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

V401
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 03/29/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-01 "Medication Policy" and Policy 1-05-01" Infection Control for Dialysis Facilities" with emphasis on but not limited to: A. Medication: 1) The Facility Administrator / designee is responsible for supervising the handling, storing, disposing, administering, and controlling of medications and performs monthly audit and inventory. 2) All open or unopened medication packages (i.e. vials, ampules, etc.) are stored according to the manufacturer's directions. Do not use any medication that has been stored improperly or has expired. 3) All medications in the facility are checked monthly for expiration dates. 4) Disposal of expired medications, including all over the counter and nutritional product samples are removed from the treatment and inventory areas and disposed of per state/local regulations. B. Infection control: 1) Supplies will be stored in a manner that maintains their integrity. 2) Expiration date and package integrity will be verified prior to use. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator or designee immediately conducted a one hundred percent (100%) audit of all medications and supplies with expiration dates. Any items identified as expired in the audit were immediately and appropriately discarded, including items identified by the surveyor's observations.
Ongoing compliance will be monitored by Facility Administrator or designee per policy with the monthly infection control audit. 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 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.

V544

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 03/29/24. 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", Policy 1-01-09 "Prescribed Treatment Time Not Met" and Policy 1-01-09A "Early Termination of Treatment Against Medical Advice" form, with emphasis on but not limited to:
A. Policy "Pre- Intra- Post Treatment...": 1) Patient data will be obtained and documented by the patient care technician (PCT) or a licensed nurse. 2) The nursing assessment will be performed and documented by a licensed nurse. The assessment includes, but is not limited to ... verification of prescription including machine parameters... 3) Patient identity, prescription and machine settings are verified by teammate prior to initiation of treatment with the exception of blood flow rate which is verified and documented when the ordered rate is obtained after onset of treatment. 4) The prescription components are confirmed by a licensed nurse within one (1) hour of treatment initiation along with the nursing assessment or as allowable by state law. Prescription components include but are not necessarily limited to ... Blood flow rate and Dialysate flow rate. 5) Intradialytic treatment monitoring and data collection which may be performed by the PCT or licensed nurse includes, but is not limited to... Blood and dialysate flows... 6) 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. 7) Abnormal findings or findings outside of any patient specific physician ordered parameters will be 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. 8) All findings, interventions and patient response will be documented in the patient's medical record.
B. Policy "Prescribed Treatment Time Not Met": 1) [Completion of the Early Termination of Treatment Against Medical Advice form]: a) The Registered Nurse (RN) will verify that a patient signs the Early Termination of Treatment Against Medical Advice form any time the patient requests to terminate their treatment earlier than the prescribed run time. b) The RN will obtain the patient's signature on the Early Termination of Treatment Against Medical Advice form prior to the patient being rinsed back from their treatment. If unable to obtain the patient's signature prior to rinse-back, the RN will obtain the patient's signature on the form prior to the patient's departure from the facility. c) An RN must countersign all Early Termination of Treatment Against Medical Advice forms. A witness signature is required only if the patient refuses to sign the form.
2) [Prescribed Treatment Time Not Met]: a) 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. b) Shortened/Early Termination of the dialysis treatment includes all reasons the prescribed dialysis time is not met by 30 or more minutes. This includes but is not limited to: the late initiation of treatment with termination at scheduled time, early termination at the end of treatment and interruptions of dialysis during the treatment i.e. machine or access problems or use of the bathroom by the patient. c) If a patient's treatment is shortened/early terminated, the RN will document the event in the patient's electronic health record. Documentation will include, as appropriate: the amount of time by which the treatment was shortened; a description of why the treatment was shortened; whether the patient's nephrologist was notified; a description of the follow-up medical orders provided by the patient's attending nephrologist (if any); a description of all other interventions planned to address the shortened treatment, including recommendations to the patient. d) A completed copy of the Early Termination of Treatment Against Medical Advice form will be kept in the patient's health record
C. Form "Early Termination of Treatment Against Medical Advice": 1) " I, ____ request to terminate my dialysis treatment prior to the prescribed time. I am fully aware that this is against the medical advice of my physician. The risk and consequences of terminating my treatment
early have been previously explained to me by my physician. I understand that if, before my next treatment, I have any unusual symptoms such as shortness of breath or chest pain I should immediately contact my physician. I hereby willfully assume the risk of my early termination of dialysis treatment and agree not to hold my physician, the dialysis facility, its employees or agents responsible for any harm or injury which may result from my action."
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:
1) to verify teammates complete appropriate documentation on the treatment record and notify the RN concerning prescribed blood flow rate, and dialysis flow rate if parameters are not meeting treatment prescription, with appropriate RN intervention documented.
2) to verify the "Early Termination of Treatment against Medical Advice" form is signed by the patient and Registered Nurse when treatment times are not met on the treatment record as prescribed.
Each audit series will be conducted 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 on the monthly ten percent (10%) medical records audits to verify compliance. 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 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.