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 starting on 09/06/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-05 "Infection Control for Dialysis Facilities", Policy 1-04-02B "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" with emphasis on but not limited to: 1. Hand hygiene: 1) Hand hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves... 2. CVC care: 1) Step #4 - Remove old dressing and discard. 2) Step #7 - Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 3) Step #8 - Holding catheter with the non-dominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds... 4) Step #10 - Remove gloves and discard, perform hand hygiene per procedure and re-glove. 5) Steps #12-13 - Place sterile 2x2 gauze over the catheter exit site leaving connections accessible. Apply label to dressing. 6) Step #14 - Remove gloves and discard, perform hand hygiene per procedure and re-glove. 7) Step #15 - Holding catheter with non-dominant hand, use other hand to place sterile 4x4 under catheter limbs. 8) Step #16 - Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Verification of attendance is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify proper hand hygiene is utilized during CVC care and treatment initiation per policy: daily for two (2) weeks and 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 the audit results with teammates during homeroom meetings and with Medical Director during monthly Quality Assessment 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 mandatory in-services for all clinical teammates starting on 09/06/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-04-02B "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" with emphasis on but not limited to: 1) Step #16 - Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly with friction making sure to remove any residue, for example blood. Hold the limbs until the antiseptic has dried. 2) Step #17 - Attach sterile 10ml syringes to the arterial and venous limbs. Verification of attendance at in-service is evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct observational audits to verify CVC care is provided per policy: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly infection control audits to verify compliance. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review the audit results with teammates during homeroom meetings and with the Medical Director during monthly Quality Assessment 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 mandatory in-services for all clinical teammates starting on 09/06/22. 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 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. 2) Prescription components include but are not necessarily limited to: ...b. Treatment time... f. Blood flow rate. g. Dialysate flow rate... i. Correct dialysate composition... 3) If the dialysis prescription is not being met ... the reason will be documented and the licensed nurse informed. 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) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 6) 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 teammate's signature on in-service sheet. The Facility Administrator or designee will conduct audits to verify orders reflected on the flowsheets are accurate and follow physician orders for treatment: 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. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review the audit results with teammates during homeroom meetings and with the Medical Director during monthly Quality Assessment 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 mandatory in-services for all clinical teammates starting on 09/06/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-01-09 "Prescribed Treatment Time Not Met" and Form 1-01-09A "Early Termination of Treatment against Medical Advice" form with emphasis on but not limited to: 1. Completion of the "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. 2. Prescribed Treatment Not Met: 1) 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. 2) If a patient's treatment is shortened/early terminated, the RN will document the event in the patient's medical record. Documentation will include, as appropriate... A copy of the "Early Termination of Treatment against Medical Advice" form signed by the patient, if shortened voluntarily by patient... Verification of attendance is evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct flowsheet audits to verify patient treatments that are not are meeting prescribed treatment times are correctly documented, and that "Early Termination of Treatment against Medical Advice" form is completed by RN: 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. 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 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 mandatory in-services for all clinical teammates and the Interdisciplinary Team (IDT) starting on 09/6/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-01-10 "Quality of Life Assessment Survey" with emphasis on but not limited to: 1) The Quality of Life (QOL) assessment survey is to be administered by the Social Worker to patients within four (4) months of initiating treatment, on an as needed basis, and repeated at least annually thereafter. 2) If a patient refuses to complete the KDQOL – 36 at any time, the Social Worker needs to document the refusal in the KDQOL Psychosocial condition in the electronic medical record. 3) The KDQOL Patient Results Report is to be reviewed by the Social Worker with the patient within 30 days of completing the survey. The completed survey and results should be maintained in the patient's medical record. 4) A patient would not be eligible to complete the KDQOL – 36 for the following reasons: the patient is under 18 years of age; has cognitive impairment, dementia or active psychosis that is documented by the attending physician; patient who is non English speaker/reader (for whom there is no native-language translation or interpreter). Patients under 18 will be presented with an age appropriate assessment tool, 'Pediatric Petey Activity Book-Your Kidneys and Dialysis.' This tool has been approved through Governing Body on 8/31/22. The social worker will document that the tool was provided and whether it was completed or refused. The completed tool will be maintained in the patient's medical record. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee, will immediately complete an audit of one hundred percent (100%) of the eligible patient medical records for a current KDQOL survey. Eligible patients without a current survey, or documented refusal, will have one completed by 10/23/22. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit findings with the Interdisciplinary Team and the Medical Director during Quality Assessment 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.

