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

The Facility Administrator or designee will in-service all clinical teammates starting on 08/15/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-07-01 "Facility Emergency Management Plan (EMP)" and Policy 5-01-21 "Home Dialysis Monitoring and Ongoing Education with emphasis on but not limited to: A. EMP: 1) the Facility Administrator or designee, is responsible to provide training for patients upon admission and quarterly: a. One drill to be conducted for each shift of patients. b. Include patient emergency takeoff procedure, policy: "Termination of Dialysis in an Emergency". Documentation of training will be kept in the patients charts, "Emergency Evacuation Acknowledgement Form" B. Home: 1) The following need to be reviewed at least Quarterly: Emergency/disaster preparedness. 2) Maintain information in the patient's medical record. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee immediately completed a one hundred percent (100%) audit of patient emergency preparedness / fire drill documentation. Missing training documentation for any patients, including for those identified by the surveyor was verified on 08/08/24. [Administrative Assistant developed tracker on 08/08/2024 to identify any patients missing on quarterly Emergency Preparedness dates going forward to ensure they are captured immediately upon return to the unit.] The Facility Administrator or designee will audit fire drill / emergency preparedness training documentation for three (3) quarters to verify compliance for all shifts of patients. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-adherence will be correctly immediately.
The Facility Administrator or designee 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 starting on 8/14/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" and 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 a. upon entering and exiting the patient treatment area, b. prior to gloving and immediately after removal of gloves... 2) Disposable gloves will be worn when caring for the patient or touching the patient's equipment at the dialysis station ... 3) Gloves should be changed when: When going from a "dirty" area or task to a "clean" area or task. B. Post dialysis vascular access care: 1) Perform hand hygiene. Put on PPE. Rationale: Hand hygiene protects patient and teammate from cross contamination. PPE is worn to protect teammate. 2) Conclude dialysis and rinse back per termination procedure specific to dialysis delivery system and blood line used in facility. 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 hand hygiene is performed appropriately prior to gloving and immediately after removal of gloves, per policy: daily for two (2) weeks, then weekly for two (2) weeks, then ongoing compliance will be monitored during 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 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 starting on 8/14/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities", Policy 1-02-08 "Emergency Equipment Checks", Policy 1-06-01 "Medication Policy" and Policy 1-08-02 "Obtaining Lab Specimens" with emphasis on but not limited to:
A. Infection control: 1) Supplies will be stored in a manner that maintains their integrity ... Expiration date and package integrity will be verified prior to use. B. Emergency cart: 1) Emergency equipment, including, but not limited to, oxygen, airways, suction, automated external defibrillator (AED), and artificial resuscitator (ambu bag), and emergency drugs will be on the premises at all times. 2) The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: Weekly: Emergency cart (crash cart) is clean, operational and supplies/medications have not expired. C. Medication: 1) Medications containing a preservative must be discarded 28 days after opening or accessed ... Each vial is labeled with the initials of the person opening the vial and the expiration date. 2) All medications are checked monthly for expiration dates. 3) Medications are ordered and replaced prior to expiration. 4) 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. D. Obtaining lab specimens: 1) Teammates are to verify the expiration date on all laboratory specimen tubes prior to collection. Expired laboratory specimen tubes are not to be used and are to be discarded in the sharp's container. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
On 08/05/24, the Facility Administrator directed teammates to remove expired items identified by surveyor's observation and appropriately discard them. The Facility Administrator or designee immediatley completed a one hundred percent (100%) audit of all medications and treatment supplies, crash cart supplies and laboratory supplies with expiration dates to verify all expired items were removed from all areas of the the facility on 08/05/24. Ongoing compliance will be monitored with the monthly infection control audit and the emergency equipment checks per policy. 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 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 starting on 08/19/24. 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) A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted... At least monthly for unstable patients, including but not limited to, patients with the following: Extended or frequent hospitalizations; Marked deterioration in health status; Significant changes in psychosocial needs; Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis. 2) Assessments continue monthly until patient is determined by interdisciplinary team to be stable. Complete patient plan of care meeting within 15 days of the completion of the re-assessment and plan of care. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator designated a Care Plan Champion who will be responsible for identifying which care plans are due with the IDT, then verify plans are completed timely. The Facility Administrator or designee will conduct an audit on all care plans scheduled to be completed during the month, to verify stability status is designated appropriately, [including but not limited to those patients meeting unstable criteria per policy], and assessments and care plans are completed timely: monthly for three (3) months. 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 audit results with the IDT during Core Team meetings, and with the Medical Director during monthly Quality Assessment 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 starting on 08/16/24. 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" [In-center], Policy 1-06-01 "Medication Policy" and Policy 5-01-29 "Daily Home Treatment Record (Flowsheet)" with emphasis on but not limited to:
A. Policy ICHD- Data collection, monitoring and nursing assessment: [Pre-treatment data collection]: 1) Patient data will be obtained and documented by the patient care technician or licensed nurse. Data collection includes: Measurement of blood pressure, sitting and standing and intradialytic BP in the sitting/reclined or supine position and pre and post patient weight. 2) 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. [Intradialytic monitoring]: 1) 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 or sooner as required by state law. 2) 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) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 4) All findings, interventions and patient response will be documented in the patient's medical record. 5) Additional documentation if applicable includes the following: a. All medications including time administered, dose, route and initials of person administering the medication; b. Indication and patient response to PRN medication... [Post Treatment]: 1) 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. [Abnormal findings]: a. 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. b. 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. c. 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. Sitting BP for patient's that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg; Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg.
B. Policy – Medication: 1) Medications are administered as prescribed and then documented in the patient's medical record. No medications are given without an order from the physician or non-physician practitioner (NPP). Medication orders must include the patient name, drug name, dose, route, frequency, date and time the order was received.
C. Policy - Daily home treatment record: 1) As clinically applicable, all treatment data outlined on the Daily Home Treatment Record must be collected. Completed Daily Home Treatment Records must be reviewed to assist in evaluating the patient's progress and self-care decision-making process. This post-treatment data review will be verified by the Peritoneal Dialysis registered nurse documenting review in the medical record per guidance below. a) The licensed nurse (RN/LPN/LVN) will review the patient's data via the submitted Daily Home Treatment Records...d) The licensed nurse is responsible for end of month review for all Daily Home Treatment Records. 2) All Daily Home Treatment Records will be reviewed, attested to, and maintained as part of the patent's medical record.
In-Center: The Facility Administrator or designee will complete flow sheet audits to verify any documentation of abnormal findings is also reported to the licensed nurse, and response is documented including but not limited to post treatment assessment, and physician notification as needed, per policy: on twenty five percent (25%) of the 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.
PD: PD nurses will re-train all patients on the new treatment form, re-educating them on the importance of placing Dextrose choice on either the flowsheet or in the Electronic Treatment Record. The Facility Administrator or designee will conduct audits on one hundred percent (100%) of the home treatment forms to verify all treatment data which is outlined on the daily treatment record is collected; PD nurse has reviewed; if abnormalities are noted, they will be documented in the clinical record and physician notified if applicable: monthly for three (3) months. 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 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 starting on 08/16/24. 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" 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 which is verified and documented when the ordered rate is obtained after onset of treatment. 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. Prescription components include but are not necessarily limited to: Blood Flow rate, Dialysate flow rate ... 2) 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. 3) 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 teammates signature on in-service sheet.
The Facility Administrator or designee will conduct audits to verify when teammates document the prescription is not being met, the licensed nurse is notified, and the nurse responds appropriately to the findings per policy: on twenty five percent (25%) of the 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-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 monthly Quality Assessment 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 8/14/24, 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 08/08/24. 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. 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 08/15/24. Surveyor observations were reviewed. Education included but was not limited to a review of facility policies outlined below. Verification of attendance is evidenced by teammate's signature on the in-service sheet.

