There are  21 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 on 09/02/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" and 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. Hand hygiene: 1) Hand hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves... 2. Access Cannulation: 1) Step #1 - Have patient wash access site with appropriate antibacterial soap, if able. If patient unable to wash access site, patient care teammate will clean access extremity with skin cleansing agent and pat dry. 2) Step #2 - Perform hand hygiene. Put on PPE. 3) Step #10 - While maintaining aseptic technique, prep each planned needle site by applying a 70% alcohol prep pad to each site using a circular rubbing motion, center out. 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. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct infection control audits to verify proper hand hygiene is utilized during AVF/AVG access care and treatment initiation per policy: daily for two (2) weeks and weekly for two (2) weeks. Ongoing compliance will be monitored 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 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 09/02/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-06-01A "Preparation and Administration of Parenteral Medications (non-Epo, non-Parsabiv) with all Dialyzer Types" with emphasis on but not limited to: 1) If the medication is in a vial, remove the vial cap, and clean vial stopper with an alcohol prep pad. A new alcohol prep pad is used prior to each time a vial is entered. 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 audits for medication preparation to verify compliance with policy: 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 teammates during homeroom 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 09/02/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-06-01 "Medication Policy" with emphasis on but not limited to: 1) All medications are checked monthly for expiration dates. 2) Medications are ordered and replaced prior to expiration. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee immediately and appropriately disposed of all expired dialysate jugs, and completed an audit of remaining dialysate. Any additional expired dialysate containers were removed and properly discarded. 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 the Medical Director during monthly Quality Assessment Performance Improvement known as Facility Health Meeting, 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 08/24/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-01-03 "Accepting End Stage Kidney Failure Patients for Treatment" with emphasis on but not limited to: 1) Prior to First Treatment at any DaVita dialysis facility, the treating facility must provide all patients, including Transfer, Visiting, and Permanent Patients, certain documents and forms to read and/or sign... These documents and forms may include, but are not limited to: ... Authorization for and Verification of Consent to Hemodialysis/Peritoneal Dialysis. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct an audit of one hundred percent (100%) of new admission records monthly for three (3) months to verify compliance of signed patient consents for treatment. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during monthly Quality Assessment Performance Improvement known as Facility Health Meeting, 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 08/24/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-01-03 "Accepting End Stage Kidney Failure Patients for Treatment" and Policy 1-14-07 "Treatment Modality Option Education for Patients" with emphasis on but not limited to: 1. Prior to first treatment: 1) Prior to First Treatment at any DaVita dialysis facility, the treating facility must provide all patients, including Transfer, Visiting, and Permanent Patients, certain documents and forms to read and/or sign... These documents and forms may include, but are not limited to: ... Modality Options (Incenter Hemo Only). 2. Modality Option Education: 1) All patients admitted to a DaVita facility will be informed that they have a choice about their treatment modality and about what their modality options are. 2) Patients will be informed of their options for treatment modalities when initial treatment begins (within the first 30 days after admission to the facility). 3) Modality options will be reviewed with the patient and/or his designee: Within the first 30 days after admission; at the patient request; whenever a new Plan of Care for the patient is created; at a minimum of once per calendar year. 4) Treatment modality option education is to include transplant, in-center hemodialysis (ICHD), home hemodialysis (HHD), peritoneal dialysis (PD), palliative and hospice care, and conservative therapy. Nocturnal options for both ICHD and HHD should also be addressed as appropriate. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct an audit of one hundred percent (100%) of new admission records monthly for three (3) months to verify documentation of modality information was provided to patient prior to treatment initiation and formal education provided within the first thirty (30) days after admission. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during monthly Quality Assessment Performance Improvement known as Facility Health Meeting, 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 08/24/22. Surveyor observations were reviewed. Education included but was not limited to 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 assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines. Verification of attendance is evidenced by teammate signature on in-service sheet. The Facility Administrator or designee will audit one hundred percent (100%) of new patients' medical records monthly for three (3) months, to verify that initial assessment/ plan of care is completed within first 30 days or 13 hemodialysis treatments per policy. Instances of non-compliance will be addressed immediately. The Facility Administrator will review the results of the audits with 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 08/24/22. Surveyor observations were reviewed. Education included but was not limited to 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 follow up 90 day re-assessment will be completed to evaluate patient's status and provide information to adjust the patient's plan of care. Verification of attendance is evidenced by teammate signature on in-service sheet. The Facility Administrator will conduct monthly audits on one hundred percent (100%) of patient assessment and plans of care for three (3) months to verify timely completion of ninety (90) day assessment and plans of care. 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 will review audit results with IDT during Core Team meetings and with Medical Director during monthly Quality Assessment Performance Improvement meeting known as Facility Health Meeting, 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 09/02/22. Surveyor observations were reviewed. Education included but was not limited to 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. Verification of attendance is evidenced by teammate signature on in-service sheet. The Facility Administrator will conduct an audit on all care plans completed during the month to verify proper stability status designation and timely completion of the plan of care 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.

