There are  24 surveys for this facility. Please select a date to view the survey results.

V111
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 11/22/24. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-06-01A "Preparation and Administration of Parenteral Medications" and Policy 1-05-01 "Infection Control for Dialysis Facilities" with the emphasis on but not limited to: A. Medication Preparation: 1) Distribute the medication to the patient station in an aseptic manner. B. Infection control: 1) Clean areas should be clearly designated for the preparation, handling and storage of medications... Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
On 11/07/24, the Facility Administrator immediately printed and laminated "clean area" signage for both med prep areas, and designated clean med prep areas at both nurses' stations.
The Facility Administrator or designee will conduct audits to verify that a clean area is designated for preparation, handling and storage of medications, utilized and maintained 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-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.

V115
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 11/22/24. Surveyor observations were reviewed. Education included but was not limited to a review Policy 1-05-01 "Infection Control for Dialysis Facilities" with the emphasis on but not limited to: 1) Clean areas should be clearly designated for the preparation, handling and storage of medications... Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
On 11/07/24, the Facility Administrator immediately printed and laminated "clean area" signage for the coat hooks storage area for teammates' personal items. The Facility Administrator reinforced that no PPE should be stored in the area used for teammates' personal items.
The Facility Administrator or designee will conduct audits to verify that clean and dirty area designations are maintained per policy, including but not limited to not storing used PPE with teammates' personal items on coat hooks: 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-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.

V147
The Facility Administrator or designee held mandatory in-service for all clinical teammates starting on 11/22/24. 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 the emphasis on but not limited to: 1) Step 8: Holding catheter with the nondominant hand and using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds, apply to the CVC exit site in a "back and forth" pattern, using gentle friction progressing from the insertion site to the periphery using both sides of the swab. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct observational audits for CVC care to verify CVC care is completed per policy, [including but not limited to CVC exit site is cleaned with the chloraprep swab, not a swabstick, using a "back and forth" pattern, using gentle friction progressing from the insertion site to the periphery using both sides of the swab]: daily for two (2) weeks then weekly for two (2) weeks, then 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 raudit 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.

V403
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 11/22/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-22-01 "Chemical Use Policy" with the emphasis on but not limited to: 1) Peracetic acid is to be stored separate from other chemicals, especially bleach. It is to be stored in a cool, dry area (32°F-75°F). Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
On 11/07/24, upon learning of the surveyor's observations, the Facility Administrator directed the Biomed Technician to move the Peracetic Acid to a secure location with an acceptable temperature range.
The Facility Administrator or designee will conduct physical plant observational audits to verify chemicals are stored appropriately, [including but not limited to the proper temperature range for Peracetic acid]: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the Monthly OSHA and Safety Checklist. 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.

V504
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 11/22/24. 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", Policy 1-01-09 "Prescribed Treatment Not Met" and Policy 1-06-01 "Medication Policy" with emphasis but not limited to:
A.[ Policy Pre- Intra- Post Treatment...]: 1) Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient's dialysis treatment, monitoring during treatment and for reviewing the patient's response to the treatment and status prior to discharge. 2) [Pre-treatment]: 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) 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). 3) 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. 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: ...Treatment time ... Heparinization... 4) 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]: 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. 6) All findings, interventions and patient response will be documented in the patient's medical record. 7) [Post Treatment]: 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. 8) 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. 9) [Abnormal Findings]: The following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record, [including but not limited to: 1.Fluid Status: a. 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... b. Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg; c. Post-treatment: If the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg. If patient is not able to stand, document reason and sitting BP. 3. Pre- Intra- Post Treatment patient reports, complaints and or teammate observation of: ... weakness or numbness... changes in mobility, ambulation or reports of falls...
B.[ Policy - Prescribed Treatment Time Not Met]: 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) 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) ... 3) Additionally, if the patient's dialysis treatment is terminated 30 or more minutes prior to the ordered treatment length, the reason must be documented in the patient electronic health record at the time the treatment was terminated while reconciling the treatment times.
C. [Policy – Medications]: 1) Medications are administered as prescribed and then documented in the patient's medical record. 2) Document the name of the medication, dose, route, time, patient response and signature of the teammate administering the medication. 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:
1. To verify that with any documentation of abnormal findings or prescribed treatment not met [including but not limited to those regarding fluid status, blood pressure readings, or changes in ambulation, treatment time, or medications not given], notification is also given to the licensed nurse, and appropriate response and intervention are documented, including but not limited to communication with the physician as needed per policy.
2. To verify 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.
3. To verify that medication is administered as ordered, and documentation includes name of the medication, dose, route, time, patient response and signature of the teammate administering the medication.
Each audit series will be completed 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.

V715
On 11/25/24, A Governing Body meeting with the Medical Director, Facility Administrator, Nursing Manager and Regional Operations Director was held to review the results of the survey ending on 11/12/24. 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 all policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and non-physician providers. 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 11/20/24. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-04-01E "AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose" with emphasis on but not limited to: 1) Step 5: Perform inspection, auscultation and palpation on entire length of access. Determine presence of bruit and thrill. 2) Step 8: Locate and palpate the needle cannulation sites prior to skin preparation. 3) Step 10: While maintain aseptic technique, prep each planned needle site by applying a 70% alcohol prep pad to each site using a circular rubbing motion, center out. Rationale: Using a single 70% alcohol prep pad removes skin oil and debris from the skin surface only. This is not skin antisepsis for cannulation.
4) Step 11: While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. 5) Step 13: Do not palpate insertion site once area has been prepped. Rationale: Once the access site has been prepped, touching it will contaminate the site and possibly allow for the introduction of bacteria during cannulation. 6) Step 18: While maintaining aseptic technique, grasp the wings of appropriate fistula needle and remove cap... 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 teammates follow cannulation prep in accordance with policy, [including but not limited to maintaining aseptic technique and not touching the cannulation site after being prepped]: 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-adherence will be corrected immediately.
The Medical Director will review progress of teammate education, results of audits, and adherence to this plan of correction during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meeting. 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 if applicable to achieve sustained compliance. Supporting documentation will be included in the meeting minutes. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.