There are  8 surveys for this facility. Please select a date to view the survey results.

LVH: Medicare Recertification Survey of ESRD Facility) Plan of Correction Dialysis

V0116 494.30(a)(1)(i) IC-IF TO STATION = DISP/DEDICATE OR DISINFECT

CITED FOR: FAILURE TO ENSURE STAFF FOLLOWED IC PROTOCOLS: "RETURNED THE METER IN THE COMMON AREA AND DID NOT DISINFECT AFTER USE'
1. On 2/3/23, clinical dialysis staff were immediately reeducated about the proper disinfection of the phoenix meter in between patient use and prior to returning to common storage.
2. A mandatory learning module will be developed by the Dialysis director, in collaboration with Infection Control and Prevention, which addresses proper disinfection of the phoenix meter in between patient use and prior to returning to common storage. The education reflects protocols in the policy 'Dialysis Center: Infection Control'.
3. Dialysis clinical staff will compete the assigned education by March 15, 2023. Proper disinfection method will be reinforced during daily Patient Safety Huddle through the end of March.
4. The Director or trained designee will conduct cleaning, disinfection, and disposal observations of items taken into the dialysis treatment stations. Audits will occur beginning 3/20/23 and will be conducted 3 times per day for 2 weeks, then 3 times/week for 2 weeks, and then 20 observations/month for a minimum of 3 months.
5. Observation data will initially be reported weekly to the Vice President of Patient Care Services, and then monthly to the Vice President of Patient Care Services, CNO Council, and Vice President/Chief Nursing Quality & Patient Safety Officer. It will also be reported bimonthly during the Division of Nephrology meeting and reviewed monthly at the outpatient dialysis QAPI meeting.
6. The Vice President Patient Care Services is responsible for implementation of this plan of correction.

LVH: Medicare Recertification Survey of ESRD Facility) Plan of Correction Dialysis

V0190 494.40(A) SOFTENERS-AUTO REGENERATE/TIMERS/SALT LVL

CITED FOR: FAILURE TO ENSURE SALT PELLETS FILL AT LEAST HALF THE BRINE TANK FOR WATER LOGS REVIEWED

1. The 'Reverse Osmosis- Water System- Renal Therapies' policy was revised to include a requirement for salt pellets to fill the brine tank a minimum level of greater than half full.
2. The Dialysis facility's form 'Water System Checks -RDC' was revised to include a brine tank minimum level of greater than ½ half full.
3. The Dialysis Director will develop a mandatory learning module by 3/1/23 to include rationale and requirements for minimum salt pellet quantity in the brine tank, as well as revisions to the policy and log.
4. Facilities Management staff assigned to dialysis tasks and all dialysis clinical staff will complete the education by 3/15/23 and information will be reinforced at daily Facility Management huddles led by the Supervisor, Plumbing through the end of March.
5. The Director of Dialysis or Supervisor of Facilities will conduct observations 2 times/week of the brine tank to verify the required amounts of pellets are present and documented on the log 'Water System Checks-RDC'. Observations will begin 3/20/23 for a minimum of 3 months
6. Data results will initially be reported weekly to the Vice President of Patient Care Services, and then monthly to the Vice President of Patient Care Services, CNO Council, and Vice President/Chief Nursing Quality & Patient Safety Officer. It will also be reported bimonthly during the Division of Nephrology meeting and reviewed monthly at the outpatient dialysis QAPI meeting.
7. The Administrator, Facilities Management, is responsible for implementation of this plan of correction.

LVH: Medicare Recertification Survey of ESRD Facility) Plan of Correction Dialysis

CITED FOR: FAILED TO ENSURE RESISTIVITY MONITOR READINGS WERE RECORDED TWICE EACH TREATMENT DAY, NOTE: THE POLICY DOES NOT SPECIFY RECORDING READINGS ON LOG SHEET TWICE EACH TREAMENT DAY AS PER REGULATORY REQUIREMENTS.
V0202 494.40(A) DI-CONTIN MONITOR/LOGGED 2X/DAY

