QA Investigation Results

Pennsylvania Department of Health
DIALYSIS CLINIC, INC.
Health Inspection Results
DIALYSIS CLINIC, INC.
Health Inspection Results For:


There are  9 surveys for this facility. Please select a date to view the survey results.

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Initial Comments:



Based on the findings of an onsite unannounced Medicare recertification survey conducted December 9, 2019 through December 11, 2019, Dialysis Clinic Inc was found to be in compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services-Emergency Preparedness.



Plan of Correction:




Initial Comments:



Based on the findings of an onsite unannounced Medicare recertification survey conducted on December 9, 2019 through December 11, 2019, Dialysis Clinic Inc, was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.










Plan of Correction:




494.30 STANDARD
IC-SANITARY ENVIRONMENT

Name - Component - 00
The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas.


Observations:


Based on observation and interviews with staff the facility failed to maintain a sanitary environment to minimize the transmission of infectious agents within and between the unit and other public areas. The facility permitted patients to place personal belonging on the treatment floor for three (3) of three (3) observations.

Findings Included:

Observation on 12/9/2019 at approximately 10:10 a.m. Surveyor observed patient's coffee cup sitting on the floor of station #3 due to the fact that the dialysis chair did not have tables attached to the chair. When the patient finished dialysis treatment at approximately 10:20 a.m. Staff picked up the coffee cup off the floor did not disinfect the bottom of the cup and gave it back to the patient to take home.

Observation on 12/9/2019 at approximately 11:22 a.m. Surveyor observed EMP2 place the patients belongings on the floor near the dialysis chair prior to the initiation of treatment at station 11 due to the fact that the dialysis chair did not have tables attached to the chair. Patient belonging remained on the floor throughout treatment. Patient bag was of cloth material and unable to be disinfected prior to leaving treatment floor.

Observation on 12/9/2019 at approximately 3:45 p.m. Surveyor observed patient belongings sitting on the floor of station 17 near the dialysis chair due to the fact that the dialysis chair did not have tables attached to the chair. Patient belongings remained on the floor throughout treatments. Patient bag was of cloth material and unable to be disinfected prior to leaving the treatment floor.


Interview completed on 12/11/2019 at approximately 3:11 p.m. with EMP1, EMP2 and agency administrator confirmed the findings.











Plan of Correction:

The nurse manager and/or designee will prepare an educational inservice for all clinic staff emphasizing the need for patient materials/belongings to be properly stored at all times. Additionally, plastic bins capable of being disinfected are to be placed behind each patient chair (on chase). These bins will be labeled and patient specific and stored after individual use and disinfection until the patient's next treatment. The inservice will include procedure details for bin use and disinfection of the chase. There will also be an educational handout for patients helping them to understand that their personal belongings cannot be placed on the floor or machines. Both offering will be completed and administered by 1/17/2020 after review by facility governing body at the December Quality Meeting. Evidenced by meeting notes from the Governing body and attendance sign-in sheets.
Finally, the nurse manager and/or designee will audit randomly at least daily audits for 2 weeks, weekly for 2 weeks and monthly for 2 months following the completion of training. Providing that audit is 100% the facility will then audit at least twice per month for the remainder of the year. All audit results will be shared with the Governing Body at subsequent Monthly quality meetings for their review, feedback, and oversight. Evidenced by meeting notes from the Governing Body.



494.30(a)(1) STANDARD
IC-WEAR GLOVES/HAND HYGIENE

Name - Component - 00
Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.




Observations:


Based on a review of facility policy, observations of staff during patient care, and staff (EMP) interview it was determined the facility failed to ensure staff performed hand hygiene after removal of soiled gloves and before donning clean gloves for two (2) of four (4) staff observed. (EMP3, EMP5) and facility failed to ensure patients performed hand hygiene after removed of soiled gloves and before leaving the treatment area for two (2) of two (2) patients (PT) observed (PT2, PT3)

Findings Included:

Review of facility policy completed on 12/11/2019 at approximately 3:00 p.m. revealed: "Hemodialysis Catheter Initiation Policy...effective date 11/20/19...6. Remove gloves, hand hygiene, and don new gloves. 7 Scrub catheter exit site with ChloraPrep...for 30 seconds...9. Remove gloves, hand hygiene, and apply new gloves...11 Apply dry sterile dressing. 12. Scrub each cap with one large alcohol wipe for one minute..."

