There are  4 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 05/01/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with emphasis on but not limited to: 1) All teammates, Physicians and Non-Physician (NPP) will perform hand hygiene... b. prior to gloving and immediately after removal of gloves, c. after contamination with blood or other infectious material, d. after patient and dialysis delivery system contact... e. before touching clean areas such as supplies, supply cart and chairside keyboard/mouse. 2) Gloves should be changed when: i. When soiled with blood, dialysate or other body fluids ii. When going from a "dirty" area or task to a "clean" area or task. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet.
The Facility Administrator will conduct infection control audits to verify teammates perform hand hygiene, glove wearing and glove changing per policy: daily for two (2) weeks, then weekly for two (2) weeks, then 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 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.

The Facility Administrator held mandatory in-services for all clinical teammates starting on 05/1/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-06-01 "Medication Policy", Policy 1-08-02 "Obtaining Patient Lab Specimens", Policy 1-05-01 "Infection Control for Dialysis Facilities" and Policy 1-02-08 "Emergency Equipment Checks" with emphasis on but not limited to: A. Medications: 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) Medications containing a preservative must be discarded 28 days after opening or accessed (e.g., needle punctured)... Each vial is labeled with the initials of the person opening the vial and the expiration date. B. Lab supplies: 1) Teammates are to verify the expiration date on all laboratory specimen tubes prior to collection. Expired laboratory specimen tubes are not to be used and are to be discarded in the sharp's container. C. 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. D. Emergency equipment checks: 1) The following equipment checks will be performed by a licensed nurse teammate to verify the designated equipment is available and functional: Weekly: Emergency cart (crash cart) is clean, operational and supplies/medications have not expired. 2) In addition, the FA or designee will review the contents of the emergency evacuation kit(s) and replace missing or expired supplies at least monthly. The date and initials of the teammate checking the contents should be placed on a label outside the kit(s). Verification of attendance is evidenced by teammate's signature on the in-service sheet.

The Facility Administrator or designee immediately conducted an audit of all supplies and medications with expiration dates. The Facility Administrator directed teammates to immediately remove and appropriately discard all expired supplies and medications, [including unlabeled, open medication vials] and expired items identified by the surveyor. Ongoing audits will be conducted monthly by the Facility Administrator or designee per policy, who will also verify incoming stock is rotated as it arrives. 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 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.

The Facility Administrator or designees held mandatory in-services for members of the Interdisciplinary Team (IDT) starting on 05/01/24. Surveyor observations were reviewed. Education included but was not limited a review of Policy 1-14-01 "Interdisciplinary Team (IDT) Patient Assessment and Plan of Care" emphasizing but not limited to: 1) A comprehensive re-assessment of each patient and a revision in the plan of care will be conducted: At least annually for stable patients. 2) Timing: One (1) year after the 90 Day reassessment or unstable reassessment. Ongoing annual reassessments will be completed 1 year after the annual re-assessment or unstable reassessment. Complete patient plan of care meeting within 15 days of the completion of the re-assessment and Plan of Care. Verification of attendance at the in-service will be evidenced by teammate's signature on the in-service sheet.

The Facility Administrator or designee will notify the IDT monthly of assessments / plans of care due dates. The Facility Administrator will conduct monthly audits on one hundred percent (100%) of patient assessments and plans of care for three (3) months to verify timely completion of annual assessments and plans of care. 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 IDT during Core Team Meetings, and with the Medical Director during monthly Quality Assurance 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.

The Facility Administrator held mandatory in-services for all clinical teammates starting on 05/01/24. 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" emphasizing but not limited to: [Pre-treatment data collection]: 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) 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. 3) 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 by one (1) hour of treatment initiation along with the nursing assessment... including but not limited to ... Blood flow rate. [Intradialytic monitoring]: 4) 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. 5) 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. [Post treatment]: 6) The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 7) 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. 8) Licensed nurse will use his/her clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary prior to discharge of the patient from the facility. 9) All findings, interventions and patient response will be documented in the patient's medical record. [Abnormal findings]: Blood pressure - Pre or post dialysis: Systolic less than 90 mm/Hg; Diastolic less than 50 mm/Hg. Fluid Status ... Post-treatment: If patient is above or below 1kg from target weight. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.

The Facility Administrator and Clinical Coordinator will conduct audits to verify treatment documentation is accurate and complete, licensed nurse is notified of abnormal findings and appropriate interventions are implemented and documented by the licensed nurse: on twenty five percent (25%) of 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 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.

