There are  18 surveys for this facility. Please select a date to view the survey results.

An in-service was given to all Direct Patient Care (DPC) staff on 4/2/2025 by the Clinic Manager (CM) regarding the importance of following facility policy regarding the monitoring of expirations dates on all medications including the change of procedure per below. Procedure IC 61 was updated to reflect A medication list containing all medications in the facility will be maintained and expiration dates monitored on a monthly basis. A box of medication that is opened will have each vial in the box checked for expiration date. Unopened boxes of medication will have the expiration date on the box checked until opened and documented on the medication inventory list. Medications will not be consolidated from two different boxes to one box of the same medicine. Only one box of each medication should be opened at any given time.
The Clinic Manager will ensure compliance by reviewing the monthly medication inventory list and medication expiration dates prior to the monthly Quality Assurance Performance Improvement (QAPI) meeting and document on the CM Monitoring Tool her findings. The CM Monitoring Tool is to be brought to the monthly QAPI meetings for review and all findings discussed by the committee. Further action will be taken as deemed appropriate, which could include more frequent monitoring (bi-weekly), more staff education or disciplinary action.

The facility policy IC 13 was updated to reflect the manufacturers guidelines in use of Chloraprep swabs for catheter care to reflect the back and forth strokes for 30 seconds. An in-service was given to all Direct Patient Care (DPC) staff on 3/25/2025 by Clinic Manager (CM) reviewing the updated procedure change and demonstration of catheter care with emphasis on maintaining aseptic technique during catheter care. All Direct Patient Care (DPC) staff will be observed performing catheter site care by the Clinic Manager and each DPC staff member will have a certificate of competency signed by the Clinic Manager and the Medical Director in their personnel file by 4/30/2025. The Clinic Manager will ensure compliance by observation of catheter care weekly for 6 weeks by each DPC staff with documentation of observations on the Clinic Manager monitoring tool. All breaks in procedure will be immediately addressed by the Clinic Manager. The Clinic Manager will ensure continued compliance through direct observation utilizing the Monthly Infection Control Audit. The audit will be reviewed monthly prior to the Quality Assurance Performance Improvement (QAPI) meeting. All findings will be addressed at the monthly QAPI meeting where additional action will be taken as deemed appropriate, such as additional training, continuing the weekly observations and documentation or if trends are identified, disciplinary action.

An in-service was given to all of the Direct Patient Care (DPC) staff on 4/4/2025 by the Clinic Manager (CM) reinforcing that every part of the dialysis prescription must be supported by a physician order or justified in writing on the treatment sheet as to why the order was not carried out as ordered. This includes Blood Flow Rates (BFR). If the BFR cannot be achieved as ordered, it needs to be documented in the medical record with the reason that the prescribed BFR could not be obtained and the charge nurse notified. The charge nurse must perform and document an assessment. If the BFR cannot be achieved as ordered repeatedly, the physician will be notified and a new BFR ordered. Documentation to this effect will be placed in the patient's medical record. Progress to achieving the maximum BFR needs to be addressed on the Comprehensive Assessment and Plan of Care (CA/POC). The Nurse in Charge, after each shift of patients is on treatment, is to round on each patient to make sure that they are receiving the correct BFR as ordered or justification documented and nursing assessment performed. This will be documented on the Charge Nurse Rounding Log during rounds, the Nurse in Charge is to review treatment sheets upon completion of treatment to verify the patient's ran on their prescribed BFR as ordered by the physician or justification is noted and a nursing assessment documented. Any findings are to be reported to the CM and if repeated inability to obtain ordered BFR, reported to the physician for a new BFR order or other orders per the MD. . The Clinic Manager will ensure compliance through review of this rounding tool and will also review one day of treatment records weekly for 6 weeks to ensure that the BFR is being delivered as prescribed or justified. This review will be documented on the CM Monitoring Tool. All findings from the CN and CM tools will be brought to the monthly Quality Assurance Performance Improvement (QAPI) meeting for review and further action will be taken as deemed appropriate by the committee.

The Vice President of Clinical and Regulatory met with the Medical Director on 4/5/2025 to review the responsibilities of the position of medical director. Emphasis was placed on the responsibility of ensuring that all policies and procedures relative to patient admissions, patient care, infection control and safety are adhered to by all staff that treats patients in the facility including physicians, non-physician providers, registered nurses and patient care technicians. The Medical Director is responsible for ensuring that all staff are following the facility policies including the management of treatment adherence especially related to hypotension pre/during and post treatment. The DPC staff was in-serviced on 4/04/25 by the Clinic Manager in regard to patients presenting with hypotension of 20 or more points pre/during or post treatment. The DPC staff will notify the Charge RN and document this notification. The charge RN will assess the patient for interventions needed by following the standing orders (hypotension procedure IC 34) and if no response in 10 minutes the attending physician will be notified for further orders. If patient continues to be hypotensive for consecutive treatments the charge RN will notify the Clinic Manager. The Clinic Manager will bring this to the attention of the Medical Director for review and a Comprehensive Assessment and Plan of Care (CA/POC) will be implemented until the patient is declared stable. The Charge nurse will review and complete the Charge Nurse Daily Round Sheet by reviewing patient treatment sheets after each shift to identify any areas that were not addressed with BP management during treatment. If any deficiencies are identified the charge nurse will report to the Clinic Manager for further action. The Clinic Manager will ensure compliance by completing an audit of all treatment sheets for one day once per week for 6 weeks to ensure notification, documentation and intervention of hypotension is addressed per policy. The audits will be documented on the CM Monitoring Tool. Any deficiencies identified will be immediately presented to the Medical Director for action to be taken. All findings from the CN and CM tools will be brought to the monthly Quality Assurance Performance Improvement (QAPI) meeting for review and further action will be taken as deemed appropriate by the committee.