A Governing Body meeting was held on 8/31/2022, with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 8/24/22. 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 the facility teammates are trained and follow policy and procedure relative to patient admissions, patient care, infection control, and safety. 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 starting on 09/06/22. Surveyor observations were reviewed. Education included but was not limited to a review of facility policies with areas of emphasis on but not limited to:
1. Policy 1-06-01 "Medication Policy": 1) Medications are administered as prescribed and then documented in the patient's medical record. The Facility Administrator or designee will conduct flowsheet audits to verify medications given match medication ordered per physician: twenty five percent (25%) daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.
2. Policy 4-06-05 "Tuberculosis (TB) Monitoring and Follow-up": 1) Baseline new hire requirements for all new teammates ... will complete the following: c. If exemption criteria for TST is not met, the following testing options are available: i. Baseline TST using a two-step Purified Protein Derivative (PPD) Mantoux test (a *second TST repeated one to three weeks after the first, if the initial test is negative)... iv. Baseline TST results must be documented and recorded in millimeters within 10 days of employment.
Policy 8-02-03 "Color Vision Evaluation": 1) Teammates/patients/helpers who will be utilizing test kits or strips that rely on color differentiation for test results will be evaluated for ability to see color. Color blindness testing is performed at time of hire. 2) Documentation of the color vision evaluation will be documented in the teammate's file and/or patient's medical record. The Facility Administrator or designee will complete an audit of one hundred percent teammate medical files in next two (2) weeks to verify documentation of Tuberculosis screening within first ten days of employment and Color blindness screening as applicable per role, upon hire. Any missing documentation will be updated by 10/23/22. Ongoing compliance will be monitored with the quarterly teammate file audits. Instances of non-compliance will be addressed immediately.
3. Policy 2-05-02 "Daily Water System Total Chlorine Monitoring": 1) If the results of Total Chlorine testing from the primary carbon filter or set of tanks indicate a level of less than or equal to 0.1 ppm (< 0.1 ppm), record results on the "Routine Total Chlorine Testing" log which contains entries for day, date, test number, test time, signature of person performing the test, test results, and signature of licensed nurse verifying that each test on the daily log is complete and results appropriate. The Facility Administrator or designee will conduct an audit of the Routine Total Chlorine Testing log for the presence of licensed nurse signature, which verifies the daily log is complete and results are appropriate: daily on treatment days for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. Instances of non-compliance will be addressed immediately. Verification of attendance at all in-services will be evidenced by teammates' signatures on the in-services sheets. The Medical Director will review progress of teammate education, results of audits, and adherence to this plan of correction, as provided by the Facility Administrator during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, 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.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/06/22. 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: i. Measurement of patient temperature; ii. Measurement of Blood Pressure (BP) ... iii. Heart or pulse rate, noting also if the beat is regular or irregular; iv. Patient weight; v. Respiration rate; vi. Patient's report of well-being, level of pain or discomfort, complaints, hospitalization; vii. Vascular access status. 2) The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 3) 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. Verification of attendance at in-service is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee will conduct audits on flowsheet to verify documentation of post treatment data collection / assessment: on twenty five percent (25%) flowsheets daily on treatment days for two (2) weeks, then weekly for two (2) weeks. 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 teammates during homeroom meetings and with Medical Director during monthly Quality Assessment 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.