There are  18 surveys for this facility. Please select a date to view the survey results.

The Facility Administrator or designee will hold mandatory in-services for all clinical teammates starting on 02/05/24. Surveyor observations will be reviewed. Education will include but not be limited to a review of Policy 4-07-01 "Emergency Management Plan (EMP)" with emphasis on but not limited to: 1) The facility will conduct and/or participate in one (1) exercise to test the facility EMP at least annually, conducted on opposite years (one year full-scale, next year facility-based / exercise of choice). Verification of attendance at in-service will be evidenced by teammate's signatures on in-service sheet.
On 1/31/24, the Facility Administrator in partnership with the Clinical Coordinator scheduled all remaining quarterly and annual EMP drills for the next two years in the facility calendar.
The Facility Administrator or designee will own the scheduling, selection and administration of all annual emergency drills. Documentation including event activated, plans and policies activated, evaluation of plan, required plan revisions and Governing Body review will be maintained in facility's Emergency Management Plan and reviewed quarterly.
The Facility Administrator or designee will review the results of the emergency preparedness drill with teammates during homeroom meetings and with Medical Director during monthly Quality Assessment and Performance Improvement 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 will hold mandatory in-services for all clinical teammates starting on 02/05/24. Surveyor observations will be reviewed. Education will include but not be 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 to have only natural nails and fingernail length should not extend more than ¼ inch. Traditional nail polish that is not chipped may be worn. Verification of attendance at in-service will be evidenced by teammate's signatures on in-service sheet.
On 01/25/24, patient care technicians identified in the survey were coached on the infection control risks of artificial nails and directed to have them removed. All active patient care technicians were coached on the DaVita's policy regarding nail hygiene.
The Facility Administrator or designee will conduct infection control audits to verify teammates comply with the nail requirement: weekly for four (4) weeks then ongoing monitoring during 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 Medical Director during monthly Quality Assessment and Performance Improvement 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.

The Facility Administrator or designee will hold mandatory in-services for all clinical teammates starting on 02/05/24. Surveyor observations will be reviewed. Education will include but not be limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 1) Cleaning and/or disinfection of equipment and work surfaces will be performed as soon as possible following exposure to blood or other potentially infectious materials. 2) Use an appropriate disinfectant such as 1:100 (one to one hundred) bleach solution for routine disinfection of environmental surfaces. 3) Surfaces to disinfect include but are not necessarily limited to: all surfaces in contact with the patient or their belongings (e.g., dialysis chair, tray tables, blood pressure cuffs) and frequently contacted by healthcare personnel (e.g., control panel; top, front and sides of dialysis machine; touchscreens; countertops). Verification of attendance at in-service will be evidenced by teammate's signature on the in-service sheet.
Facility Administrator or designee will place emphasis on cleaning the Hansen connectors attached to the delivery system and all areas accessible to patients including the chaise wall behind the dialysis chair. The Facility Administrator or designee will conduct infection control audits to verify machine disinfection and station cleaning comply with infection control policy: daily for two (2) weeks, then weekly for two (2) weeks, then ongoing monitoring 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 and Performance Improvement 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.

The Facility Administrator or designee will hold mandatory in-services for all clinical teammates starting on 02/05/24. Surveyor observations will be reviewed. Education will include but not be limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with the emphasis on but not limited to: 1) Supplies will be stored in a manner that maintains their integrity. 2) Expiration date and package integrity will be verified prior to use. Verification of attendance at in-service will be evidenced by teammates signatures on in-service sheet.
Facility Administrator or designee will emphasize the practice of: 1) regular auditing of housed supplies to check for expired items as part of a monthly process to minimalize the spread of infections or bloodborne pathogens; 2) rotation of new supplies to be placed behind existing supplies when stocking to decrease the risk of supplies expiring prior to use.
On 01/22/24, expired supplies found in the lab room cabinet were immediately and appropriately discarded and the lab room was further audited for any remaining misplaced supplies. Supply room and treatment floor were fully audited 01/29/24 for any remaining expired supplies.
The Facility Administrator or designee will conduct observational audits for expired supplies weekly for four (4) weeks with expected compliance of ninety eight percent (98%), then 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 the audit results with teammates during homeroom meetings, and with Medical Director during monthly Quality Assessment and Performance Improvement 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.

The Facility Administrator or designee will hold mandatory in-services for all clinical teammates starting on 05/05/24. Surveyor observations were reviewed. Education will include but not be 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: A. Pre- Intra- Post Treatment..." 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, 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. 3) All findings, interventions and patient response will be documented in the patient's medical record.
B. Prescribed Treatment Not Met: 1. Completion of 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) 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) All Early Termination of Treatment against Medical Advice forms will be reviewed for completion and filed each shift by the Charge Nurse. 2. Prescribed Treatment Time 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) 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 treatment record at the time the treatment was terminated... 3) The facility's Facility Administrator (FA) will verify that all shortened treatments are recorded and trended, and the FA shall verify that such records are reviewed and discussed at the Facility Health Meetings (FHM), as appropriate.
Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee completed a one hundred percent (100%) audit of treatment prescriptions orders performed on 1/27/24 and shared results with teammates on 1/29/24. Root cause analysis of the findings was completed with the teammates.
The Facility Administrator or designee will conduct audits to verify complete and accurate documentation and Registered Nurse notification, with appropriate response concerning prescribed blood flow rate, and dialysis flow rate not meeting prescription: on twenty five (25%) of the treatment records daily for two (2) weeks with expected compliance of ninety five percent (95%), then weekly for two (2) weeks with an expected compliance of ninety eight percent (98%).
The Facility Administrator or designee will conduct audits to verify the "Early Termination of Treatment against Medical Advice" form is signed by patient and RN for prescribed treatments not met: on twenty five (25%) of the treatment records daily for two (2) weeks with expected compliance of ninety five percent (95%), then weekly for two (2) weeks with an expected compliance of ninety eight percent (98%).
The Facility Administrator or designee will monitor ongoing compliance for both audits with the monthly ten percent (10%) medical records audit with expected compliance rate of one hundred percent (100%). The Facility Administrator or designee will review the audit results with teammates during homeroom meetings, and with Medical Director during monthly Quality Assessment and Performance Improvement 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.