There are  3 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 12/21/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-04-01B "Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles" and Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 1. Vascular Access Care: 1) the patient will be encouraged to hold their own sites if their condition permits. When the patient holds their cannulation sites, the patient will be offered gloves and performs hand hygiene when completed. Rationale: Gloves and hand hygiene protects patient and family members from cross contamination. 2. Infection Control: 1) Patients are encouraged to wash their hands and access extremity upon entering the treatment area prior to the initiation of dialysis and wash their hands after treatment before leaving treatment area. 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 all patients complete hand washing upon entering the treatment area, hand hygiene upon removing gloves when holding access sites, and handwashing prior to leaving the treatment area: 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 the 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, 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-service(s) for all Clinical Teammates starting on 12/21/22. 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) 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 minimum obtain and document...blood pressure. 2) Any changes in patient conditions or concerns will be documented and reported to nurse at any time. 3) Abnormal Findings: 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. Blood pressure: Blood Pressure-Intradialytic: Difference of 20 mm/Hg increase or decrease from patient's last intradialytic treatment BP reading. 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 teammate's signature on in-service sheet. The Facility Administrator or designee will conduct treatment records audits to verify documentation of proper notification to, and response by the licensed nurse regarding abnormal findings: 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 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 12/21/22. 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 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. 2) 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: ...Whether the patient's nephrologist was notified... 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 which are not are meeting prescribed treatment times for greater than thirty minutes are correctly documented, and that the Registered Nurse has documented notification of patient's nephrologist in the patient's medical record: 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.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 12/23/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-04-01B "Post Dialysis Vascular Access Care: Fistula/Graft Using Safety Fistula Needles" with emphasis on but not limited to: 1) Once bleeding has stopped, discard gauze or band-aid used to hold site. Inspect site for any trauma and for hemostasis. 2) Apply band-aid type or sterile dressing over cannulation site... Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee will conduct vascular access care audits post dialysis to verify care is compliant with policy, and sites are inspected post bleeding for trauma and hemostasis: daily for two (2) weeks, weekly for two (2) weeks, and monthly for two (2) months. 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 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.

A Governing Body meeting was held on 01/04/23 with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 12/21/22. 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 01/04/23. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 3-02-03 "Physician Orders for Patient Care" with emphasis on but not limited to: 1) A physician, in accordance with DaVita Medical Staff Bylaws, federal and state regulations, provides orders for patient care activities in one of the following ways: a. Hand writes or electronically enters orders in the patient medical record; b. Gives verbal or telephone orders; c. Gives orders via DaVita approved secure message via DaVita approved secure message service ("Secure Message")... d. Approves by signature patient specific standing orders. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee will conduct physician orders audits to verify physicians are providing orders for patient care in compliance with one of four ways listed in DaVita policy: daily for two (2) weeks, and 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 Medical Director will review progress of teammate education, results of audits, and adherence to this plan of correction during monthly Quality Assessment and Performance Improvement meetings known as 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.