There are  3 surveys for this facility. Please select a date to view the survey results.

Plan of Correction:

V0113 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" with emphasis on but not limited to: [Hand Hygiene]: 1) All teammates, Physicians and Advanced Practice Providers (APP) will perform hand hygiene a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact ... f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet. The Facility Administrator or designee will conduct infection control audits to verify teammates are performing hand hygiene, with glove wearing and glove changing per policy: 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.

V0115 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" with the emphasis on but not limited to: PPE: [i.e., gown, gloves, eye protection, face shield] 1) Appropriate Personal Protective Equipment (PPE) will be worn whenever there is the potential for contact with body fluids, hazardous chemicals, contaminated equipment and environmental surfaces, for example, patient care areas. 2) Appropriate fluid resistant/fluid impervious gowns will be worn by all teammates, Physicians/Advanced Practice Providers (APP) and visitors when in the treatment area. Verification of attendance at in-service will be evidenced by teammate signature on in-service sheet. The Facility Administrator or designee will conduct infection control audits to verify fluid resistant / impervious gowns are worn by all teammates, Physicians / Advanced Practice Providers (APP)and visitors when in the treatment area, per policy: daily for two (2) weeks, then weekly for two (2) weeks, then 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 Assessment 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 Procedure 1-04-02B "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" with emphasis on but not limited to: 1) Step 1: Teammates and patients will wear masks covering the nose and mouth during this procedure. Rationale: These measures are vital to preventing the exposure of the catheter and exit site to nasal droplets and infectious bacteria such as methicillin-resistant Staphylococcus aureus (MRSA)., especially during discontinuation of dialysis with a Central Venous Catheter. Verification of attendance at in-service will be evidenced by teammate signatures on in-service sheet. The Facility Administrator or designee will conduct observational audits for CVC care to verify adherence to teammates and patients wearing face mask properly during the CVC care, initiation and treatment disconnection, per procedure: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly infection control 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, 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: 1) Data collection includes but is not necessarily limited to: i. Measurement of patient temperature ii. Measurement of Blood Pressure (BP) 1. 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) ... iii Heart or pulse rate, noting also if the beat is regular or irregular. 2) 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. 3) All findings, interventions and patient response will be documented in the patient's medical record. 4) 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. 5) Abnormal Findings: 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. a.
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 or less than 50 mm/Hg. b. Blood Pressure Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg; Diastolic greater than or equal to 100 mmHg or less than 50 mm/Hg; c. 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. If patient is not able to stand, document reason and sitting BP. 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. d. Heart or Pulse Rate Pre/Intra/Post: Less than 60 beats per minute or greater than 100 beats per minute and/or an irregular heart beat.
Verification of attendance will be evidenced by teammate signatures on the
in-service sheet. The Facility Administrator or designee will conduct flowsheet audits to verify any documentation of abnormal findings ,[or patient specific physician parameters not met], is also documented as reported to the licensed nurse, and nurse response is documented, including but not limited to assessment or communication with physician, per policy: on twenty five percent (25%) of flowsheets, 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-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 clin education 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: 1) 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. 2) 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. 3) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 4) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance will be evidenced by teammate signatures on an in-service sheet. The Facility Administrator or designee will conduct flowsheet audits to verify that with any documentation of abnormal findings, or prescribed treatment not met, [including but not limited to blood flow rate] there is also documentation of report to the licensed nurse, with nurse response documented, including but not limited to assessment or physician notification as needed, per policy: on twenty five percent (25%) of the flowsheets 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-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.