There are  11 surveys for this facility. Please select a date to view the survey results.

V 0111 The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 04/16/25. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities", Infection Control Quick Reference Guide, Policy 1-06-01 "Medication Policy" with emphasis on but not limited to: A. Infection Control: 1) Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. 2) Cleaning and/or disinfection of equipment and work services will be performed as soon as possible following exposure to blood or other potentially infectious materials... B. IC Quick Reference Guide: 1) After each treatment the floor area around chair/bed and dialysis delivery system will be evaluated and cleaned if necessary. Verification of attendance is evidenced by teammate's signature on the in-service sheet.

Water pitchers are no longer in use on the treatment floor. Paper cups for oral medication administration will be filled as needed. Verification of attendance is evidenced by teammate's signature on the in-service sheet.

The water pitcher is no longer in use on the treatment floor, and has been removed. Paper cups will be filled for oral medication administration as needed.

The Facility Administrator or designee will conduct observational audits to verify the facility is maintained in a clean and sanitary manner, including the floor area in the dialysis station as needed, per infection control guidance: daily for two (2) weeks, then weekly for two (2) weeks, then ongoing compliance will be monitored with the monthly during infection control audits. Instances of non-adherence will be corrected 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

V 0113 The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 04/16/25. 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, Physicians and Non-Physician (NPP) will perform hand hygiene ... b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact ... 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. Verification of attendance is evidenced by teammate's signature on the in-service sheet.

The Facility Administrator or designee will conduct infection control audits to verify teammates perform hand hygiene appropriately, including with glove wearing and glove changing 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.

Relabel each bleach container making sure staff are using the appropriate bleach solution to clean the equipment. Teammates are being audited each turnover that equipment needs wiped down to make sure that they are using the appropriate bleach solution. Teammates will be audited for the next 2-3 weeks to make sure that they following the appropriate policy.

Audit RN every shift to make sure that they are initialing, dating and timing the medications. Making sure that the RN is following the protocol for medications. RN will be audited each shift that medications are given. Medication labels are pre printed for patients as well but theses must also must be checked when the RN is initialing, dating and timing.

V 0715 Governing Body meeting was held on 04/16/2025with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 04/15/25. 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 04/16/25. 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) Food and drinks in the treatment area will be limited to patients. Sharing and storage in the treatment area is not allowed. Verification of attendance is evidences by teammate's signature on the in-service sheet.

The Facility Administrator or designee will conduct infection control audits to verify food and drink are limited to patients' use 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-adherence will be corrected immediately.

The Medical Director will review progress of teammate education, results of audits, and adherence to this plan of correction, as provided by the Facility Administrator during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, 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.