There are  3 surveys for this facility. Please select a date to view the survey results.

V 113
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 07/15/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-05 "Infection Control for Dialysis Facilities", Policy 1-04-01E "AV Fistula or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose" and Policy 1-03-12I "Termination of Dialysis Utilizing B Braun Dialog+ Dialysis Delivery Systems with all Single Use Dialyzer Types and Streamline Blood Lines" with emphasis on but not limited to: 1. Hand hygiene: 1)Hand hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, before touching clean areas such as supplies and on exiting the patient treatment area. 2. 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. 2) Perform hand hygiene. Put on PPE. Rational: Hand hygiene protects patient and teammate from cross contamination. 3. Treatment termination: 1) Disconnect venous blood line from the venous access. 2) Discard gloves, perform hand hygiene and put on new gloves. Rationale: Hand hygiene and new gloves are used for performing post dialysis access care per procedure. 3) Perform post dialysis access care per procedure. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct observational infection control audits to verify proper hand hygiene is utilized during cannulation and treatment termination per policy: daily for two (2) weeks and weekly for two (2) weeks. Ongoing compliance will be monitored with the monthly infection control audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review the audit results with teammates during homeroom meetings and with 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 130
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 07/15/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-02 "Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance" with emphasis on but not limited to: 1) Dedicated ancillary supplies such as blood pressure cuffs, clamps, tourniquets, stethoscope, blood glucose meter, bicarb/dialysate jugs, bleach buckets, sharps' container, thermometer, pens, centrifuge, and non-disposable items will be used. 2) Such supplies will be labeled "isolation" and remain in the isolation room/area or station ...Verification of attendance is evidenced by teammate's signature on the in-service sheet. On the day of surveyor's observations, the Facility Administrator directed teammates working in the Isolation room to properly label all dedicated supplies "Isolation", including the stethoscope, centrifuge, sharps container and dialysis chair. The Facility Administrator or designee will perform observational audits daily for two (2) weeks, then weekly for two (2) weeks to verify compliance with proper labeling for "Isolation" supplies. Ongoing compliance will be monitored via the monthly infection control audit. Instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit
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findings with teammates during homeroom meetings and with the Medical Director during the monthly Quality Assessment Performance Improvement meetings known as Facility Health Meeting, with supporting documentation in the meeting minutes. The Facility Administrator is responsible for compliance with this plan of correction.
V 147

V 147
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 07/15/22. 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" with emphasis on but not limited to: 1) Verify patient's clothing is secured away from the exit site/work area. Rational: Securing the patient's clothing away from the work area minimizes the risk of cross contamination. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee will conduct audits to verify CVC care complies with policy: 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 will review audit results with the Medical Director during monthly Quality Assessment Performance Improvement Meeting known as Facility Health Meeting, with supporting documentation in the meeting minutes. The Facility Administrator is responsible for ongoing compliance with this plan of correction.

V 543
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 07/15/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-01-09 "Prescribed Treatment Time Not Met" with emphasis on but not limited to: 1) If a patient's treatment is shortened/early terminated, the RN will document the event in the patient's medical record. Documentation will include, as appropriate... A copy of the 'Early Termination of Treatment against Medical Advice' form signed by the patient, if shortened voluntarily by patient... Verification of attendance is evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct flowsheet audits to verify patient treatments that are not are meeting prescribed treatment times are correctly documented and that 'Early Termination of Treatment Against Medical Advice' form is completed by RN: 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. 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 552
The Facility Administrator or designee held mandatory in-services for all clinical teammates and the Interdisciplinary Team (IDT) starting on 07/15/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-01-10 "Quality of Life Assessment Survey" with 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 Psychosocial condition in the electronic medical record. Verification of re-education will be evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee, with assistance from the Master Social Worker, will complete an audit of one hundred percent (100%) of the patient medical records for current KDQOL surveys by 07/22/22. Patients without a current survey will have one completed by 08/15/22. Ongoing compliance will be monitored with the monthly ten percent (10%) medical records audit. 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.