There are  8 surveys for this facility. Please select a date to view the survey results.

E038
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 06/19/24. 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: Conduct and review quarterly fire safety and evacuation training and drills for compliance, identify additional training and education needs. 2) Fire safety drills: a. Required on a quarterly basis; one drill to be conducted for each shift of patients; b. Include patient emergency takeoff procedure, policy: Termination of Dialysis in an Emergency; c. Document training for both teammates and patients; d. Complete exercise evaluation and teammate attendance sheet; e. Document in Governing Body and maintain with facility EMP. Verification of education is evidenced by teammate's signature on the in-service sheet.
Both patient and teammate training documentation for fire safety drills will be filed in education section of Medical Record.
The Facility Administrator or designee will audit all teammate and patient files immediately for the documentation of fire safety training. Updates will be completed by 08/02/24 as needed. Ongoing compliance for patients will be monitored with monthly ten percent (10%) medical records audits; ongoing compliance for teammates will be monitored with quarterly teammate file audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with teammates and Administrative Assistant 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.

V126
The Facility Administrator or designee held mandatory in-services for clinical teammates starting on 06/19/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-02 ¡°Hepatitis Surveillance, Vaccination and Infection Control Measures¡± with emphasis on but not limited to: 1) all patients will be routinely tested for Hepatitis B Virus. Hepatitis B Virus serologic testing will be drawn immediately upon admission to the facility and results known within seven (7) days. 2) Results will be reviewed promptly to verify that patients are managed appropriately based on their testing results. 3) Admission Screening: a. Antigen: Negative; Total Core: Negative; Repeat core: N/A; Status: Susceptible; b. Obtain physician an additional full series, and retest for HBsAb one (1) to two (2) months after the last dose of the second series. i. No additional doses of vaccine are warranted for those patients who do not respond to a full second series. ii. Such patients are considered vaccine non-responders. They remain susceptible to hepatitis B infection and monthly hepatitis B surface antigen (HBsAg) testing is required. 5) Routine annual surveillance testing is required for patients with Hepatitis B Antibodies greater than 10 due to vaccination or past infection; or patients with antibodies less than 10 due to previous or recent infection, currently inactive. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct an audit of all the patients' Hepatitis test and vaccination status. Updates will be completed immediately for patients with missing information / actions, including but not limited to patient identified by surveyor¡¯s observations.
The Facility Administrator or designee will conduct audits of the Hepatitis Report to verify admission screening, routine testing for hepatitis and vaccinations are up to date: weekly for two (2) weeks, then monthly for two (2) months. 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 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.
order. Offer vaccination series. c. The patient will consent to the vaccination or will decline. The completed form will be kept in the patient¡¯s health record. 4) Test all vaccinated patients for HBsAb one (1) to two (2) months after the last dose of the full vaccine series (adequate response is defined as greater than or equal (¡İ) 10 mIU/mL). a. If hepatitis B surface antibody (HBsAb) is less than (<) 10 mIU/mL, consider the patient susceptible, revaccinate with

V401
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 06/19/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01A "Infection Control For Dialysis Facilities" and Policy 4-07-01 "Facility Emergency Management Plan" with emphasis on but not limited to: A. 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. B. Evacuation kit: 1) Facility Administrator or designee will review the contents of the kit(s) and replace missing or expired supplies at least monthly. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee completed a one hundred percent (100%) audit of supplies with expiration dates, including the Emergency Evacuation Kit, and appropriately discarded any items which were expired the day of the surveyor's visit. Ongoing compliance will be monitored with a monthly inventory of supplies and emergency evacuation kit. 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.

V506
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 06/19/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-03 "Tuberculosis Infection Control Policy" with emphasis on but not limited to: 1) Patients with chronic kidney disease (CKD) are considered high risk for progression from latent TB infection (LTBI) to active TB disease and will be screened for TB prior to first treatment, as well as participate in ongoing surveillance following admission, per the requirements of this policy, regardless of BCG history. 2) Admission testing for patients new to dialysis or permanent admission from a non-DaVita facility: If Tuberculin Skin Test (TST) or Interferon Gamma release assays (IGRA) are not available prior to admission, and chest X-ray (CXR) is present, patient must complete upon admission: a) TB-RAQ (Risk Appraisal Questionnaire); b) First one-step TST, followed by a second TST one (1) to three (3) weeks after the admission TST or Draw QFTG; Annual surveillance TB-RAQ and single step TST or QFTG. 3) Notes: Pre-admission TST, IGRAs and CXR must be within three (3) months of admission to be valid. Two-step testing where both step 1 and step 2 of the process are not completed within 28 days should be repeated. A physician's order will be obtained for the administration of the tuberculin skin test (TST), QFTG, and CXR. TST will be administered by a licensed nurse using the purified protein derivative (PPD) Mantoux skin test method. TST results are to be read within 48-72 hours of placing the test by a licensed nurse and reaction documented in millimeters (mm) of induration. A TB-Risk Appraisal Questionnaire (TB-RAQ) ... will be administered by a licensed nurse. Verification of attendance is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee is responsible to conduct monthly TB audits and schedule appropriate testing. One hundred percent (100%) of the patients' TB testing and status will be audited and action taken accordingly. The Facility Administrator or designee will conduct audits of the TB Report weekly for two (2) weeks then monthly for two (2) months to verify testing and vaccinations are up to date. 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 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 Interdisciplinary Team members starting on 06/19/24. 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) a comprehensive assessment will be conducted on all new patients 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 signature on in-service sheet.
The Facility Administrator or designee will conduct an audit on all new patients' medical records to verify assessments are initiated and completed timely by the IDT: monthly for three (3) months. 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 audit results with the IDT during Core Team 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.

