There are  20 surveys for this facility. Please select a date to view the survey results.

included in the meeting minutes. The Facility Administrator is responsible for compliance with The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/25/23. Surveyor observations were reviewed. Education included but was not limited to a review of
A. Policy 1-05-01 "Infection Control for Dialysis Facilities", B. Procedure 1-04-02B "Central Venous Catheter with Clearguard HD Antimicrobial End Caps Procedure", C. Procedure 1-04-01E "AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose", D. Procedure 1-03-12A "Termination of Dialysis Utilizing Fresenius 2008 Series Dialysis Delivery Systems and Combiset or Nipro Blood Lines" and E. Procedure 1-04-01B "Post Dialysis Vascular Access Care: Fistula Graft using Safety Fistula Needles" with emphasis on but not limited to:
A. Infection control: 1) All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene... prior to gloving and immediately after removal of gloves; after contamination with blood or other infectious material... 2) Disposable gloves will be worn when caring for the patient or touching the patient's equipment at the dialysis station... Gloves should be changed when... when soiled with blood, dialysate or other body fluids; when going from a "dirty" area or task to a "clean" area or task... 3) Priming containers are to be emptied prior to disinfection. 4) Dialysis station must be completely vacated by the previous patient before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station and set up for the next patient. B. CVC care: 1) Step 12: Place sterile 2x2 gauze over the catheter exit. 2) Step 13: Apply label to the dressing... 3) Step 14: Remove gloves and discard, perform hand hygiene per procedure and re-glove. 4) Step 15: Holding catheter with nondominant hand, use other hand to place sterile 4x4 under catheter limbs... 5) Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub... C. AVF/AVG 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 11: While maintaining aseptic technique, cleanse the site by applying skin antiseptic... D. Termination of dialysis: 1) Step 14: Disconnect venous blood line from venous access. 2) Step 15: Discard gloves, perform hand hygiene and put on new gloves. 3) Step 16: Perform post dialysis access care per procedure. E. Post dialysis access care: 1) Step 1: Perform hand hygiene. Put on PPE. 2) Step 7: Remove needle... 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 teammate infection control practices per policy of proper glove wearing/changing with hand hygiene during CVC and fistula/graft care, treatment initiation and discontinuation, dialysis machine and station disinfection: 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 the Medical Director during Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation this plan of correction.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/25/23. 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: 1) at the end of each treatment, the dialysis station will be cleaned and disinfected. 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). 2) Dialysis station must be completely vacated by the previous patient before teammates can begin to bring disinfection supplies to the station, clean or disinfect the station and set up for the next patient. 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 dialysis station is vacant while station disinfection and set up for the next patient takes place: 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 the Medical Director during 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 was held on 9/20/23 with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 09/15/23. 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 that 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 9/25/23. Surveyor observations were reviewed. Education included but was not limited to a review of policies with areas of emphasis on but not limited to:
1. Policy 1-03-07 "CWOW-Initial Patient Nursing Assessment for New Patients": 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) Whenever possible, the registered nurse will review the patient's current home medications and determine any potential treatment implications, e.g., potential for hypotension. 4) 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.
The Facility Administrator or designee will audit one hundred percent (100%) of new admissions for the presence of the initial pre-treatment nurse assessment, 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.

2. Policy 1-03-08 "CWOW- Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment": 1) Pre-treatment: any abnormal findings or findings outside of any patient specific physician ordered parameters discovered during pre-treatment data collection will be documented and immediately reported to the licensed nurse... 2) Intra-dialytic: 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) Post treatment: 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. 4) All findings, interventions and patient response will be documented in the patient's medical record.
The Facility Administrator or designee will audit treatment records to verify abnormal findings are documented, reported to the RN and addressed appropriately: on twenty five percent (25%) of treatment records daily for two (2) weeks, then weekly for two (2) weeks.

Ongoing compliance for each audit series will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.

Verification of attendance at all in-services will be evidenced by teammates' signatures on the in-services sheets. 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.