A Governing Body meeting on 9/2/2022, with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 08/24/22. 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 the facility teammates are trained and follow policy and procedure relative to patient admissions, patient care, infection control, and safety. 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 09/02/22. Surveyor observations were reviewed. Education included but was not limited to a review of the following:
1. Policy 1-03-07 "New Patient Pre-Treatment Evaluation" and Policy 1-03-074A "New Patient Pre-Treatment Initial Nurse Assessment" form with emphasis on but not limited to: 1) A registered nurse (RN) as required by federal regulation will perform an initial pretreatment evaluation of all new patients prior to the initiation of their first treatment at the facility. 2) The minimal nursing evaluation prior to initiating treatment for a patient new to the facility should include: a. Neurologic; b. Respiratory; c. Cardiovascular; d. Gastrointestinal; e. Fluid status; f. General assessment; g. Personal; h. Subjective Complaints; and i. Access: assessment. 3) This pre-treatment evaluation will be documented on the 1-03-07A New Patient Pre-Treatment Initial Nurse Assessment 0910 rev 0421, which includes Registered Nurse signature, date and time of completion.
2. Policy 5-01-23 "Peritoneal Dialysis Home Environment Adaptation" with emphasis on but not limited to: 1) The ESRD Conditions for Coverage require an initial home visit when a patient starts home dialysis and when problems are identified as part of monitoring the patient's home adaptation. 2) A Peritoneal Dialysis registered nurse (PD RN) will conduct all home visits. The facility Social Worker and/or Dietitian may accompany the PD RN as needed. 3) For PD patients, home visits must be conducted on the following occasions: a. prior to the initiation of PD training (only if required under Paragraph 5, of Section a. of this Policy and/or applicable state law); b. upon initiation of PD treatment in the patient's home (following PD training); c. if the patient changes permanent residence; d. at such other times as may be required by applicable state law. 4) Consistent with the "New Patient Pre-Treatment Evaluation" Policy, (Policy 1-03-07) a PD RN will perform a new patient pre-treatment evaluation prior to the patient's initiation of PD training. The PD RN will document the pre-treatment evaluation on the DaVita New PD Patient Pre-Treatment Evaluation Form. Verification of attendance is evidenced by teammates' signature on the in-service sheet. The Facility Administrator or designee will audit one hundred percent (100%) of new Hemodialysis (HD) and Peritoneal Dialysis (PD) patient admissions for the presence of the new patient pre-treatment initial nurse assessments, and for PD initial home visits monthly for three (3) months. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will the addressed immediately. The Medical Director will review progress of teammate education, results of audits, and adherence to this plan of correction, as provided by the Facility Administrator during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. Action plans will be evaluated for effectiveness, new plans developed as applicable to achieve compliance with teammate adherence to policy and procedure. The Facility Administrator on behalf of the Governing Body is responsible for compliance with this plan of correction.