There are  19 surveys for this facility. Please select a date to view the survey results.

The Facility Administrator or designee held in-services for all clinical teammates starting on 05/17/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-02-08 "Emergency Equipment Checks" with emphasis on but not limited to: 1) emergency equipment, including, but not limited to, oxygen, airways, suction, automated external defibrillator (AED), and artificial resuscitator (ambu bag), and emergency drugs will be on the premises at all times. 2) Equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional. Daily: Check Status Indicator for green check for Zoll AED; Manufacturer's AED pads are present on cart. Verification of attendance is evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will perform audits to verify supplies are available and checks are being performed: daily for two (2) weeks, then weekly for two (2) weeks, then ongoing compliance will be monitored monthly per policy. 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. 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 held mandatory in-services for all clinical teammates starting on 05/17/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: [Hand Hygiene]: 1) All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene... b. prior to gloving and immediately after removal of gloves... d. after patient and dialysis delivery system contact... f. between patients even if the contact is casual, g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. [Disposable Gloves]: 1) Disposable gloves will be worn when caring for the patient or touching the patient's equipment at the dialysis station ... a. Gloves should be changed when: ii. When going from a "dirty" area or task to a "clean" area or task iii. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify teammates perform hand hygiene and glove wearing and glove changing 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-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. 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 held mandatory in-services for all clinical teammates starting on 05/17/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 8-04-01 "Physical Environment" and Policy 1-06-06 "Medications Requiring Refrigeration" with emphasis on but not limited to: A. 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. B. Medications requiring refrigeration: 1) The refrigerator is checked during facility normal operating hours, by a licensed nurse teammate or designee. Checks will be documented on the 'Medication Refrigerator Management Log'. a. Twice daily temperature checks located on the Digital Data Logger (DDL) display, at the beginning and end of the day. i. Verify that the temperature remains between 2° C and 8° C (36° F and 46°F)... d. Temperature excursions and issues noted during daily check will be noted on log with actions taken and outcome(s). Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. On 06/17/2024, the medication refrigerator thermometer was installed by biomed upon arrival. The Facility Administrator or designee will conduct audits of the 'Medication Refrigeration Management Log' to verify thermometer is functional and documentation is accurate: daily for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. 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. 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 held mandatory in-services for all clinical teammates starting on 05/17/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 8-04-01 "Physical Environment" and Policy 1-06-06 "Medications Requiring Refrigeration" with emphasis on but not limited to: A. 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. B. Medications requiring refrigeration: 1) The refrigerator is checked during facility normal operating hours, by a licensed nurse teammate or designee. Checks will be documented on the 'Medication Refrigerator Management Log'. a. Twice daily temperature checks located on the Digital Data Logger (DDL) display, at the beginning and end of the day. i. Verify that the temperature remains between 2° C and 8° C (36° F and 46°F)... d. Temperature excursions and issues noted during daily check will be noted on log with actions taken and outcome(s). Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. On 06/17/2024, the medication refrigerator thermometer was installed by biomed upon arrival. The Facility Administrator or designee will conduct audits of the 'Medication Refrigeration Management Log' to verify thermometer is functional and documentation is accurate: daily for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. 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. 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.

On 05/21/2024, 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 05/17/24 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 05/17/2024. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-06-01 "Medication Policy" and Policy 08-02-04 "Cardiopulmonary Resuscitation Certification (CPR) with emphasis on but not limited to: A. Medication policy: 1) ... If the medication is not immediately administered or is to be administered by another teammate, the medication must be labeled with the patient name, name of medication, date, time prepared, dose and initials of teammate preparing the medication. B. CPR: 1) All direct patient care teammates (i.e., nurses and patient care technicians) except patient care technician trainees must have current BLS CPR/AED certification. 2) It is the responsibility of the teammate to maintain current BLS CPR/AED certification. Failure to do so will be grounds for termination of employment. 3) Documentation of BLS CPR/AED certification will be maintained in each patient care teammate's personnel file. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will conduct medication preparation and administration audits to verify syringes are proper labeled per medication policy: daily for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. Instances of non-compliance will be addressed immediately
The Facility Administrator or designee immediately completed a one hundred percent (100%) teammate file audit for current CPR certification, with any needed updates scheduled for immediate completion, by 05/24/2024, including for the teammate identified by surveyor record review. Ongoing compliance will be addressed with quarterly teammate file audits. Teammate CPR was completed 06/06/2024 at the next available class. Instances of non-compliance will be addressed 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.