There are  36 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 02/22/23. 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: 1) It is a requirement for all DaVita Teammates whose primary location is working in a facility have only natural nails. Artificial finger nails, nail extenders, sculptor, acrylic resin overlays or bonding, gels, tips, wraps, hybrid gels are not permitted. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify that teammates are compliant with infection control policy regarding artificial fingernails: 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 the 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 mandatory in-service for all clinical teammates starting on 02/08/23. 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. 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) and 2. Intradialytic BP in the sitting/reclined or supine position; 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 or concern is identified post treatment, this needs to be communicated to the nurse. The licensed nurse will assess the patient prior to discharge. 4) Licensed nurse will use his/her 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. 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 treatment documentation reflects any abnormal findings or concern identified post treatment is reported to the nurse, with nurse assessing patient prior to discharge:
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 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 mandatory in-services for all clinical teammates starting on 02/08023. 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: 1. Policy 1-03-08: 1) Patient identity, prescription and machine settings are verified by teammates prior to initiation of treatment. Prescription components include but are not necessarily limited to: ... Blood Flow rate and Dialysate flow rate ... 2) 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. Policy 1-01-09: 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. 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. 4) 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. 5) If a patient's treatment is shortened/early terminated, the RN will document the event 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 teammate documentation of abnormal findings to the licensed nurse, and the appropriate response by the nurse to the findings: on twenty five percent (25%) of the flow sheets daily for two (2) weeks then weekly for two (2) weeks.
The Facility Administrator or designee will perform a one hundred percent (100%) daily review of run time report and compare with submitted AMA's by RNs, prior to filing in patient charts: daily for two (2) weeks, weekly for two (2) weeks. Ongoing compliance for both audits 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 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.