Review of facility policy completed on 12/11/2019 at approximately 3:00 p.m. revealed: "Fresenius Take Off Procedure...effective date 2/19/2019...14...Patient to hold sites with gloved hand...Patient to be encouraged to do hand hygiene once glove is removed..."

Observation 1.1 on 12/9/2019 at approximately 11:50 a.m. Surveyor observed EMP3 performing Central Venous Catheter (CVC) exit site care and Initiation of Dialysis with CVC. EMP3 removed the old dressing, removed the soiled gloves and and performed hand hygiene and donned clean gloves, scrubbed the site with ChloraPrep for the required time, and then failed to remove the soiled gloves, perform hand hygiene and don clean gloves prior to performing disinfection on the catheter limbs.

Observation 1.2 on 12/11/2019 at approximately 10:30 a.m. Surveyor observed EMP5 performing CVC exit site care and Initiation of Dialysis with CVC. EMP5 removed the old dressing, removed the soiled gloves and and performed hand hygiene and donned clean gloves, scrubbed the site with ChloraPrep for the required time, and then failed to remove the soiled gloves, perform hand hygiene and don clean gloves prior to performing disinfection on the catheter limbs.

Observation 5.1 on 12/9/2019 at approximately 10:05 a.m. Surveyor observed PT2 holding access sites with a gloved hand until hemostasis was achieved. Once hemostasis was achieved EMP2 removed the soiled glove from PT2 hand. PT2 then gathered his belongings, walked to the scale, weighed himself and exited the treatment floor. PT2 failed to wash or sanitize his hands prior to leaving the treatment floor.

Observation 5.2 on 12/9/2019 at approximately 10:30 a.m. Surveyor observed PT3 holding access sites with a gloved hand until hemostasis was achieved. Once hemostasis was achieved EMP3 removed the soiled glove from PT3 hand. PT3 then gathered his belongings, walked to the scale, weighed himself and exited the treatment floor. PT3 failed to wash or sanitize his hands prior to leaving the treatment floor.

Interview completed on 12/11/2019 at approximately 3:15 p.m. with EMP1, EMP3, and agency administrator confirmed the findings.







Plan of Correction:

The nurse manager and/or designee will draft an inservice/educational offering for all staff emphasizing "Hemodialysis Catheter Initiation Policy...effective date 11/20/19...6. Remove gloves, hand hygiene, and don new gloves. 7 Scrub catheter exit site with ChloraPrep...for 30 seconds...9. Remove gloves, hand hygiene, and apply new gloves...11 Apply dry sterile dressing. 12. Scrub each cap with one large alcohol wipe for one minute..." and administer by Jan 6, 2020. Evidenced by attendance sign-in sheet.
The Nurse Educator will begin with focused observation audits each week for 2 weeks beginning on January 6, 2020, then weekly audits for weeks and monthly for 2 months followed by quarterly audits. All audits results will be reported to the Governing Body at the QAPI/Risk meetings monthly as evidenced by meeting minutes from the Governing Body.
The need for further monitoring will be decided and discussed at the QAPI meeting by the governing body in August 2020 after review of outcomes.



494.30(a)(4)(ii) STANDARD
IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL

Name - Component - 00
[The facility must demonstrate that it follows standard infection control precautions by implementing-
(4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-]
(ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment.



Observations:


Based on a review of facility policy and procedure, direct observation (OBS), and staff (EMP) interview, the facility failed to ensure staff cleaned/disinfected contaminated surfaces/equipment for two (2) of two (2) observations and facility failed to ensure staff placed patient belongings in a clean area for one (1) of one (1) observation.

Findings Included:

Review of facility policy completed on 12/11/2019 at approximately 3:00 p.m. revealed: "Machine/Station Disinfection...Effective date: 3/19/19...Station Disinfection:...Wipe down pillow..."