1. [Visible access]: Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: 1) Intradialytic treatment monitoring and data collection includes, Vital signs completed at least every thirty (30) minutes. At a minimum, obtain and document: Vascular access visible and line connections intact... 2) The vascular access site, blood line connections and the patient's face should be visible throughout the dialysis treatment.
The Facility Administrator or designee will conduct daily observational audits to verify teammates are confirming patient's access site, face and bloodline connections are visible throughout the dialysis treatment, including but not limited to uncovering the blanket from the access site]: daily for two (2) weeks, then weekly for two (2) weeks, then ongoing monthly during infection control audits. Instances of non-adherence will be addressed immediately. Patients refusing to keep access, bloodline connection or faces visible will be re-educated by the physician. Care conferences will be scheduled with the Interdisciplinary team and the patient to develop individual plans of correction.

2. [Cleanse access extremity]: Policy 1-05-01 "Infection Control for Dialysis Facilities and Policy 1-04-01E "AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula
Needles (SFN) and Administration of Heparin Loading Dose" with emphasis on but not limited to:
A. Infection control: 1) Patients and caregivers will be encouraged to a. Wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis.
B. AV Fistula or Graft Cannulation: 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. Rationale: Verifies that access extremity has been cleaned.
The Facility Administrator or designee will conduct observational audits to verify teammates are encouraging patients to wash hands and access extremity upon entering the treatment area and confirm with the patients they are doing so: daily for two (2) weeks, then weekly for two (2) weeks, then monthly for two (2) months. Instances of non-adherence will be corrected immediately.

3.[Home treatment flow sheets]: Policy 5-01-29 "Daily Home Treatment Record" [Home] with emphasis on but not limited to: 1) As clinically applicable, all treatment data outlined on the Daily Home Treatment Record must be collected. Completed Daily Home Treatment Records must be reviewed to assist in evaluating the patient's progress and self-care decision-making process. 2) All Daily Home Treatment Records will be reviewed, attested to, and maintained as part of the patent's medical record.
The Facility Administrator or designee will conduct audits on one hundred percent (100%) of the home treatment forms to verify all treatment data which is outlined on the daily treatment record is collected, [including but not limited to pre and post temperature readings]; PD nurse has reviewed; if abnormalities are noted, they will be documented in the clinical record and physician notified if applicable: monthly for three (3) months. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audits. Instances of non-compliance will be addressed 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.