There are  12 surveys for this facility. Please select a date to view the survey results.

V 0146
The Facility Administrator or designee held mandatory in-service(s) for all clinical teammates starting on 10/3/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities", Policy 1-12-17 "DSD Infection Control for Dialysis Facilities" Procedure 1-04-02B (ICHD), and Procedure 12-06-02B (HHD) "Central Venous Catheter (CVC) with Clear guard HD Antimicrobial End Caps Procedure" with emphasis on but not limited to A. Infection control – Hand Hygiene: 1) All teammates, Physicians, and Non-Physician (NPP) will perform hand hygiene before gloving and immediately after removal of gloves B. CVC care: 1) Step 4: Remove and discard gloves, conduct hand hygiene, and don new gloves. Place sterile gauze over the catheter and exit site leaving catheter limbs accessible. 2) Step 7: Remove gloves and discard. Perform hand hygiene per procedure and re-glove. Rationale: alcohol-based hand rubs may be used unless hands are visibly contaminated. Hand washing will be performed if hands are visibly contaminated with blood or bodily fluids. 3) Step 8: ...using an aseptic technique, clean the exit site... 4) Step 10: Remove gloves and discard, perform hand hygiene per procedure, and re-glove. Verification of attendance at in-service will be evidenced by teammates' signatures on the in-service sheet.
The Facility Administrator or designee will conduct observational audits for CVC care to verify hand hygiene with glove wearing and changing is performed per policy: daily for two (2) weeks then weekly for two (2) weeks then ongoing monthly during internal infection control audits to verify compliance. 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 and 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.

V403
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 10/03/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 8-04-01 "Physical Environment" with emphasis on but not limited to 1) The dialysis facility will implement and maintain a program to verify that all equipment, including emergency equipment, dialysis delivery systems, and water treatment systems are maintained and operated according to the manufacturer's recommendations. Verification of attendance at in-service will be evidenced by the teammate's signature on the in-service sheet.

Preventive Maintenance for all identified ancillary equipment due October 2023 will be completed by Skilled Nursing Facility at Pottstown and DaVita Teammate with supervision from the Regional Operations Manager (ROM) on 11/15/24.
- Laboratory centrifuge
- Scale
- Hoyer Lift
- Automated External Defibrillator
- Suction Machine
- Medication Fridge
- Biohazard Fridge
- Oxygen Concentrators
The Facility Administrator or designee will conduct physical plant observational audits to verify preventive maintenance has been completed as evidenced by a new sticker with a future due date attached to each piece of equipment: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be audited with the Monthly OSHA Safety audits. 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 and 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.

V543
The Facility Administrator or designee held mandatory in-service(s) for all clinical teammates starting on 10/03/24. 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 1) Abnormal findings or findings outside of any patient-specific physician parameters will be reported to the licensed nurse immediately (refer to "Abnormal Findings" section in this policy). 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. 4) The following are abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record. 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. Verification of attendance at in-service will be evidenced by teammates' signatures on the in-service sheet.
The Facility Administrator or designee will complete flow sheet audits to verify that any documentation of abnormal findings is also documented as reported to the licensed nurse, and that nurse response is documented, including but not limited to communication with the physician as needed, per policy:
Conduct audits on twenty-five percent (25%) of the flow sheets 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 to verify compliance. 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 and 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.