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

The Facility Administrator or designee held mandatory held in-services with all clinical teammates starting on 09/27/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-02-08 "Emergency Equipment Checks" and Policy 1-06-01 "Medication Policy" with emphasis on but not limited to: A. Emergency equipment checks: 1) The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: Daily: Check Status Indicator for green check for Zoll AED; break away lock is intact. Weekly: Emergency cart (crash cart) is clean, operational and supplies/medications have not expired. 2) A list of all dated supplies will be posted, with the expiration dates, on the cart and is to be checked weekly by licensed nurse teammate assigned to check the emergency cart. B. Medication policy: 1) Medications are ordered and replaced prior to expiration. 2) Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations. Verification of attendance is evidenced by teammate's signature on in-service sheet.
On 09/11/23 the Facility Administrator immediately removed expired medication from emergency cart and appropriately disposed of it.
The Facility Administrator or designee will perform audits of emergency equipment cart to verify checks are being performed and fresh supplies are available: daily for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. 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 the 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 all clinical teammates starting on 9/27/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-07-01 "Facility Emergency Management Plan (EMP)" with emphasis on but not limited to: 1) the Facility Administrator or designee, is responsible to conduct fire safety drills. 2) Fire Safety drills: a. Required on a quarterly basis; one drill to be conducted for each shift of patients; b. Include patient emergency takeoff procedure, policy: Termination of Dialysis in an Emergency; c. Document training for both teammates and patients; d. Complete exercise evaluation and teammate attendance sheet; e. Document in Governing Body and maintain with facility EMP. Verification of attendance is evidenced by teammate's signature on in-service sheet.


The Facility Administrator or designee will audit one hundred percent (100%) of patient medical records for the documentation of quarterly fire safety preparedness trainings: quarterly for three (3) quarters. Ongoing compliance will be monitored by the Facility Administrator or designee with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit results with the Medical Director during the 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 09/27/23. 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) All teammates ... will perform hand hygiene b. prior to gloving and immediately after removal of gloves... d. after patient and dialysis delivery system contact ... g. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2) Gloves should be changed when: going from a "dirty" area or task to a "clean" area or task. 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 glove wearing and changing with hand hygiene per policy: daily for two (2) weeks, then weekly for two (2) week. 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 the 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 09/27/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 8-04-01 "Physical Environment", Policy 4-08-09 "Eyewash Station / Sink / Drench Shower / Hose Checks" and Policy 1-08-06 "Blood Glucose Testing" with emphasis on but not limited to:
A. Physical environment: 1) the dialysis facility will implement and maintain a program to verify that all equipment, including emergency equipment, dialysis delivery systems and the water treatment systems are maintained and operated in accordance with the manufacturer's recommendations.
B. Eyewash station: 1) Plumbed eyewash stations/sinks/drench showers/hoses are to be activated weekly to flush the line and verify proper operation. 2) Inspections will be documented on the Weekly Eyewash and Drench Shower/Hoses Inspection log.
C. Blood glucose testing: 1) Quality control testing is completed prior to the first use of the day when the DaVita approved blood glucose monitor is used for patient blood glucose testing... Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct audits of:
A. Glucose control log to verify control tests are performed and documented prior to first use of each treatment day: 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.
B. Weekly Eyewash ... Inspection log to verify activation to flush line and verify operation: weekly for four (4) weeks and monthly for two (2) months. Ongoing compliance will be monitored with the Monthly OSHA and Safety Checklist. Deficiencies not corrected immediately will be documented on the Monthly OSHA and Safety Plan of Correction [last page of the checklist] outlining the: deficiency, cause of the deficiency and corrective action: expected date of correction and actual date of correction.
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.

A Governing Body meeting was held on 9/25/2023 with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 09/14/23. 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, including the Interdisciplinary Team (IDT) starting on 09/27/23. Surveyor observations were reviewed. Education included but was not limited to a review of facility policies with areas of emphasis on but not limited to:
1. Policy 1-14-01 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. 2) An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis 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 the 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 patient assessment and plan of care documents are completed within thirty (30) days or thirteen (13) hemodialysis treatments per policy. Ongoing compliance will be monitored by the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.
2. Policy 1-3-08 "CWOW - Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: 1) The Nursing assessment will be performed and documented by a licensed nurse; specifically a Registered Nurse (RN) or if performance of a nursing assessment is permitted by state law, a Licensed Practical Nurse (LPN) / Licensed Vocational Nurse (LVN). 2) 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. 3) The licensed nurse will round on those patients without reported abnormal findings and complete the nursing assessment within one (1) hour of dialysis treatment initiation. The Facility Administrator or designee will conduct audits to verify the nurse assessment is completed on each patient within one (1) hour of treatment initiation: on twenty five percent (25%) of treatment records daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately.
3. Policy 1-06-01 "Medication Policy" with emphasis on but not limited to: 1) Medications are administered as prescribed and then documented in the patient's medical record. The Facility Administrator or designee will conduct audits to verify medications given match medications ordered per physician: on twenty five percent (25%) of treatment records daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with monthly ten percent (10%) medical records audits. 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 all audits, and adherence to this plan of correction during monthly Quality Assessment Performance Improvement meetings known as the Facility Health Meeting. The Facility Administrator will report progress, as well as any barriers to maintaining compliance, 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.