director, who acknowledges that he/she is responsible to ensure the policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and non-physician providers. Plans of correction have been developed and initiated to correct identified deficiencies and to sustain compliance.
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 10/13/23. Surveyor observations were reviewed. Education included but was not limited to a review of facility policies with areas of emphasis on but not limited to the following:
1. Policy 1-06-01 "Medication Policy": 1) each vial is labeled with the initials of the person opening the vial and the expiration date. 2) All medications in the facility are checked monthly. Insulin and other medications with preservatives are dated and initialed once opened. The Facility Administrator or designee immediately audited all opened medications for licensed nurse initials and date. All medications which were missing the date and initials were removed from inventory used for patients and appropriately discarded, including all medications identified in the surveyor's observations #1 and #4. The Facility Administrator or designee will conduct medication audits to verify opened vials and bottles have licensed nurse initials and date: daily for two (2) weeks, then weekly for two (2) weeks and ongoing compliance monitored with the monthly infection control audit. Instances of non-compliance will be addressed immediately.

2. Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nurse Assessment":
A. Pre-treatment Data Collection: 1) Any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse ... If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 2) The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner [NPP] if applicable) will be notified of any concerns that may preclude the initiation of dialysis.
B. Intradialytic Data Collection: 1) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately ... The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. 2) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 3) All findings, interventions and patient response will be documented in the patient's medical record.
C. Abnormal Findings: Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record. 1) Blood pressure: a. Pre-dialysis: Systolic greater than 180 mm Hg or less than 90 mm Hg; Diastolic greater than or equal to 100 mm Hg. b. Intradialytic: Difference of 20 mm Hg increase or decrease from patient's last intradialytic treatment BP reading. c. Blood pressure post-treatment: Standing systolic BP greater than 140 mm Hg or less than 90 mm Hg; Standing diastolic BP greater than 90 mm Hg or less than 50 mm Hg. Sitting BP for patient's that cannot stand: Sitting systolic BP greater than 140 mm Hg or less than 90 mm Hg; Sitting diastolic BP greater than 90 mm Hg or less than 50 mm Hg. 2) Pre/Intra/Post Patient Reports/ Complaints and/or Teammate Observations of: Pain, chest pain ... Weakness or numbness ... Cramping ... Changes in level of consciousness, ability to communicate.

The Facility Administrator or designee will conduct audits to verify teammate document all findings during treatment, notify nurse of abnormal findings and/or patient complaints, and nurse responds appropriately to the findings per policy: on twenty five percent (25%) of the treatment records daily for two (2) weeks, then weekly for two (2) weeks, including for the five (5) patients identified by surveyor. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.

Verification of attendance at all in-services will be evidenced by teammates' signatures on the in-services sheets. The Medical Director will review progress of teammate education, results of audits, and adherence to this plan of correction, as provided by the Facility Administrator during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. Action plans will be evaluated for effectiveness, new plans developed as applicable to achieve compliance with teammate adherence to policy and procedure. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.