There are  5 surveys for this facility. Please select a date to view the survey results.

E 0040
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting 08/04/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-07-01 "Facility Emergency Management Plan (EMP)" with emphasis on but not limited to: 1) The Facility Administrator or designee, is responsible to: Conduct and review quarterly fire safety and evacuation training and drills for compliance, identify additional training and education needs. 2) Fire safety drills: a. Required on a quarterly basis; one drill to be conducted for each shift of patients; b. Include patient emergency takeoff procedure, policy: Termination of Dialysis in an Emergency; c. Document training for both teammates and patients; d. Complete exercise evaluation and teammate attendance sheet; e. Document in Governing Body and maintain with facility EMP. Verification of attendance is evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will audit fire drill 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-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with the Medical Director during the monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation 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 08/04/23. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-04-01E "AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose" with the emphasis on but not limited to: 1) Step #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. 2) Step #2: Perform hand hygiene. Put on PPE. Rationale: Hand hygiene protects patient and teammate from cross contamination... Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee will conduct infection control audits to verify hand hygiene is performed per vascular access policy: daily for two (2) weeks, then weekly for two (2) weeks; then ongoing compliance will be monitored with the 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 Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

V 0143
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 08/04/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-06-01 "Medication Policy" with emphasis on but not limited to: 1) all medications in the facility are checked monthly. Insulin and other medications with preservatives are dated and initialed once opened. All medications are checked monthly for expiration dates. 2) Medications are ordered and replaced prior to expiration. Unless an exact expiration date is specified, medications with an expiration date of month/year are considered expired the last day of the state month. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee immediately checked all medications for expiration dates. Any medications found expired were removed from inventory and appropriately disposed, including the vaccine vials identified in surveyor's observations. 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 the results of the audits with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assurance and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

V 0147
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 04/03/23. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-04-02B "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" revised April 2023, with the emphasis on but not limited to:
Notes: Perform a 15 second hub scrub of the CVC during the process of connecting or disconnecting from the blood lines, including line reversal, or if the patient is disconnected during treatment for any reason. 1) Step #1: Perform hand hygiene per procedure. Put on PPE and provide a mask to the patient. Teammate and patient will wear masks covering the nose and mouth during this procedure. 2) Step #4: Remove old dressing and discard. 3) Step #7: Remove gloves and discard. Perform hand hygiene per procedure and re-glove. 4) Step #14: Remove gloves and discard, perform hand hygiene per procedure and re-glove. 5) Step #15: Holding catheter with nondominant hand, use other hand to place sterile 4x4 under catheter limbs. 6) Step #16: Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly ... Hold the limbs until the antiseptic has dried. 7) Step #17: Attach sterile 10ml syringes to the arterial and venous limbs. 8) Upon completion of dialysis Step #26: Teammate and patient will wear masks covering the nose and mouth during this procedure. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The Facility Administrator or designee will conduct observational audits to verify teammates follow policy steps for CVC exit site care, hub scrub and appropriate use of PPE for teammates and patients during connection, treatment initiation and upon treatment completion: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audits. Instances of non-compliance will be addressed immediately.
The Facility Administrator or designee will review audit with teammates during homeroom meetings, and with the Medical Director during monthly Quality Assessment and Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

V 0550
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 08/04/23. Surveyor observations were reviewed. Education included but was not limited to a review of Procedure 1-04-01E "AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose" with the emphasis on but not limited to: 1) Step #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. 2) Step #2: Perform hand hygiene. Put on PPE. 3) Step #11: While maintaining aseptic technique, cleanse the site by applying skin antiseptic using a circular rubbing motion, moving from the center out and allow to dry. Verification of attendance is evidenced by teammate's signature on the in-service sheet.
The Facility Administrator or designee will perform observational cannulation audits to verify access sites are cleaned prior to use of antiseptic over the cannulation site [either by asking the patient or by performing the antibacterial wash/scrub]: daily for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with 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 Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

V 0552
The Facility Administrator or designee held mandatory in-services for all clinical teammates and the Interdisciplinary Team (IDT) starting on 08/04/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-01-10 "Quality of Life Assessment Survey" with the emphasis on but not limited to: 1) The Quality of Life (QOL) assessment survey is to be administered by the Social Worker to patients within four (4) months of initiating treatment, on an as needed basis, and repeated at least annually thereafter. 2) If a patient refuses to complete the KDQOL – 36 at any time, the Social Worker needs to document the refusal in the KDQOL. 3) The KDQOL Patient Results Report is to be reviewed by the Social Worker with the patient within 30 days of completing the survey. The completed survey and results should be maintained 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, will immediately complete an audit of one hundred percent (100%) of the eligible patient medical records for a current KDQOL survey. Eligible patients without a current survey, or documented refusal, will have one completed by 08/30/23. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit findings with the Interdisciplinary Team and the Medical Director during Quality Assessment Performance Improvement meetings known as Facility Health Meetings, with supporting documentation included in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.

V 0715
A Governing Body meeting was held on 08/17/23, with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 8/04/23. 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 the facility teammates are trained and follow policy and procedure relative to patient admissions, patient care, infection control, and safety. 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 08/04/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-07 "New Patient Pre-treatment Evaluation" with emphasis on but not limited to: 1) A registered nurse (RN) as required by federal regulation will perform an initial pretreatment evaluation of all patients prior to the initiation of their first treatment at the facility. 2) The minimal nursing evaluation prior to initiating treatment for a patient new to the facility should include: a. Neurologic; b. Respiratory; c. Cardiovascular; d. Gastrointestinal; e. Fluid status; f. General assessment; g. Personal; h. Subjective Complaints; and i. Access: assessment. 3) This pre-treatment evaluation will be documented on the New Patient Pre-Treatment Initial Nurse Assessment" Policy 1-03-07A. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee will conduct an audit of one hundred percent (100%) new patient medical records to verify documentation of new patient pre-treatment evaluation: monthly for three (3) months. Ongoing compliance will be monitored with monthly ten percent (10%) medical records audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit results with IDT weekly.
The Medical Director will review progress of teammate education, results of all audits, and adherence to this plan of correction during monthly Quality Assessment Performance Improvement meetings known as the Facility Health Meeting. The Facility Administrator will report progress, as well as any barriers to maintaining compliance, 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.