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 Policy 4-07-01 "Facility Emergency Management Plan (EMP)" with emphasis on but not limited to: 1) the Facility Administrator or designee, is responsible to provide training for patients upon admission and quarterly: a. One drill to be conducted for each shift of patients. b. Include patient emergency takeoff procedure, policy: "Termination of Dialysis in an Emergency". Documentation of training will be kept in the patients charts. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee immediately completed a one hundred percent (100%) audit of patient emergency preparedness / fire drill documentation. Training documentation found missing for any patients, including for those identified by the surveyor was completed immediately. The Facility Administrator or designee will audit fire drill / emergency preparedness training documentation for three (3) quarters to verify compliance for all shifts of patients. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-adherence will be correctly 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.

Based on the findings of an onsite unannounced Medicare recertification survey conducted on March 9, 2026, through March 10, 2026, South Broad Street Dialysis, was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.

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 8-04-01 "Physical Environment" and Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: A. Physical Environment: 1) The dialysis facility will be designed, constructed, equipped, and maintained to provide dialysis patients, teammates, and the public a safe, functional, and comfortable treatment environment. B. Infection Control: 1) Supplies will be stored in a manner that maintains their integrity. 2) Expiration date and package integrity will be verified prior to use. Verification of attendance is evidenced by teammate signatures on the in-service sheet.
The Facility Administrator or designee immediately completed an audit of medical supplies to verify expiration dates have not been exceeded. Any items found to be expired were immediately removed and appropriately discarded, included items identifed during surveyor observation. Ongoing compliance will be monitored with the monthly infection control audit, per policy. Instances of non-adherence will be addressed immediately. The emergency cart was found to not be closed appropriately, which allowed the snap lock to be in place, yet not securing the emergency cart drawers. The external metal flap was closed properly over the drawer and a new snap lock was immediately applied. The emergency cart is now properly secured. The Facility Administrator or designee will conduct physical plant audits to verify the facility maintains a safe, functional and sanitary environment, with fresh supplies stored to maintain their integrity, and the emergency cart secured with a snap lock, per policy: daily for two (2) weeks, then weekly for (2) weeks, and monthly for two (2) months. Instances of non-adherence will be corrected 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.

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 1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: A. [Pre-treatment data collection]: 1) Patient data will be obtained and documented by the patient care technician or licensed nurse. Data collection includes: Measurement of blood pressure, sitting and standing and intradialytic BP in the sitting/reclined or supine position and pre and post patient weight. 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 ... If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis.
B. [Intradialytic monitoring]: 1) 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. 2) Abnormal findings or findings outside of any patient specific physician ordered parameters will be reported to the licensed nurse immediately... 3) the licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status.
C. [Post treatment]: 1) The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 2) 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. 3) Licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility. 4) All findings, interventions and patient response will be documented in the patients medical record.
D. [Abnormal findings]: Blood pressure - Pre dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg; Diastolic greater than or equal to 100 mm/Hg. Blood Pressure-Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg; Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg Blood Pressure Post Treatment if the patient can stand: 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. Verification of attendance at in-service will be evidenced by teammate signatures on in-service sheet.
The Facility Administrator or designee will complete flow sheet audits to verify when abnormal findings are documented, notification given to the licensed nurse, and appropriate interventions documented by the licensed nurse, including but not limited to assessment or physician notification: 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.
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.

Governing Body meeting was held with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 03/10/26. 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 all 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. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-01-09 "CWOW-Prescribed Treatment Time Not Met" with emphasis on but not limited to: A. Completion of Early Termination of Treatment against Medical Advice Form: 1) The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. 2) The RN will obtain the patient's signature on the Early Termination of Treatment against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient's signature prior to rinse-back, the RN will obtain the patient's signature on the form prior to the patient's departure from the facility. 3) A RN must countersign all Early Termination of Treatment against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form. 4) If a patient refuses to sign the Early Termination of Treatment against Medical Advice form, the RN will document the patient's refusal with the words "patient refused" in the patient signature box along with the date. Under such circumstances, the RN will sign the form and will also obtain a witness' signature on the form. Verification of attendance at in-service will be evidenced by teammate signatures on in-service sheet.
The Facility Administrator or designee will conduct audits to verify the "Early Termination of Treatment against Medical Advice" form is signed by the patient and Registered Nurse when treatment times are not met on the treatment record as prescribed: on twenty five percent (25%) of treatment records daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored monthly with ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.
The Medical Director will review progress of teammate education, results of all audits, and adherence to this plan of correction during monthly Quality Assessment Performance Improvement meetings known as the Facility Health Meeting. The Facility Administrator will report progress, as well as any barriers to maintaining compliance, 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.