The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 5/1/24. 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" and Policy 1-01-09 "Prescribed Treatment Time Not Met" with emphasis on but not limited to: A. [Policy - Pre- Intra- Post]: 1) Patient identity, prescription and machine settings are verified by teammates prior to initiation of treatment. Prescription components include but are not necessarily limited to... Blood Flow rate... 2) If the dialysis prescription is not being met ... the reason will be documented and the licensed nurse informed. 3) The following are considered abnormal findings and should be reported to the licensed nurse and documented in the patient's medical record... Fluid Status Post treatment: If the patient is above or below 1 kg from the target weight.
B. [Policy - Prescribed Treatment Time...]: 1) 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. 2) 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. 3) 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. 4) 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. 5) 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. 6) 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. 7) A completed copy of the Early Termination of Treatment Against Medical Advice form will be kept in the patient's health 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: 1) to verify teammates complete appropriate documentation on the treatment record and notify the RN concerning prescribed blood 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 then, then 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 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.

The Facility Administrator held mandatory in-services for all Peritoneal Dialysis (PD) teammates starting on 05/1/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 5-01-21 "Home Dialysis Monitoring and Ongoing Patient Education" and Policy 5-01-29 "Daily Home Treatment Record (Flowsheet)" with the emphasis on but not limited to: A. Home dialysis monitoring: 1) The Peritoneal Dialysis facility will: a. Document in the patient's medical record that the patient, the caregiver, or both have received and demonstrated an adequate comprehension of the training by reviewing home patient clinical records for evidence of compliance with their training. b. Retrieve, and review treatment information submitted electronically, every seven (7) days from receipt of treatment level data. Based on what the patient submits, follow up may be necessary and the patient's electronic health record will be updated to reflect any new information obtained... d. Maintain information in the patient's medical record.
B. Daily home treatment record: 1) Purpose: To provide guidance for proper documentation of home peritoneal dialysis treatments and to collect data to assist in assessing the patient's response to peritoneal dialysis treatments. 2) As clinically applicable, all treatment data outlined on the Daily Home Treatment Record must be collected. Completed Daily Home Treatment Records must be reviewed to assist in evaluating the patient's progress and self-care decision-making process. This post-treatment data review will be verified by the Peritoneal Dialysis registered nurse documenting review in the medical record per guidance... b. If an abnormal finding(s) or concern is identified, the LPN/LVN will report to the RN. c. The RN will use their clinical judgment based on individual patient needs to determine if any clinical interventions or notification of physician (or NPP as applicable) is necessary. 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. a. Within each category, definitions may be adjusted by a patient specific physician order. In addition, the teammate who is observing or collecting information should report to the licensed nurse whenever there is concern for the patient's condition or the potential safety of initiating dialysis, even in the absence of specific abnormal findings. b. Members of the patient care team should report ANY changes in patient conditions or concerns of patient well-being immediately to the Registered Nurse, and Nephrologist, as applicable. c. Fluid status: If the patient is above or below 2kg from the target weight. 4) All Daily Home Treatment Records will be reviewed, attested to, and maintained as a part of the patient's medical record. In the absence of Daily Home Treatment Records, the licensed nurse will review with the patient the importance of Daily Home Treatment Records, and the patient's responsibility to provide them and issue new paper flowsheets and provide instruction as applicable for electronic documentation. All of the above will be documented and attested to by the licensed nurse in the medical record. In addition, the patient's plan of care should address any problems with adherence to this requirement. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
Patients identified by the surveyor were referred to IDT for reassessment and update to plan of care as appropriate, to address target weights and treatment documentation, with updates by 05/31/24.

The Facility Administrator or designee will conduct audits on one hundred percent (100%) of the home treatment forms to verify all treatment data which is outlined on the daily treatment record is collected; PD nurse has reviewed; if abnormalities are noted, they will be documented in the clinical record and physician notified if applicable: monthly for three (3) months. 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 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.

The Facility Administrator held mandatory in-services for all clinical teammates starting on 05/1/24. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 8-02-01 "Teammate Qualifications, Licensure and Adequate Teammate Staffing" and Policy 8-02-03 "Color Vision Evaluation" with emphasis on but not limited to: A. Teammate qualification: 1) All dialysis facility teammates will meet applicable scope of practice, board and licensure requirements in effect in the State in which they are employed. 2) The dialysis facility's teammates (or contractors) will meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility's teammates (or contractors) will have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. B. Color vision evaluation: 1) Teammates/patients/helpers who will be utilizing test kits or strips that rely on color differentiation for test results will be evaluated for ability to see color. Color blindness testing is performed at time of hire. 2) Documentation of the color vision evaluation will be documented in the teammate's file and/or patient's medical record.

Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet.
The identified teammate will complete a color vision test prior to performing duties which require a color vision evaluation. Evaluation will be recorded and maintained in the teammate's file.
The Facility Administrator will audit one hundred percent (100%) of teammate files to verify competencies and skills checklists are present and up to date by 05/30/24, including and not limited to color vision evaluation. Any missing or outdated items will be completed and placed in the teammate file. Going forward, the Facility Administrator of designee will perform teammate file audits quarterly 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.