Observation completed on 12/9/2019 at approximately 11:18 a.m. EMP6 was setting a patient into the treatment chair. The patient needed a pillow. EMP6 went over to a pile of dirty pillows picked one up. EMP6 did not disinfect the pillow, covered it with a clean pillowcase and provided it to the patient.

Observation on 12/11/2019 at approximately 10:15 a.m. patient came to clinic via wheelchair with a brown paper bag. Staff set the brown paper bag on top of the dialysis machine [dirty area]

Observation on 12/11/2019 at approximately 10:35 a.m. Surveyor observed EMP5 after starting treatment on patient with Central Venous Catheter. EMP5 had used a cart due to the dialysis chair not having tables attached. EMP5 disinfected the top and second shelf of the cart. EMP5 failed to disinfect the bottom shelf and the bottle of hand sanitizer on the cart before returning the cart to storage.



Interview completed on 12/11/2019 at approximately 3:15 p.m. with EMP1, EMP3 and facility administrator confirmed the findings.

Repeat Deficiency: 12/15/2010







Plan of Correction:

1. The Nurse Manager will review the policy to Disinfection of the Machine and Station area by January 3, 2011. The policy will include all areas of the machine, chair and station to be disinfected after patient use and will address the IV pole, hooks on the pole, blue clamps, sharps containers, acid jugs, bags containing BP cuffs, and opening the chair into a reclining position disinfecting the foot rest area and crevices of the chair. As well as ensuring policy addresses clean vs. dirty area/materials and pillows.
2. The Nurse Manager will have the Governing Body review and approve the Policy and Procedure by January 15, 2020 as needed.
3. The Nurse Manager will in-service all patient care staff on the policy by January 6, 2020. A sign-off sheet will demonstrate details of content and represent those who were in attendance and in-serviced and it will be presented to the Governing Body at the next monthly operational meeting on January 15, 2020.
4. The Nurse Educator will begin with focused observation audits each week for 4 weeks beginning on January 17, 2020. By February 14, 2020 if the audits demonstrate compliance with the policy, the audits will then be performed monthly thru August 2011. All audits results will be reported to the Governing Body at the QAPI/Risk meetings monthly as evidenced by meeting minutes from the Governing Body.
5. The need for further monitoring will be decided and discussed at the QAPI meeting by the governing body in August 2020 after review of outcomes.



494.30(a)(2) STANDARD
IC-STAFF EDUCATION-CATHETERS/CATHETER CARE

Name - Component - 00
Recommendations for Placement of Intravascular Catheters in Adults and Children

I. Health care worker education and training
A. Educate health-care workers regarding the ... appropriate infection control measures to prevent intravascular catheter-related infections.
B. Assess knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters.

II. Surveillance
A. Monitor the catheter sites visually of individual patients. If patients have tenderness at the insertion site, fever without obvious source, or other manifestations suggesting local or BSI [blood stream infection], the dressing should be removed to allow thorough examination of the site.

Central Venous Catheters, Including PICCs, Hemodialysis, and Pulmonary Artery Catheters in Adult and Pediatric Patients.

VI. Catheter and catheter-site care
B. Antibiotic lock solutions: Do not routinely use antibiotic lock solutions to prevent CRBSI [catheter related blood stream infections].





Observations:


Based on review of facility policy, observation of patient care, and staff (EMP) interviews, it was determined the facility failed to ensure staff performed catheter hub decontamination according to facility policy for one (1) of four (4) observations (OBS 3.1)


Findings Included:

Review of facility policy completed on 12/11/2019 at approximately 3:00 p.m. revealed: "Hemodialysis Catheter Takeoff Procedure...effective date: 11/20/19...3. Wrap large sterile alcohol wipes around each end of catheter, scrub for one minute..."

OBS 3.1 completed on 12/9/2019 at approximately 11:00 a.m. Surveyor observed EMP5 during the discontinuation of Dialysis with a Central Venous Catheter. EMP5 wrapped each limb of the catheter with a large alcohol wipe and scrubbed around the end of each catheter for 50 seconds.

