There are  2 surveys for this facility. Please select a date to view the survey results.

V 0116
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 08/12/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" with the emphasis on but not limited to: 1) Items taken into the dialysis station will be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before taken to a common clean area or used on another patient. 2) If electronic thermometers and/or blood glucose meters are used, measures will be taken to prevent cross contamination between patients. For example, the thermometer should not be placed on potentially contaminated equipment such as the dialysis delivery system. If the potential for contamination exists, the device outer casing is wiped with an appropriate disinfectant before being returned to clean area or using on another patient. Verification of attendance at in-service will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will perform observational infection control audits to verify teammates are compliant with disinfection practices for non-disposable items per policy: daily for two (2) weeks, and then weekly for two (2) weeks. Ongoing compliance will be monitored with the facility's monthly infection control audit. Instances of non-compliance will be addressed immediately. The Facility Administrator will review audit results with the 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 0147
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 08/12/22. 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. Exit Site: 1) Step #3: Place patient in comfortable supine position, as tolerated. Verify patient's clothing is secured away from the exit site/work area... Rationale: Securing the patient's clothing away from the work area minimizes the risk of cross contamination. 2) Step #4: Remove old dressing and discard. 2) Step #8: Holding catheter with the non-dominant hand using aseptic technique, clean exit site with 2% Chlorhexidine Gluconate/70% Isopropyl Alcohol swab for a minimum of 30 seconds, and apply to CVC exit site in a "back and forth" pattern, using gentle friction progressing from insertion site to periphery using both sides of the swab... Then wait 60 seconds for air dry time. 3) Step #12 - Place sterile 2x2 gauze over the catheter exit site leaving connections accessible. 2. Hub Scrub: 1) Step #14: Remove gloves and discard, perform hand hygiene per procedure and re-glove. 2) Step #16 - Using aseptic technique, remove each cap. One at a time, disinfect each CVC hub with a new alcohol prep pad. Scrub each CVC hub for 15 seconds including the sides, threads and end of hub thoroughly. 3) Step #17 Connection and Treatment Initiation: Attach sterile 10 ml syringes to the arterial and venous limbs. 3. Upon Completion of Dialysis: 1) Step #30: Clamp arterial catheter limb and blood line. Aseptically disconnect arterial blood line from arterial CVC limb. Attach a 10 ml syringe filled with normal saline to arterial catheter limb. Unclamp arterial catheter limb and push normal saline into arterial port and quickly clamp arterial catheter limb. Attach arterial blood line to saline infusion line and conclude dialysis and rinse back... 2) Step #31: Clamp venous catheter limb and blood line. Aseptically disconnect venous blood line and connect 10 ml syringe with normal saline to the venous catheter limb. Unclamp venous catheter limb and push normal saline into venous port and quickly clamp venous catheter limb. 3) Step #33: Remove syringes and disinfect the CVC hubs with a new alcohol prep pad for each CVC hub. Scrub the sides, threads and end of hub thoroughly with friction for 15 seconds, making sure to remove any residue, for example blood. Hold the catheter until the antiseptic has dried. 4) While holding the shield and catheter hub in one hand, remove the single ClearGuard HD cap (red or blue), by rotating the lock ring counterclockwise, taking care to only handle the lock ring, do not touch the rod. Carefully insert the ClearGuard HD rod into the catheter hub and using a simultaneous push and twist motion, tighten by rotating clockwise. Repeat with the other ClearGuard HD cap and dispose of the shield and foil pouch. 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 audits to verify compliance with procedure for CVC care: 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 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.

V 0196
The Facility Administrator or designee held mandatory in-services for all clinical teammates starting on 08/12/22. 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 with emphasis on but not limited to: 1) Total Chlorine testing is done on a daily basis prior to the first patient treatment and every four (4) hours until all activities that require use of dialysis quality water are completed. All samples are to be drawn only after the water system has been operating for at least 15 minutes... 2) Record results on the Routine Total Chlorine testing log which contains entries for day, date, test number, test time, signature of person performing the test, test results, and signature of licensed nurse verifying that each test on the daily log is complete and results appropriate. If the licensed nurse performs the total chlorine test, they may sign results as verified. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet. The Facility Administrator or designee will perform observational audits to verify total chlorine testing log is complete and compliant with policy: daily for two (2) weeks, then 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.

V 0250
The Facility Administrator held mandatory in-services for all clinical teammates starting on 08/12/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-03-06M "Priming a Non-eto Sterilized Single Use Dialyzer Utilizing B Braun Dialog+Dilaysis Delivery Systems and Streamline Blood lines" with emphasis on but not limited to: 1) Once the rinsing with UFP is initiated the pump speed will default to 400 ml/min. During rinsing with UFP, check manual pH. Verify appropriate sodium and bicarbonate level prescribed. Rationale: pH testing must be performed prior to each patient treatment. Verification of attendance will be evidenced by teammate's signature on in-service sheet. The Facility Administrator or designee will conduct observational audits to verify pH testing is completed prior to each patient treatment: daily for two (2) weeks, then 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.

V 0715
A Governing Body meeting was held on 08/12/22, with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations Director to review the results of the survey ending on 08/11/22. 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 08/12/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-06-01 "Medication Policy" with emphasis on but not limited to: 1) Medications are administered as prescribed and then documented in the patient's medical record. 2) All medication errors are reported to the Facility Administrator /designee. She/he will then notify the patient's physician of the event and of any adverse changes in the patient's condition. Physician will be notified of any medication errors prior to patient leaving the facility. Examples of medication errors include: Administration of an incorrect dosage of an ordered medication. Verification of attendance is evidenced by teammate's signature on the in-service sheet. The Facility Administrator or designee will conduct audits of treatment flowsheets to verify compliance with medication administration per physician order per policy: daily each treatment day for two (2) weeks, then weekly for two (2) weeks. Ongoing compliance will be monitored with the ten percent (10%) monthly medical records audit. 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, as provided by the Facility Administrator during monthly Quality Assessment Performance Improvement meetings known as Facility Health Meetings, 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.