There are  11 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 07/19/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-07-01 "Facility Emergency Management Plan (EMP)" with emphasis on but not limited to: 1) The Facility Administrator or designee, is responsible to: Conduct and review quarterly fire safety and evacuation training and drills for compliance, identify additional training and education needs. 2) Fire safety drills: a. Required on a quarterly basis; one drill to be conducted for each shift of patients; b. Include patient emergency takeoff procedure, policy: Termination of Dialysis in an Emergency; c. Document training for both teammates and patients; d. Complete exercise evaluation and teammate attendance sheet; e. Document in Governing Body and maintain with facility EMP. Verification of attendance is evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will audit fire drill documentation for three (3) quarters to verify compliance for all shifts of patients. 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 the Medical Director during the 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 7/19/22. Surveyor observations were reviewed. Education included but was not limited to a review Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 1) Clean sinks should be easily accessible and readily available in the treatment area...clean sink should be dedicated to clean activities such as hand washing and remain clean. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet. An immediate correction was made to this on 07/12/22 when the Facility Administrator directed a new "clean sink" signage be created and posted to the sink. The Facility Administrator or designee will conduct infection control audits to verify clean sinks are clearly marked and dedicated to clean activities: 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 the teammates during homeroom meetings and with the Medical Director during monthly Quality Assessment Performance Improvement meeting known as Facility Health Meeting, with supporting documentation 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 DATE. 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) Perform hand hygiene per procedure. Put on PPE and provide a mask to the patient. Teammate and patient will wear masks covering the nose and mouth during this procedure. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct observational infection control audits to verify patients and teammates are wearing masks properly during CVC dialysis initiation: 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 or designee will review audit results with teammates during homeroom meetings, and with Medical Director during monthly Quality Assurance 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 DATE. Surveyor observations were reviewed. Education also included but was not limited to a review of Policy 1-06-01 "Medication Policy" with emphasis on but not limited to: 1) Medications containing a preservative must be discarded 28 days after opening or accessed ... Each vial is labeled with the initials of the person opening the vial and the expiration date. 2) 2) Medications are ordered and replaced prior to expiration. Unless an exact expiration date is specified, medications with an expiration date of month/year are considered expired the last day of the state month. 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 medication preparation and labeling 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 Assurance 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 07/19/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 8-04-01 "Physical Environment" and Policy 2-01-13 "Electrical Safety Test on Incoming Equipment and Routine Testing" with emphasis on but not limited to: 1. Physical environment: 1) The dialysis facility will implement and maintain a program to verify that all equipment, including emergency equipment, dialysis delivery systems and the water treatment systems are maintained and operated in accordance with the manufacturer's recommendations. 2. Electrical safety: 1) All applicable incoming equipment used in the treatment area will have an electrical safety check performed prior to being placed in service. 2) Electrical leakage should be performed at least annually and the highest result from the tests performed will be documented on a BART service ticket and an Electrical Safety sticker. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. On 07/27/22, the electrical safety test was completed on the Intravenous infusion pump.
The Facility Administrator or designee will conduct physical plant observational audits to verify appropriately dated inspection stickers: weekly for two (2) weeks, then ongoing will monitor compliance with the monthly OSHA safety checklist. 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, 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 07/19/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-03 "Tuberculosis Infection Control Policy" with emphasis on but not limited to: 1. Admission requirements: 1) Patients with chronic kidney disease (CKD) are considered high risk for progression from latent TB infection (LTBI) to active TB disease and will be screened for TB prior to first treatment, as well as participate in ongoing surveillance following admission, per the requirements of this policy, regardless of BCG history. 2) A physician order will be obtained for the administration of the tuberculin skin test (TST). A TST will be administered using the purified protein derivative (PPD) Mantoux skin test method. TST results are to be read within 48-72 hours of placing the test and reaction documented in millimeters (mm) of induration. 3) QuantiFERON®-TB Gold In-Tube test (QFT-G) and T-SPOT® test results will be accepted in lieu of the TST. DaVita does not require nor provide the testing; however DaVita will accept the results. 4) A Chest X-Ray (CXR) obtained for any purpose that has been interpreted by a radiologist as clear, negative, normal, or unremarkable, is acceptable. 5) A TB-Risk Appraisal Questionnaire (TB-RAQ) (attached) will be administered by a licensed nurse to patients on admission and annually thereafter. 6) A TST will be administered annually to patients who demonstrate a negative TST finding on the most recent prior TST. 2. Surveillance following admission: 1) Requirements for ongoing TB surveillance following admission and annually is based on the specific requirement that has been met and the findings of ongoing surveillance (algorithms ...). Verification of in-service is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee completed an audit of patient records to verify documentation of appropriate Tuberculosis testing upon and following admission. Any needed updates are scheduled for completion by DATE. The Facility Administrator or designee will complete audits of new patients within thirty (30) days of admission for appropriate TB surveillance: monthly for three (3) months. Ongoing compliance will be monitored with ten percent (10%) monthly medical records audits. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review the results of the audits 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 held mandatory in-services for all Inter(s) for all members of the Interdisciplinary Team (IDT) starting on 07/19/22. Surveyor observations were reviewed. Education included a review of Policy 1-14-01 "Interdisciplinary Team (IDT) Patient Assessment and Plan of Care" with emphasis on but not limited to: 1) A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted at least monthly for unstable patients including, but not limited to, patients with the following: extended or frequent hospitalizations; marked deterioration in health status; significant changes in psychosocial needs; concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. 2) Monthly re-assessments and plan of care will be completed until the patient is deemed stable. Verification of attendance is evidenced by teammate's signature on the in-service sheet. Any assessments due or upcoming will be reviewed during weekly CORE Team meetings. The Assessment/Care Plan manager will develop a calendar to track due dates. The Facility Administrator or designee will conduct an audit on all care plans completed during the month to verify proper stability status designation and timely completion, monthly for three (3) months. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit findings with the IDT during Core Team 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 07/19/22. 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. Treatment monitoring: 1) Intra dialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes vital signs and treatment monitoring at least every 30 minutes. At minimum obtain and document...blood pressure... 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. 2. Post Treatment: 1) The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 2) 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. 3. 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... 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. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct flowsheet audits to verify documentation of proper notification to and response by the licensed nurse regarding abnormal findings: 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 Assurance 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.