Interview completed on 12/11/2019 at approximately 3:15 p.m. with EMP1, EMP3 and agency administrator confirmed the findings.





Plan of Correction:

The nurse manager and/or designee will draft an inservice/educational offering for all staff emphasizing ""Hemodialysis Catheter Takeoff Procedure...effective date: 11/20/19...3. Wrap large sterile alcohol wipes around each end of catheter, scrub for one minute..." and administer by Jan 6, 2020. Evidenced by attendance sign-in sheet.
The Nurse Educator will begin with focused observation audits dailyfor 4 weeks beginning on January 6, 2020. when the audits demonstrate compliance with the policy, the audits will then be performed monthly thru August 2020. All audit results will be reported to the Governing Body at the QAPI/Risk meetings monthly as evidenced by meeting minutes from the Governing Body.
The need for further monitoring will be decided and discussed at the QAPI meeting by the governing body in August 2020 after review of outcomes.




494.60(a) STANDARD
PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY

Name - Component - 00
The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public.



Observations:


Based on observation, medical record review (MR), and interview with staff (EMP), the facility failed to ensure the treatment area, patients and staff were secured from unauthorized access.

Findings included:

Observation completed on 12/9/2019 at 8:45 a.m. Surveyor was escorted to conference room via open door. Surveyor noted that door was not able to be locked from inside. Conference room leads to a series of offices that then leads to the treatment floor allowing for unauthorized access.

Observation completed on 12/9/2019 at approximately 9:30 a.m. Surveyor was escorted during flash tour and noted that their is a patient bathroom located off the treatment floor that also has a door that opens off the reception/waiting area allowing for unauthorized access to the treatment floor.

Observation completed on 12/9/2019 at approximately 9:30 a.m. Surveyor was escorted during flash tour and noted that the doors leading to the supply area were propped open during the entire day.

All observations remained unchanged during entire survey days of 12/9/19, 12/10/19 and 12/11/19. Allowing for unauthorized access to treatment floor, staff, patients and water room.

Review of MR9 completed on 12/10/2019 at approximately 11:10 a.m. due to involuntary discharge. Patient was involuntarily discharged due to threats to staff. Police were called and patient was escorted off premises. During chart review patient was noted to utilize areas of unauthorized access to access treatment floor when not allowed.

Interview completed on 12/11/2019 at approximately 3:15 p.m. with EMP1, EMP3, agency biomed, and agency administrator confirmed the findings.


Repeat Deficiency: 12/15/2010




Plan of Correction:

The Administrator will secure bids for wall/lockable door for both the 'patient bathroom' and office area by Jan 15th as possible. This construction will allow the access doors to the clinic areas from both areas to be secured with locks. The work will be approved as soon as bids received. In the interim we will install a 'pin lock' on the office area. There is currently no safe way to close off the patient bathroom while maintaining quick access to patients who might have emergency needs in that bathroom. Temporarily a lock will be placed on the 'clinic side' making access to the treatment floor impossible from within the visitor/patient bathroom. This should be done by 1/06/2020.


494.90(a)(1) STANDARD
POC-MANAGE VOLUME STATUS

Name - Component - 00
The plan of care must address, but not be limited to, the following:
(1) Dose of dialysis. The interdisciplinary team must provide the necessary care and services to manage the patient's volume status;


Observations:


Based on review of facility policy and medical records (MR) and staff (EMP) interview the facility failed to assess and/or manage patient's blood pressure for two (2) of four (4) incenter hemodialysis MR reviewed (MR5, MR8)

Findings Included:

Review of facility policy completed on 12/11/19 at approximately 3:00 p.m. revealed: "Patient Monitoring...effective date: 2/19/19...1. BP [blood pressure] and pulse are to be taken and recorded on initiation of treatments, every 30 minutes and prn [as needed] if patient symptomatic. 2 Document S/S [signs and symptoms] and medication/intervention given...for every event during treatment. A response to every intervention should be documented in a time appropriate manner..."

