There are  12 surveys for this facility. Please select a date to view the survey results.

V 0178

The Facility Administrator or designee held mandatory in-services for all clinical and biomed teammates starting on 10/06/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 2-06-01 "Water Culture Policy" with emphasis on but not limited to: 1) The Facility Administrator or designee is responsible for verifying that cultures are obtained, results recorded, reviewed and necessary actions taken, as applicable. 2) The Medical Director documents a review of all water culture results monthly. 3) Results and trends are reviewed during the Facility Health Meeting (FHM) and documented in the meeting minutes. 4) Routine water cultures are collected monthly and within 72 hours prior to scheduled disinfection of distribution systems. Monthly is defined as within a calendar month. 5) Interpreting culture results: Acceptable level = below 50 cfu/ml; Action level = 50 – 99 cfu/ml; Unacceptable level = 100 cfu/ml or greater. 6) Required responses to action or unacceptable culture results for single site at or above the action level: a. Notify Medical Director of results within 48 hours of receiving the result. b. Re-culture of the site within 7 days of original sample collection date. c. If repeat sampling result is below the action level, no further action is required. d. If repeat sampling result is at or above the action level, notify the Facility Administrator/designee, Biomedical Services, Medical Director and enter Troubleshooting Mode...
Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheets. Any staff member not present will review the in-service with the Facility Administrator or designee upon returning to work.
The Facility Administrator or designee will conduct audits on water culture results to verify results are within acceptable range and if not, the appropriate actions have been taken within the appropriate timeline of seven (7) days: monthly for two (2) months with ongoing compliance monitored monthly per policy. 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 the Medical Director during monthly Quality Assessment and 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.

V 0199

The Facility Administrator or designee held mandatory in-services for all clinical and biomed teammates starting on 10/06/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 2-04-02A "Daily Water Treatment Log" with emphasis on but not limited to: 1) All observations and test results must be recorded on the approved Daily Water Treatment Log and required IT Clinical System entries. 2) Only teammates who have been trained to perform the observations and testing required to complete the Daily Water Treatment Log will be permitted to observe, test and document their findings. 3) Observations and test results listed on the Daily Water Treatment Log and in the IT Clinical System are entered each facility operating day prior to the use of dialysis quality water for any process and the start of dialysis treatments, except for hardness testing, done at the end of the treatment day. 4) The initials and signature of the teammate performing and recording all observations and test results are entered where indicated on the Daily Water Treatment Log. A separate entry of time and initials is provided for the teammate performing end of day hardness testing. 5) A licensed nurse reviews the Daily Water Treatment Log for completeness and verifies that all parameters are within specified limits. Upon satisfactory completion of this review, the licensed nurse initials and signs the log form where indicated. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheets. Any staff member not present will review the in-service with the Facility Administrator or designee upon returning to work.
The Facility Administrator or designee will conduct audits of Daily Water Treatment Logs to verify a separate entry of time and initials is provided for the teammate performing end of day hardness testing: daily for two weeks, then weekly for two (2) weeks, then monthly for tow (2) months. Ongoing compliance will be monitored for Facility Monthly Report. 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 the Medical Director during monthly Quality Assessment and 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.

V 0503

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 10/06/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection Monitoring and Nursing Assessment" with emphasis on but not limited to: 1) Patient identity, prescription and machine settings are verified by teammates prior to initiation of treatment with the exception of blood flow rate (BFR) which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment. Prescription components include but are not necessarily limited to: Blood flow rate... 2) Intra dialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes vital signs and treatment monitoring at least every thirty (30) minutes. 3) 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. 4) 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. 5) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 6) All findings, interventions and patient response will be documented in the patient's medical record. Verification of attendance at in-service will be evidenced by teammate's signature on the in-service sheets. Any staff member not present will review the in-service with the Facility Administrator or designee upon returning to work.
The Facility Administrator or designee will conduct audits to verify accurate and complete documentation and nurse notification as required per policy: on twenty five percent (25%) of the treatment records daily for two weeks (2) then weekly for two weeks. 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 or designee will review the audit results with teammates during homeroom meetings and with the Medical Director during monthly Quality Assessment and 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.

V 0506

The Facility Administrator or designee held mandatory in-service(s) for all clinical teammates starting on 10/06/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-02-28 History and Physical (H&P) Policy" and Policy 3-02-01A "1st Document Recommended Medical Record – HD" rev 1023 with emphasis on but not limited to: A. H&P 1) A comprehensive medical History and Physical (H&P) that addresses the patient's current presentation and health status, including the patient's medical condition related to his or her renal disease, is to be completed or obtained for all new patients within 30 days of admission and in accordance with DaVita policy and state regulations. 2) Recommended Elements of a History and Physical (H&P): 1. Patient Name, MPI#, and Date of Birth...5. Current Medications with dosage including Over the Counter medications and vitamins...9. Allergies 10. Review of Systems/Physical Exam 11. Assessment/Impression
12. Plan..." B. Medical Record: 1) 1) Allergy stickers placed on outside Front Cover of Record (If applicable); remains on active record; update as needed. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheets. Any staff member not present will review the in-service with the Facility Administrator or designee upon returning to work.
The Facility Administrator or designee will conduct audits on one hundred percent (100%) of patients' medical records to verify allergies listed on History and Physical document and allergy labels on the charts are in agreement, by 10/20/23. 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 the results of the audits with teammates during homeroom meetings and with the Medical Director during monthly Quality Assurance and 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.