There are  10 surveys for this facility. Please select a date to view the survey results.

V 0113
The Facility Administrator (FA) or designee will educate all clinical teammates on: 1) policy 1-03-12F Termination of Dialysis with Single Use Dialyzer Types specifically steps 16-18 focusing on changing of gloves and hand hygiene between disconnection of patient post treatment and prior to removing needles. 2) Policy 1-05-01 Infection Control for Dialysis Facilities with emphasis on equipment including the dialysis delivery system, the interior and exterior of the prime waste container will be wiped clean with a bleach solution after the completion of procedures and after each treatment. TMs were instructed to empty the prime waste container, return it on the machine, remove gloves, perform hand hygiene, don clean gloves and proceed to disinfect the equipment within the patient station. In addition, hand hygiene is to be performed upon entering the patient treatment area and on exiting the patient treatment area. Verification of attendance will be evidenced by teammate signature on in-service sheet. The FA or designee is audit daily for five (5) days then weekly for four (4) weeks then monthly during internal infection control audits to verify compliance. The results of the audits will be reviewed with the teammates during homeroom meeting and with the Medical Director at Facility Health Meetings (FHM-QAPI) with the supporting documentation included in the meeting minutes. The Fa is responsible for compliance with this plan of correction.

V 0116
The FA or designee will educate all clinical teammates on policy 1-05-01 Infection Control for Dialysis Facilities specifically steps 46 all work surfaces and non-disposable equipment including blood pressure cuffs will be wiped clean with a bleach solution of the appropriate strength before being used on another patient. Verification of attendance will be evidenced by teammate signature on in-service sheet. The FA or designee will audit daily for five (5) days then weekly for four (4) weeks then monthly during internal infection control audits to verify compliance. The results of the audits will be reviewed with the teammates during homeroom meeting and with the Medical Director at FHM-QAPI with the supporting documentation included in the meeting minutes. The Fa is responsible for compliance with this plan of correction.

V0250
The FA or designee will educate all clinical teammates on policy 2-08-01G Measuring conductivity, Temperature and/or pH using the Phoenix Conductivity meter specifically step 8, when finished with the Phoenix meter, Rinse interior thoroughly with dialysis quality water and clean exterior of meter with 1:100 bleach solution before taking to a common clean area or used in another station. Verification of attendance will be evidence by teammate signature on in-service sheet. The FA or designee will audit daily for five (5) days then weekly for four (4) weeks then monthly during internal infection control audits to verify compliance. The results of the audits will be reviewed with the teammates during homeroom meeting and with the Medical Director at FHM-QAPI with the supporting documentation included in the meeting minutes. The Fa is responsible for compliance with this plan of correction.

V 0587
The FA or designee will educate all Peritoneal Dialysis (PD) clinical teammates on policy 5-01-29 Daily Home Treatment Record with emphasis on steps 1, 3, 4, and 7 concentrating on completeness of documentation for all treatments performed, nurse review of flowsheet documentation, and follow-up documentation in the medical record to include education provided to reinforce previously instructed information. Verification of attendance will be evidenced by teammate signature on in-service sheet. The FA or designee will audit ten percent (10%) of medical records monthly to verify compliance. The audit results will be reviewed with the PD teammates and with the Medical Director at FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with the plan of correction.

V 0589
The FA or designee will educate all PD clinical teammates on policy 5-16-01 Peritoneal Dialysis Services in Skilled Nursing Facilities (SNF) specifically step 9, a Peritoneal Dialysis Registered Nurse must visit the SNF to complete a preliminary home visit upon patient being admitted to a SNF. Verification of attendance will be evidenced by teammate signature on in-service sheet. The FA or designee will audit the next five (5) SNF patient admissions for compliance then ten percent (10%) of the medical records during monthly medical records audits. The audit results will be reviewed with the PD teammates and with the Medical Director at FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with the plan of correction.

V 0715
The FA or designee will educate all PD clinical teammates on: 1) policy 5-02-28 New Patient Pre-Treatment Evaluation 5-02-28A New PD Patient Pre-Treatment Initial Nurse Assessment with emphasis on steps 1 and 4, initial pre-treatment evaluation of all new patients must be completed prior to initiation of first treatment/training in the facility and documented on the New PD Patient Pre-Treatment Initial Nurse Assessment form. 2) Policy 5-16-01 Peritoneal Dialysis Services Rendered in Skilled Nursing Facilities with focus to provide compliance guidance in administering PD to patients residing in SNF. DaVita will provide initial and ongoing training to SNF licensed nurses who are designated as DaVita Trained Caregiver or Care Partners for the purpose of dialysis treatment oversight. Only DaVita Trained Caregivers or Care Partners who have completed DaVita's training program may be involved in the dialysis care of patients. Verification of attendance will be evidenced by teammate signature on in-service sheet. The patient training treatment record used during treatment/training in the facility will be updated to include a data field to record treatment start time. The FA will meet with the administrators of SNF facilities where PD patients receive PD treatments to review contract expectations related to initial and ongoing training and develop a plan to ensure ongoing training needs are communicated to DaVita. Training will be completed to ensure all nurses providing care in a SNF are trained by DaVita with competencies verified and documented. The FA or designee will audit all new PD patient admissions medical records monthly for three (3) months to verify the New PD Patient Pre-Treatment Nursing Assessment is completed prior to the initiation of treatment/training. In addition, the FA or designee will audit SNF PD patient flowsheets weekly for four (4) weeks and monthly for three (3) months to verify only trained SNF staff perform peritoneal dialysis treatments for patients as evidenced by signature on flow sheet. The results of the audits will be reviewed with the PD teammates and with the Medical Director at FHM-QAPI with supporting documentation included in the meeting minutes. The FA is responsible for compliance with this plan of correction.