Review of MR5 completed on 12/10/2019 at approximately 1:10 p.m. revealed an admission date of 10/1/2017. Treatment sheets were reviewed dated 11/18/2019 through 12/9/2019.
Treatment sheet dated 11/20/2019 revealed patient was assessed at 6:21 a.m. and patient was not assessed again until 7:01 a.m. [40 minutes between assessments]

Review of MR8 completed on 12/10/2019 at approximately 3:35 p.m. revealed an admission date of 7/14/2014. Treatment sheets were reviewed dated 11/18/2019 through 12/6/2019.
Treatment sheet dated 11/20/2019 revealed patient was assessed at 2:51 p.m. and patient was not assessed again until 3:29 p.m. [38 minutes between assessments]
Treatment sheet dated 11/25/2019 revealed PCT assessed patient BP at 12:42 p.m. to be 84/47 and did not notify the RN. PCT again assessed the patient BP at 1:23 p.m. and found the BP to be 82/41 and did not notify the RN or provide any intervention.

Review of standings orders completed on 12/11/2019 at approximately 2:00 p.m. revealed: "Fluid Replacement: NSS [Normal Sterile Saline] up to 500 cc IV [intervenous] per treatment...Sodium Chloride 23.4 % IV ...prn [as needed] hypotension...with 20 minute intervals between doses..."

Interview completed on 12/11/19 with EMP1, EMP3 and facility administrator confirmed the findings.

Repeat Deficiency: 12/6/2016







Plan of Correction:

The Nurse Manager will review the policy specific to Patient Monitoring by December 28th, 2020 and ensure an inservice for all staff is completed by 1/6/2020. This policy addresses the standard of care for patients to have a hour check starting within 30 minutes of their put on time and continuing throughout their entire treatment.
The Nurse Educator will in-service all patient care staff on the policy by January 15th , 2020 by re-educating all patient care staff on timing of hour checks and assignments designated on the daily assignment sheets acknowledging hour checks are assigned and being completed on time. A dated sign-off sheet from each individual staff member will demonstrate details of content and represent staff are educated and have had the opportunity to review the policy in place.
The Nurse Manager will have the Governing Body review this documentation has been completed at the next meeting on January 15th, 2020
The Nurse Educator will begin with focused observation audits each day, for 4 weeks, beginning on January 20th, 2020. When the weekly audits demonstrate compliance with the policy, the audits will then be performed every 2 weeks for one month, then monthly for 2 months, then quarterly. All audits results will be reported to the Governing Body at meetings monthly.
The need for further monitoring will be decided and discussed at the QAPI meeting by the governing body in November 2020, after the 4th quarter results of the audits are discussed by the governing body.



494.90(a)(1) STANDARD
POC-ACHIEVE ADEQUATE CLEARANCE

Name - Component - 00
Achieve and sustain the prescribed dose of dialysis to meet a hemodialysis Kt/V of at least 1.2 and a peritoneal dialysis weekly Kt/V of at least 1.7 or meet an alternative equivalent professionally-accepted clinical practice standard for adequacy of dialysis.


Observations:


Based on a review of facility policy, medical records (MR) and staff (EMP) interviews, it was determined that the facility failed to ensure treatments were delivered in accordance with the dialysis prescriptions ordered by the physician for two (2) of four (4) MR reviewed (MR5, MR10).

Findings Included:

Review of facility policy completed on 12/11/2019 at approximately 3:00 p.m. revealed: "Fresenius Machine Put On Procedure...effective date 1/18/19...6. In the heparin screen set the following...Rate...Infusion time...Bolus amt [amount]...14. Turn blood pump on slowly to 200 and observe for signs of infiltration. Within one minute, increase the blood pump to prescribed blood flow rate [BFR]...17. Prepare to administer heparin bolus if it is ordered..."



Review of MR5 completed on 12/10/2019 at approximately 1:10 p.m. revealed an admission date of 10/1/2017. Treatment sheets were reviewed dated 11/18/2019 through 12/9/2019. Orders effective during treatment sheets reviewed revealed Heparin 6000 units bolus with 500 units each hour of treatment time for hours 1-3.
Treatment sheet dated 12/2/2019 revealed Heparin bolus 6000 units administered. Heparin 500 units each hour for hours 1-3 was not documented as given.
Treatment sheet dated 12/9//2019 revealed Heparin bolus 6000 units administered. Heparin 500 units each hour for hours 1-3 was not documented as given.