V517
The Facility Administrator or designee held mandatory in-services for all Interdisciplinary Team members starting on 6/19/24. 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) A follow up 90 day re-assessment will be completed to evaluate patient's status and provide information to adjust the patient's plan of care. 2) Re-assessment initiated on Day 91, completed within 30 days. Verification of attendance is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct an audit on all new patients after 90 days to verify assessments are initiated and completed timely: monthly for three (3) months. Ongoing compliance will be monitored with monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with the IDT during Core Team 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.

V519
The Facility Administrator or designee held mandatory in-services for all Interdisciplinary Team members starting on 06/19/24. 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) A comprehensive reassessment of each patient and a revision of the plan of care must be conducted at least annually for stable patients or semiannually when required by State Regulation. Verification of attendance is evidenced by teammate's signature on in-service sheet.
The Facility Administrator will conduct audits on all patient assessments and plans of care to verify timely completion of annual assessment and plans of care: monthly for three )3) months. 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 audit results with the IDT during Core Team 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.

V543
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 06/19/24. 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) Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. a. Data collection includes but is not necessarily 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)... Patient weight... 2) The Nursing assessment will be performed and documented by a licensed nurse; specifically, a Registered Nurse...The assessment includes the following components: Review of patient reports, data collection... physical assessment of the patient which includes...evaluation of volume status including edema... 3) Patient identity, prescription and machine settings are verified by teammates prior to initiation of treatment with the exception of blood flow rate (BFR) which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse by 1 hour of treatment initiation along with the nursing assessment. Components include but are not necessarily limited to: ... target weight, ultrafiltration rate (UFR) and Max UFR ... 4) Pre-treatment: 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. 5) Intradialytic: Abnormal findings or findings outside of any patient specific physician ordered 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. The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 6) Post treatment: The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre-dialysis findings... 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. Licensed nurse will use their 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. 7) 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. [Fluid Status]: a. Pre-treatment: Any weight loss from last post weight; removal goal not to exceed maximum ordered by physician; b. Post-treatment: If patient is above or below 1 kg from the target weight. 2. [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 or less than 50 mm/Hg; b. 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; c. Post treatment: systolic BP greater than 140 mm/Hg or less than 90 mm/HG; diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. 8) 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 teammates signature on in-service sheet.
The Facility Administrator or designee will conduct audits to verify that any documented abnormal findings are also reported to the licensed nurse, and nurse interventions are documented in the patient's medical record: on twenty five percent (25%) of the flow sheets daily for two (2) weeks, then weekly for two (2) weeks, then 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 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.

V544
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 06/19/24. 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" and Policy 1-01-09 "Prescribed Treatment Time Not Met" with emphasis on but not limited to:
A. Policy "Pre- Intra- Post Treatment...": 1) Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. 2) The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to ... Blood flow rate and Dialysate flow rate. 3) Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes, but is not limited to... Blood and dialysate flows... 4) If the dialysis prescription is not being met (including dialysis flow rate or change to /inability to obtain prescribed blood flow rate) the reason will be documented and the licensed nurse informed. 5) 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. 6) All findings, interventions and patient response will be documented in the patient's medical record.
B. Policy "Prescribed Treatment Time Not Met": 1) [Completion of the Early Termination of Treatment Against Medical Advice form]: a) 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. b) 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. c) An 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. 2) [Prescribed Treatment Time Not Met]: a) If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient's attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient's specific needs. b) Shortened/Early Termination of the dialysis treatment includes all reasons the prescribed dialysis time is not met by 30 or more minutes. This includes but is not limited to: the late initiation of treatment with termination at scheduled time, early termination at the end of treatment and interruptions of dialysis during the treatment i.e. machine or access problems or use of the bathroom by the patient. c) If a patient's treatment is shortened/early terminated, the RN will document the event in the patient's electronic health record. Documentation will include, as appropriate: the amount of time by which the treatment was shortened; a description of why the treatment was shortened; whether the patient's nephrologist was notified; a description of the follow-up medical orders provided by the patient's attending nephrologist (if any); a description of all other interventions planned to address the shortened treatment, including recommendations to the patient. d) A completed copy of the Early Termination of Treatment Against Medical Advice form will be kept in the patient's health record. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will conduct audits to verify:
1. that any documented abnormal findings [including but not limited to blood flow rates and/or dialysis flow rates not meeting treatment prescription], are reported to the licensed nurse, and nurse interventions are documented in the patient's medical record per policy;
2. 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 by physician. Each audit series will be conducted on twenty five percent (25%) of the flow sheets daily for two (2) weeks, then weekly for two (2) weeks, then 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 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.