There are  7 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 08/05/24. . 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 documentation for any patients, including for those identified by the surveyor was completed by 08/09/24. 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-service(s) for all clinical teammates starting on August 5, 2024. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 5-06-01 "Infection Control for Dialysis Facilities (PD)" with emphasis on but not limited to: 1) Supplies will be stored in a manner that maintains their integrity... Expiration date and package integrity will be verified prior to use. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee immediately checked all supplies medications for expiration dates. Any supplies found expired were removed from inventory and appropriately disposed, including those identified in surveyor's observations on 08/01/24. The Facility Administrator or designee will monitor ongoing compliance with the monthly infection control audit. 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 08/05/24. 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] and Policy 5-01-29 "Daily Home Treatment Record" [Home] with emphasis on but not limited to: A. Policy - In-center: 1) Patient identity, prescription and machine settings are verified by teammates prior to initiation of treatment with the exception of blood flow rate (BFR) which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription component are confirmed by a licensed nurse by 1 hour of treatment initiation along with the nursing assessment. Prescripton components include but are not necessarily limited to:.....Blood fow rate (BFR). 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) Abnormal findings or findings outside of any patent specifc physician ordered parameters will be reported to the licensed nurse immediately. The licensed nurse will use his/her clinical judgment based on individual patent needs to determine if any clinical interventons are necessary.. 4) Abnormal Findings: ... the following are considered abnormal findings and should be reported to the licensed nurse and documented on the patient's medical record. Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the licensed nurse at any time ... [Blood Pressure: Pre dialysis]: ... Systolic greater than 180 mm/Hg (millimeter/Mercury) or less than 90 mm/Hg; Diastolic greater than or equal to 100 mm/Hg. [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. [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. 5) 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. 6) All findings, interventions and patient response will be documented in the patient's medical record.
B. Policy – Home: 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) Abnormal findings:
the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record. [Fluid Status]: If patent is above or
below 2 kg from the target weight and if patent is using 4.25% (red) dialysate. [Blood Pressure]:
Systolic greater than 150mm/Hg or less than 90mm/Hg, Diastolic greater than or equal to 100mm Hg. [Temperature Pre/Post/PRN]: Greater than 100 degrees Fahrenheit or 2 degree rise over baseline. 3) All Daily Home Treatment Records will be reviewed, atested to, and maintained as part of the patent'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 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 treatement 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.
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 08/05/24. 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", Policy 1-01-09 "Prescribed Treatment Time Not Met" with emphasis on but not limited to: A. Policy "Pre- Intra- Post Treatment...": 1) Patient identity, prescription and machine settings are verified by teammate 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 ... 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) 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. 5) All findings, interventions and patient response will be documented in the patient's medical record.
B. Policy "Prescribed Treatment Time Not Met": 1) [Completion of the Early Termination of Treatment Against Medical Advice form]: a) The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. b) The RN will obtain the patient's signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient's signature prior to rinse-back, the RN will obtain the patient's signature on the form prior to the patient's departure from the facility. c) An RN must countersign all Early Termination of Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form.
2) [Prescribed Treatment Time Not Met]: a) If shortened/early termination of treatment time exceeds 30 or more minutes, the RN will notify the patient's attending nephrologist to discuss the appropriate intervention (if any), including what additional medical orders may be necessary to address the patient's specific needs. b) Shortened/Early Termination of the dialysis treatment includes all reasons the prescribed dialysis time is not met by 30 or more minutes. This includes but is not limited to: the late initiation of treatment with termination at scheduled time, early termination at the end of treatment and interruptions of dialysis during the treatment i.e. machine or access problems or use of the bathroom by the patient. c) If a patient's treatment is shortened/early terminated, the RN will document the event in the patient's electronic health record. d) A completed copy of the Early Termination of Treatment Against Medical Advice form will be kept in the patient's health record.
The Facility Administrator or designee will conduct audits: 1) to verify any documentation of abnormal findings including but not limited to inability to obtain blood flow rate], is also reported to the licensed nurse, and response is documented per policy: 2) to verify the "Early Termination of Treatment against Medical Advice" form is signed by the patient and Registered Nurse when treatment times are not met on the treatment record as prescribed. Each audit series will be conducted on twenty five (25%) of the flow sheets daily for two (2) weeks then weekly for two (2) weeks, then ongoing compliance will be monitored with the mothly 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.

A Governing Body meeting with the Medical Director, Facility Administrator, Nursing Manager and Regional Operations Director was held on 08/05/24, to review the results of the survey ending on 08/01/24. 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 08/05/24. Surveyor observations were reviewed. Education included but was not limited to a review of policies outlined below. Verification of attendance at the in-service 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. 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: 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 Cannulaton with Nipro or Medisystems Safety Fistula
Needles (SFN) and Administraton 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 patients 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 addressed immediately.
3. Policy 4-06-05 "Tuberculosis Monitoring and Follow-Up" with emphasis on but not limited to: 1) Testing options ... c. If exemption criteria for TST is not met, the following testing options are available: i. Baseline TST using a two-step Purified Protein Derivative (PPD) Mantoux test (a second TST repeated one to three weeks after the first if the initial test is negative). Test results will be recorded on the Teammate Health Monitoring Record. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator will audit one hundred percent (100%) of new teammate's medical records monthly for two (2) months to verify screening is completed and documentation recorded per policy. 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.