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

The Facility Administrator or designee held mandatory in-services for all clinical Teammates starting on 08/17/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 02-05-02 "Daily Water System Total Chlorine Monitoring" and Policy 2-05-02H "Total Chlorine Test using RPC Ultra Low Total Chlorine Test Strip" with emphasis on but not limited to: 1) Rinse the sample collection cup thoroughly with the water to be tested. Fill the sample cup to the line marked 100 ml with the sample. 2) Remove one test strip from the foil package and dip it in the water sample for 60 seconds. While dipping the strip, move it back and forth at a constant gentle rate of approximately two, 1-2 inch wide strokes per second. 3) Remove the strip and shake once, briskly, to remove excess water. 4) Wait 20 seconds for the test strip color to develop. While waiting, fold the white plastic handle of the test strip under the test pad area so that it provides a consistent viewing background. 5) After the 20 second wait period, immediately compare the strip color to the K100-0118 color chart to determine the Total Chlorine level in the sample. 6) Document tests results and take any necessary actions per the policy: "Daily Water System Total Chlorine Monitoring". Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet. The Facility Administrator will perform observational audits to verify teammates, including those observed by surveyor, are performing total chlorine monitoring per policy: daily on treatment days for two (2) weeks, then weekly for two (2) weeks, and monthly for two (2) months. Instances of non-compliance will be addressed immediately. Repeat non-compliance will require additional education and possible disciplinary attention. The Facility Administrator will review the 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.

The Facility Administrator held mandatory in-services for all clinical teammates starting on 08/07/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 4-06-05 "Tuberculosis (TB) Monitoring and Follow Up" with the emphasis on but not limited to: 1) NOTE: Teammates will adhere to requirements related to initial and annual testing if required by their institution or local/state health departments. 2) Baseline new hire requirements for all new teammates including volunteers, per diem teammates, non-agency personnel and teammates will complete the following: 1. TN-Risk Assessment and Symptom Evaluation Questionnaire. 2. Successful completion of Tuberculosis Education for New Teammates course. 3. 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 Facility Administrator or designee will review the audit results 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.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/12/22. 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 (BFR) which is verified and documented when the ordered rate is obtained after onset of treatment. The prescription components are confirmed by a licensed nurse within 1 hour of treatment initiation along with the nursing assessment. 2) Intra dialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes vital signs and treatment monitoring at least every 30 minutes. At a minimum, obtain and document the following: blood and dialysate flows... 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) The licensed nurse notifies the physician (or NPP if applicable) as needed of changes in patient status. 5) 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 teammate's signature on in-service sheet. The Facility Administrator or designee will conduct audits to verify complete and accurate documentation, with notification of and response by the licensed nurse, per policy: on twenty five percent (25%) of the flow sheets daily on treatment days 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 will review the 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.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/12/22. 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 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) Abnormal findings or findings outside of any patient specific physician ordered parameters will be documented and 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. 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 complete and accurate documentation, with notification of and response by the licensed nurse, per policy: on twenty five percent (25%) of the flow sheets daily on treatment days 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 will review the 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.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 09/12/22. 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" and Policy 1-14-01 "Interdisciplinary Team (IDT) Patient Assessment and Plan of Care" emphasizing but not limited to: 1. Data Collection: 1) 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. 2) The licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions are necessary. The physician (or non-physician practitioner (NPP) if applicable) will be notified of any concerns that may preclude the initiation of dialysis. 3) The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 4) 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. 5) Unless other abnormal parameters are established by the facility Governing Body and documented in the Governing Body Meeting minutes, the following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record. Fluid Status: Pre-treatment: Removal goal not to exceed maximum ordered by physician. Post treatment: If the patient is above or below one (1) kg from the target weight. 2. IDT: 1) The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs... 2) Assessment criteria will include, but not be limited to, evaluation of: Dialysis prescription, blood pressure and fluid management needs. 3) The adequacy of the patient's dialysis prescription will be assessed on an ongoing basis as follows: For hemodialysis patients, at least monthly calculations of delivered Kt/V or an equivalent measure. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The IDT will assess and update the patient care plan for MR1 within thirty days, to address post treatment target weight. The Facility Administrator or designee will conduct flow sheet audits for documentation of post treatment patient weight above or below target weight on twenty five percent (25%) of the flow sheets: daily for two (2) weeks, then weekly for two (2) week. Ongoing compliance will be monitored with 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 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.