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

The Facility Administrator or designee held an in-service starting on 09/29/22 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 Policy 1-04-01B "Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles" with emphasis on but not limited to: 1. Infection control: 1) Gloves should be provided to patients and gloves and gown to visitors if these individuals assist with procedures such as self-cannulation or holding access sites. 2. Post dialysis vascular access care: 1) the patient will be encouraged to hold their own sites if their condition permits. When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed. Rationale: Gloves and hand hygiene protects patient and family members from cross contamination. Verification of attendance at in-service will be evidenced by teammate's signature on the in-service sheet. Teammates will remind patients to perform hand hygiene when gloves are removed. The Facility Administrator or designee will conduct infection control audits to verify patients perform proper hand hygiene once gloves are removed after holding cannulation sites: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly infection control audits. Instances of non-compliance will be addressed immediately. The Facility Administrator 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, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

The Facility Administrator or designee held an in-service starting on 09/29/22 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: 1) Equipment including dialysis delivery system, interior and exterior of the prime waste container, the dialysis chair and side table including opening the chair to reach crevices, blood pressure equipment ... as well as all work surfaces will be wiped clean with a bleach solution of the appropriate strength after completion of procedures, before being used on another patient. Verification of attendance at in-service will be evidenced by teammate's signature the in-service sheet. The Facility Administrator or designee will conduct infection control audits to verify teammates are performing equipment cleaning/disinfection appropriately per policy: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audit. 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, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

The Facility Administrator or designee held an in-service on for all clinical teammates starting on 09/29/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 2-04-02 "Daily Water Treatment System Monitoring" with emphasis on but not limited to: 1) Purpose: To verify the dialysis water system operates safely and reliably through daily observations and/or testing of specific component performance parameters. 2) All observations and test results will be within the limits specified on the Daily Water Treatment Log. If observations or test results are outside the specified limits, follow the instructions given on the Daily Water Treatment Log for the parameter(s) in question. In addition to following the log form instructions, the teammate completing the log will notify the Facility Administrator/designee and Biomed assigned to the facility of any observation or test result that is found outside the limits specified in the Daily Water Treatment Log. 3) The licensed nurse reviews the Daily Water Log for completeness and verifies that all parameters are within specified limits. Upon satisfactory completion of this review, the licensed nurse initials and signs the log form where indicated. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee will conduct audits of the water treatment log for accuracy and for notification and follow up for readings outside of parameters: daily for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. 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, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

The Facility Administrator or designee held an in-service on for all Peritoneal Dialysis clinical teammates starting on 09/28/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 5-01-07 "Failure to Comply with Home Dialysis Training Program Objectives" with emphasis on but not limited to: 1) Home patients/caregivers are responsible for the following: ... Maintaining home treatment records; if home treatment records are maintained on paper, bringing to clinic visit for the nurse to review at least monthly. 2) Document in patient's medical record non-compliance, interventions taken and patient/caregiver response. 3) If team actions are not successful, then further assistance will be sought from the Facility Administrator/designee and the Medical Director. Verification of attendance is evidenced by the teammate's signature on the in-service sheet. The Facility Administrator or designee will audit one hundred percent (100%) of the home treatment forms for the next three (3) months, to verify completeness of the Daily Home Treatment Record. Ongoing compliance will be monitored with the ten percent (10%) monthly medical records audit. The patient's plan of care should address any problems with adherence to this requirement. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction

The Facility Administrator or designee held an in-service on for all Peritoneal Dialysis clinical teammates starting on 09/28/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 5-01-22 "Routine Support Service" with emphasis on but not limited to: 1) A Peritoneal Dialysis Registered Nurse (RN) must supervise the clinic visit and provide Initial Patient Training, but may delegate certain tasks to Licensed Vocational Nurse (LVN)/Licensed Practical Nurse (LPN)/Patient Care Technician (PCT), as allowable by state regulation. 2) Support services will be provided on a monthly basis. 3) Clinic visits are the preferred method of routine support. 4) Clinic visits may include the following: a. Data collection and assessment of vital signs and weight, fluid balance, exit sit status, adequacy of dialysis, home flowsheets, home medications, laboratory results if not previously completed; b. Obtain laboratory specimens or make appropriate arrangements; c. Perform transfer set change, if due; d. Renal dietitian assessment; e. Social worker assessment; f. Monthly education. 5) Alternative support services may include: a. Laboratory draw in the clinic; b. Interdisciplinary team care plan meeting and co-ordination of home patient care: Development and periodic review of the patient's individualized comprehensive plan of care that specifies the services necessary to address the patient's needs and meets the measurable and expected outcomes per the patient plan of care; c. Collaboration with other health providers; d. Telephone support to patient / partner / caregiver. 6) All support services are documented in the patient's medical record. Verification of attendance is evidenced by the teammate's signature on the in-service sheet. The Facility Administrator or designee will audit one hundred percent (100%) of the home patient medical records treatment forms for the next three (3) months, to verify routine support is provided and documented, and patient assessment and plan of care is appropriate and up to date. Ongoing compliance will be monitored with the ten percent (10%) monthly medical records audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.