There are  13 surveys for this facility. Please select a date to view the survey results.

The Facility Administrator held mandatory in-services for all clinical teammates starting on 11/22/24. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-06-01A "Preparation and Administration of Parenteral Medications" with emphasis on but not limited to: 1) If medication is in a vial, remove vial cap and clean vial stopper with an alcohol prep pad. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Adminstrator or RN designee will conduct observational audits to verify medication preparation is compliant with policy, including but not limited to cleaning the vial stopper with an alcohol pad prior to withdrawing medication: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly infection control audits. Instances of non-adherence will be corrected immediately. The Facility Administrator 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-serviced for all clinical teammates starting on 11/22/24. 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" and "PRN Order - Clonidine" revised 11/27/24, with emphasis on but not limited to: A. "Pre- Intra – Post Treatment Data Collection...": Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient's dialysis treatment, monitoring during treatment and for reviewing the patient's response to the treatment and status prior to discharge. 1) Patient data will be obtained and documented by the patient care technician or licensed nurse. Data collection includes but is not necessarily limited to: ii. Measurement of blood pressure, sitting and standing BP measurement required pre and post treatment (if patient unable to stand, document reason in the patient electronic record or flow sheet)... iv. Patient weight... 2) Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment ... The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to: ... Treatment time, Target weight ... 3) 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 ... If an abnormal finding is reported to the licensed nurse pre-treatment, the nurse will assess the patient prior to the initiation of dialysis. 4) 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. 5) Abnormal finding parameters or findings outside of any patient specific physician ordered parameters will be documented and 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. 6) All findings, interventions and patient response will be documented in the patients' medical record. 7) Additional documentation if applicable includes the following: ... Indication and patient response to PRN medication. 8) 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. 9) Licensed nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician ... is necessary prior to discharge of the patient from the facility.

[Abnormal Findings]: 1) The following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record. a. Fluid status – Post-treatment: If patient is above or below 1 kg from the target weight. b. Blood pressure: Pre-dialysis: Systolic greater than 180 mm/Hg or less than 90 mm/Hg; Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg. c. Blood pressure: Intradialytic: Systolic greater than 180 mm/Hg or less than 90 mm/Hg; Diastolic greater than or equal to 100 mm/Hg or less than 50 mm/Hg. d. Blood Pressure Post-treatment if the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg; Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. If patient is not able to stand, document reason and sitting BP. e. Pre/ Intra / Post Patient Reports / Complaints / and / or teammate observation of: ... Weakness or numbness... Changes in mobility, ambulation or reports of falls...

B. PRN Order - Clonidine Revised: On 11/27/24, the Facility Administrator, Clinical Coordinator and Medical Director met to review the PRN Clonidine order currently entered for patients. The Medical Directed updated the order to include parameters for administration and frequency. The revised PRN Clonidine order was reviewed by all nurses during the in-services starting on 11/22/24, and includes these parameters: Give 0.1 mg orally every 60 minutes PRN for systolic pressure greater than 180 or diastolic pressure greater than 100. May hold for known intolerance / hypotension / undesirable side effects. Max dose is 0.3 mg per HD treatment. Call physician if unable to maintain Systolic BP less than 180 or Distolic BP less than 100 after max dose administered. Prescription changes were updated in the patients' order set effective 12/02/24. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.

The Facility Administrator or designee will complete flow sheet audits to verify: a. any documentation of abnormal findings or prescription not met, [including but not limited to standing BP not taken with no documented reason and sitting BP; post weight above or below 1 kg difference from target weight], is also reported to the licensed nurse;

b. nurse response is documented, [including but not limited to indication and patient response to PRN medication, and / or notification of physician, as needed];

c. PRN Clonidine is administered as needed, per the revised order set with updated parameters effective 11/27/24.

All audits will be conducted using twenty-five percent (25%) of the treatment flow sheets: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the

monthly ten percent (10%) medical records audits. Instances of non-adherence will be corrected immediately.

The Facility Administrator 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 and the Interdisciplinary Team (IDT) starting on 11/25/24. 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) The facility's interdisciplinary team (IDT) consists of, at a minimum, the patient or the patient's personal representative, a registered nurse, a physician or Non-Physician Practitioner (NPP), if allowed by state ESRD licensure regulations, treating the patient for ESRD, a social worker, and a qualified renal dietitian per CMS. 2) 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's signature on in-service sheet. The Facility Administrator or designee will conduct an audit on all new patients' medical records to verify that initial patient assessment and plan of care documents are completed within thirty (30) days or thirteen (13) hemodialysis treatments per policy: monthly for three (3) months. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-adherence will be addressed immediately. The Facility Administrator or designee will review audit results with the IDT during Core Team 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 held mandatory in-services for all clinical teammates starting on 11/22/224. Surveyor observations were reviewed. Education included but was not limited to a review of Policy1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment. This information will be used in planning and documenting the patient's dialysis treatment, monitoring during treatment and for reviewing the patient's response to the treatment and status prior to discharge. 1) Patient identity, prescription and machine settings are verified by teammates prior to initiation of treatment with the exception of blood flow rate 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, Dialysate flow rate ... 2) Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes: at a minimum, obtain and document the following: ... Blood and dialysate flows, arterial and venous pressures ... 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) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 5) All findings, interventions and patient response will be documented in the patient's medical record. 6) 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. 7) Licensed nurse will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee, including Patient Care Technicians or Registered Nurses will audit flow sheets to verify that documentation of abnormal findings, or prescription not being met, [including but not limited to blood flow rate and / or dialysate flow rate] is also documented as reported to the licensed nurse, and nurse response is documented, including but not limited to communication with physician as needed, per policy: on twenty five percent (25%) of flowsheets daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-adherence will be corrected immediately. The Facility Administrator 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 11/27/24, 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 11/21/24. 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. A plan of correction has been developed and initiated to correct the identified deficiency and to sustain compliance.

The Facility Administrator or designee held mandatory in-services for all for all clinical teammates starting 11/20/24. 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 refrigerated medications ... are to be locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations. Non-refrigerated medications are to be stored in cabinet(s) and locked at the close of each business day or if not under supervision by the licensed teammate or per state regulations. Verification of attendance is evidenced by teammate's signature on the in-service sheet.

On 11/20/24, the medication cabinets were immediately locked upon hearing surveyor's observation. The Facility Administrator or designee will conduct medication audits to verify medications are locked at the end of the business day or if not under supervision by the licensed teammates: daily for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. Instances of non-adherence will be corrected 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.