There are  24 surveys for this facility. Please select a date to view the survey results.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 12/22/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 1) Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station and if contaminated between uses. 2) Stethoscopes taken to the patient's station will be disinfected with alcohol prep pad and/or 1:100 (one to one hundred) bleach solution and if they are visibly contaminated with blood or body fluids should be disinfected with a 1:10 (one to ten) bleach solution. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or Clinical Coordinator or Manager of Clinical Services will conduct infection control audits to verify non-disposable items are disinfected after each patient use per policy: daily for two (2) weeks, then weekly for two (2) weeks, then monthly during infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

Immediate action included verifying with the outside vendor that the oxygen concentrator was not included in the last maintenance visit, and scheduling return maintenance visit by 01/15/24. The concentrator was immediately removed from used on the treatment floor.
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 12/22/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 8-04-01 "Physical Environment" and Policy 2-01-09 "Preventive Maintenance (PM) Schedules for Equipment" with emphasis on but not limited to: A. Physical environment: 1) The dialysis facility will implement and maintain a program to verify that all equipment, including emergency equipment, dialysis delivery systems and the water treatment systems are maintained and operated in accordance with the manufacturer's recommendations.
B. Preventive maintenance: 1) Purpose: the dialysis delivery systems and all ancillary equipment, are maintained in good working condition and are operating according to the manufacturer's specifications. 2) Preventive maintenance (PM) schedules must be made in accordance with the manufacturer's recommendation for all equipment used to perform a patient treatment. A copy of the equipment PM schedule will be filed in the appropriate Equipment Maintenance Manual. 3) All miscellaneous equipment will receive PM performed by trained Biomed teammate or outside vendor per manufacturer's recommendations. Examples of miscellaneous equipment may include, but are not limited to... oxygen concentrators...
Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator will review the preventive maintenance schedule with the Biomed teammate and verify the updated schedule is filed in the Equipment Maintenance Manual per policy. The Facility Administrator or designee will conduct daily physical plant observational audits to verify all oxygen concentrators have received preventive maintenance: daily for two (2) weeks, and weekly for two (2) week. Ongoing compliance with the Equipment Maintenance scheduled will be monitored with the Monthly OSHA and Safety Checklist. Deficiencies not corrected immediately will be documented on the Monthly OSHA and Safety Plan of Correction [last page of the checklist] outlining the: deficiency, cause of the deficiency and corrective action: expected date of correction and actual date of correction.
The Facility Administrator or Biomed or designee will review the audit results, the maintenance schedule and maintenance results with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 12/22/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "Pre- Intra- Post treatment Data Collection Monitoring and Nursing Assessment" with emphasis on but not limited to:
[Pre-treatment] 1) Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse, including but not limited to: measurement of Blood Pressure (BP)... Sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet)... 2) 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 (refer to "Abnormal Findings" section of this policy). If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 3) If there are no abnormal findings or concerns identified during the pretreatment data collection, the treatment may be initiated. 4) The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation.
[Intradialytic] 5) Intra dialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes vital signs and treatment monitoring at least every 30 minutes. 6) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately... 7) the licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 8) All findings, interventions and patient response will be documented in the patient's medical record.
[Post treatment] 9) If an abnormal finding(s) or concern is identified post treatment, this needs to be reported to the licensed nurse. The licensed nurse will assess the patient prior to discharge. 10) ABNORMAL FINDINGS: Fluid Status: Pre-treatment- Any weight loss from last post weight; Post-treatment- If patient is above or below 1 kg from the target weight. 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. Post Treatment: Standing / sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg, Standing / sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg... If patient is not able to stand, document reason and sitting BP. Heart or Pulse Rate Pre/ Intra/ Post: Less than 60 beats per minute or greater than 100 beats per minute and/ or an irregular heartbeat. 11) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct treatment records audits to verify timely nursing assessments, proper documentation of data collection, with appropriate notification of abnormal findings to nurse and response by nurse: on twenty five percent (25%) of the treatment records daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meeting, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 12/26/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-14-01 "Interdisciplinary Team (IDT) Patient Assessment and Plan of Care" with emphasis on but not limited to: 1) the interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient's treatment plan and expectations for care. 2) An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines. Verification of attendance is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee or care plan manager will audit one hundred percent (100%) of new patient care plans monthly for three (3) months to verify initial assessments and plans of care are completed within thirty (30) days (or thirteen (13) outpatient dialysis sessions for hemodialysis) per policy, with ongoing compliance being monitored with monthly ten percent (10%) medical records audit.
Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review the audit results with the IDT during Core Team meetings and with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.