There are  17 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. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-18-01 of will include, but not be limited to Procedure 1-18-01 "Hardness test using RPC Water Hardness Test Strips", Policy 8-04-01 "Physical environment", Policy 1-06-01 "Medication Policy" and Policy 1-05-01 "Infection Control Policy" with emphasis on but not limited to: A. Hardness Test: Notes: Do not use test strips after the manufacturer expiration date which is printed on bottle. Procedure: 1) Step 1: Unopened test strips cannot be used after the expiration date on the bottle. Rationale: Test strips must be stored and handled according to manufacturer's instructions for proper function of the test strips. B. Physical Environment: 1) Purpose: To provide guidance on the physical environment of the dialysis facility and treatment area. Policy: 1) The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public with a safe, functional, and comfortable physical environment. 2) 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. 3) Incoming supplies are visually inspected prior to acceptance by the facility to verify: supplies are not expired. C. Medication Policy: 1) The Administrator or designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medications and performs a monthly audit and inventory. 2) All open or unopened ampules and/or vials are stored .... Do not use any ampule or vial that has been stored improperly or has expired. 3) All medications in the facility are checked monthly. All medications are checked monthly for expiration dates. 4) Medications are ordered and replaced prior to expiration. 5) Disposal of expired medications ... are removed from the treatment and inventory areas and disposed of per state/local regulations. D. Infection Control: 1) Supplies will be stored in a manner that maintains their integrity. Expiration date and package integrity will be verified prior to use. Verification of attendance at in-service will be evidenced by teammate signatures on the in-service sheet. The Facility Administrator or designee immediately conducted an audit of all supplies and medications with expiration dates, to determine no expired items are in the inventory and available for patient use. Any expired items were immediately removed and appropriately disposed per policy, including supplies and medications identified during surveyor's observations. Ongoing compliance will be monitored with the monthly infection control audits, per policy. Instances of non-adherence will be addressed immediately. The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings, also known as Facility Health Meetings. The Facility Administrator is responsible for ongoing compliance with this plan of correction.

The Facility Administrator or designee held mandatory in-services for all clinical teammates. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control For Dialysis Facilities" and Procedure 1-03-12I "Termination of Dialysis Utilizing B Braun Dialog+ Delivery Systems with All Single Use Dialyzer Types and Streamline Blood Lines" with emphasis on but not limited to: A. Infection Control Policy: 1) All teammates, .....will perform hand hygiene: ... b. prior to gloving and immediately after removal of gloves ... d. after patient and dialysis delivery system contact ... g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2) Disposable gloves will be worn when caring for the patient or touching the patient's equipment at the dialysis station. a. Gloves should be changed when ... ii. When going from a "dirty" area or task to a "clean" area or task; iii. When moving from a contaminated body site to a clean body site of the same patient... B. B Braun Procedure: 1) Step 1: Gather supplies. Perform hand hygiene. Put on personal protective equipment (PPE). Rationale: Hand hygiene helps to prevent cross contamination. 2) Step 14: Disconnect venous blood line from the venous access. 3) Step 15: Discard gloves, perform hand hygiene and put on new gloves. Rationale: Hand hygiene and new gloves are used for performing post dialysis access care per procedure. Verification of attendance at in-service will be evidenced by teammate signatures on the in-service sheet. The Facility Administrator or designee will conduct observational audits to verify teammates are compliant with hand hygiene in glove wearing and glove changing, including but not limited to patient care activities during treatment discontinuation, per policy and procedure: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audits. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings. The Facility Administrator will report progress, as well as any barriers to maintaining compliance. Action plans will be evaluated for effectiveness and new plans developed when needed until sustained compliance is achieved. Supporting documentation will be included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.