Review of MR10 completed on 12/10/2019 at approximately 12:20 p.m. revealed an admission date of 9/2/2019. Treatment sheets were reviewed dated 11/18/2019 through 12/6/2019. Orders effective during treatment sheets reviewed revealed BFR ordered 400.
Treatment sheet dated 12/2/2019 revealed BFR ran at 350 during entire treatment with no reason given. MD not notified.

Interview completed on 12/11/2019 at approximately 3:15 p.m. with EMP1, EMP3 and facility administrator confirmed findings. EMP3 stated, "If MR5 had not received the heparin hourly MR5 system would have clotted so I am sure it was just an error in documentation. With this system we have to document it in each hour as given."

Repeat Deficiency: 12/6/2016





Plan of Correction:

The Nurse Manager will review the Policy on Documentation by December 28th, 2020 and develop an inservice for all patient care staff involved. This policy addresses the need to document when changes in a patient's BFR are made and the reason for the change at any time throughout the patient's treatment.
The Nurse Educator will in-service all patient care staff on the policy by January 15th, 2020. An in-service sign off sheet will demonstrate details of content, those who were in attendance and in-serviced, and the date it was completed.
The Nurse Manager will have the Governing Body review the Policy and Procedure along with the signed off in-service sheets at the meeting scheduled on January 15th, 2020.
The Nurse Educator will begin with observation audits focused on patients running at their prescribed blood flow rate as ordered, or with documentation completed as to why the patient did not run at the prescribed BFR, daily for 2 weeks beginning on January 20th, 2020. When the weekly audits demonstrate compliance with the policy, the audits will then be performed every 2 weeks for one month, then monthly for 2 months, then quarterly. All audit results will be reported to the Governing Body at meetings monthly.
The need for further monitoring will be decided and discussed at the QAPI meeting by the governing body in November 2020, after the 4th quarter results of the audits are discussed by the governing body.



494.90(a)(5) STANDARD
POC-VASCULAR ACCESS-MONITOR/REFERRALS

Name - Component - 00
The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.


Observations:


Based on review of facility policy and procedure, observation (OBS), and staff (EMP) interview, the facility failed to ensure the site was cleaned with antiseptic for the appropriate time for one (1) of two (2) observations (OBS #4.1)

Findings included:

Review of facility policy completed on 12/11/2019 at approximately 3:00 p.m. revealed: "Insertion of Access Needles...effective date 2/19/19...6. Cleanse area with approved anti-microbial...Alcohol is a 60 second contact time..."

OBS 4.1 completed on 12/9/2019 at approximately 11:18 a.m. Surveyor observed EMP6 during the initiation of dialysis with an arteriovenous fistula or graft. EMP6 applied 1 small alcohol wipe to the arterial site and scrubbed it for 5 seconds and then applied 1 small alcohol wipe to the venous site and scrubbed it for 5 seconds and then inserted the needles.

Interview completed on 12/11/2019 at approximately 3:15 p.m. with EMP1, EMP3 and facility administrator confirmed the findings.







Plan of Correction:

The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.

The nurse manager and/or designee will draft an inservice/educational offering for all staff emphasizing "Insertion of Access Needles...effective date 2/19/19...6. Cleanse area with approved anti-microbial...Alcohol is a 60 second contact time..." and administer by Jan 6, 2020. Evidenced by attendance sign-in sheet.
The Nurse Educator will begin with focused observation audits daily for 4 weeks beginning on January 17, 2020. When the audits demonstrate compliance with the policy, the audits will then be performed monthly thru August 2011. All audits results will be reported to the Governing Body at the QAPI/Risk meetings monthly as evidenced by meeting minutes from the Governing Body.
The need for further monitoring will be decided and discussed at the QAPI meeting by the governing body in August 2020 after review of outcomes.