1. The Dialysis Director revised the 'Reverse Osmosis- Water System- Renal Therapies' policy to include the specific requirement for completion of resistivity readings 'twice each treatment day' and green light presence when using DI water.
2. This facility runs on R/O water, with DI water being the backup water system and utilized infrequently. The DI Water System Log was revised to reflect the revised policy, and includes documentation requirements for readings twice each treatment day, with time initiated, time discontinued, notification of Medical Director, Dialysis Director or designee, recording of greenlight and sensitivity according to the policy only when DI water is used.
3. The Dialysis Director will develop a mandatory e-learning module by 3/1/23 which includes the requirements of second resistivity readings, documentation twice each treatment day when there has been a disruption of R/O water and DI water is used, and notification to Dialysis leadership.
4. Facilities Management staff assigned to dialysis tasks and all dialysis clinical staff will complete the education by 3/15/23 and information will be reinforced at daily Facility Management huddles led by the Supervisor, Plumbing through the end of March.
5. The Director of Dialysis or Supervisor of Facilities will conduct weekly audits of the DI Water System Log to verify resistivity readings are recorded as required if DI water has been used during that week. If the backup DI water system has not been used during 4 consecutive weeks, a mock change to the backup DI water system will occur. Audits will begin 3/20/2023 for a minimum of 3 months.
6. Results of data collection will be reported monthly to the Vice President of Patient Care Services, CNO Council, and Vice President/Chief Nursing Quality & Patient Safety Officer. It will also be reported monthly during the Division of Nephrology meeting and reviewed monthly at the outpatient dialysis QAPI meeting.
7. The Vice President of Patient Care Services is responsible for implementation of this plan of correction.

LVH: Medicare Recertification Survey of ESRD Facility) Plan of Correction Dialysis

CITED FOR: FAILED TO ENSURE WATER CULTURES WERE REPEATED WEEKLY WHEN BACTERIAL COUNTES EXCEEDED THE ALLOWABLE LEVELS, NOTE: THIS POLICY /PROCEDURE IS NOT COMPLIANT WITH REGULATION
V0255 494.40(A) MICROB MONITOR-REPEAT CULTURES

1. A 'Water Testing: ROs and Stations – Renal Therapy' policy will be developed by 3/01/23 by the Dialysis Director and Infection Control Director to ensure repeat cultures are conducted according to 494.40(a), which includes repeating cultures weekly when bacterial counts exceed allowable levels.
2. A mandatory water system update learning module will be developed by the Dialysis Director which includes repeat weekly sampling of those specimens exceeding action level.
3. Facilities Management staff assigned to dialysis tasks and all dialysis clinical staff will complete the education by 3/15/23 and information will be reinforced with clinical staff during daily Patient Safety Huddles and with the Facilities Management staff during daily Facilities Management huddles by the Supervisor, Plumbing and will continue until the end of March.
4. The Dialysis Director will conduct monthly audits of all water and dialysate samples to assure weekly repeat testing occurred on water system and dialysis machines exceeding permissible standards. Audits will begin 3/20/2023 for a minimum of 3 months.
5. Data results will be reported monthly to the Vice President of Patient Care Services, LVH-
Cedar Crest Director of Facilities Management, CNO Council, and Vice President/Chief Nursing Quality & Patient Safety Officer. It will also be reported monthly during the Division of Nephrology meeting and reviewed monthly at the outpatient dialysis QAPI meeting.
6. The Vice President of Patient Care Services is responsible for implementation of this plan of correction.

LVH: Medicare Recertification Survey of ESRD Facility) Plan of Correction Dialysis

CITED FOR: FAILED TO ENSURE TESTING EQUIPMENT WAS CALIBRATED DAILY
V0403 494.60(B) PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU

1. The Dialysis Director reviewed the Manufacturer's Directions for Use (DFU). The Dialysis Safety Huddle Sheet was revised to include the name of the person responsible for calibration of the Phoenix meter on each day that it is used.
2. The Dialysis Director will develop a mandatory e-learning module by 3/1/23 which includes a requirement for daily meter calibration as per the Manufacturer's DFU and required documentation.
3. All dialysis clinical staff will complete the education by 3/15/23 and information will be reinforced at daily Patient Safety Huddle through the end of March.
4. The Dialysis Director or designee will conduct daily audits of the calibration logs for both Phoenix meters for 2 weeks, then weekly for 2 weeks, and then monthly audits to ensure daily calibration has been completed. Audits will begin 3/20/23 for a minimum of 3 months.
5. Data results will initially be reported weekly to the Vice President of Patient Care Services, and then monthly to the Vice President of Patient Care Services, CNO Council, and Vice President/Chief Nursing Quality & Patient Safety Officer. It will also be reported bimonthly during the Division of Nephrology meeting and reviewed monthly at the outpatient dialysis QAPI meeting.
6. The Vice President Patient Care Services is responsible for implementation of this plan of correction.

LVH: Medicare Recertification Survey of ESRD Facility Plan of Correction
Dialysis
V0550 494.90(A)(5) POC-VASCULAR ACCESS-MONITOR/REFERRALS

CITED FOR: FAILURE TO USE SOAP AND WATER OR ANTIBACTERIAL SCRUB ON ACCESS

1. On 2/3/23 the staff were immediately educated on the need to use soap and water or antibacterial scrub prior to disinfecting fistulas and grafts.
2. The "Initiating Hemodialysis" policy will be revised by 3/1/23, to include requirements for using soap and water or antibacterial scrub to disinfect the access site.
3. A mandatory learning module will be developed by the Director which addresses the requirement for using soap and water or antibacterial scrub prior to accessing fistulas and grafts. The education will reflect protocols in the policy "Initiating Hemodialysis".
4. All dialysis clinical staff will complete the education by 3/15/23, and information will be reinforced during the Patient Safety Huddle through the end of March.
5. The Director or designee will conduct an audit observing the use of an antibacterial wash prior to disinfecting the access site. All outpatient hemodialysis patient access site disinfection will be observed daily for 2 weeks, then weekly for 2 weeks, then monthly for a minimum of 3 months beginning 3/20/23.
6. Data results will initially be reported weekly to the Vice President of Patient Care Services, and then monthly to the Vice President of Patient Care Services, CNO Council, and Vice President/Chief Nursing Quality & Patient Safety Officer. It will also be reported bimonthly during the Division of Nephrology meeting and reviewed monthly at the outpatient dialysis QAPI meeting.
7. The Vice President Patient Care Services is responsible for implementation of this plan of correction.

LVH: Medicare Recertification Survey of ESRD Facility) Plan of Correction
Dialysis
V0626 494.10 QAPI-COVERS SCOPE SERVICE/EFFECTIVE/IDT/INVOL

1. A facility dialysis QAPI program will be developed for the outpatient hemodialysis program. The policy outlining the QAPI program will be completed by the Dialysis Director, with input from the interdisciplinary team and Administrator, Quality Services.

2. A monthly outpatient dialysis QAPI meeting will be established to review the required minimum components of the program, as applicable to this patient population with a length of stay generally less than two weeks. The medical director will lead the interdisciplinary team QAPI meeting. The minimum components include adequacy of dialysis, nutritional status, mineral metabolism/renal bone disease, anemia management, vascular access, medical injuries/medical errors identification, patient satisfaction/grievances, infection control, and monitoring performance improvement.

3. All dialysis staff, including the interdisciplinary dialysis team, will be assigned the QAPI program and policy education by the Director of Dialysis via a mandatory learning module for completion by 3/15/2023.

4. The Director of Dialysis will audit completion of monthly outpatient dialysis QAPI meetings, which will include inclusion of component data, beginning in April 2023.

5. The corrective actions will be completed by 3/22/2023. Audit data will be shared monthly with the Vice President Patient Care Services, and Administrator, Quality Services.

6. The Vice President Patient Care Services is ultimately responsible for this plan of correction.

LVH: Medicare Recertification Survey of ESRD Facility) Plan of Correction
Dialysis
V0715 494.150(C)(2)(I) MD RESP-ENSURE ALL ADHERE TO P&P
1. A policy entitled 'Nursing Assessment/Evaluation of Outpatient Hemodialysis Patient' is being developed and will be approved by 2/27/23.
2. A mandatory e-learning module outlining requirements for timing of assessment and its components prior to initiating first dialysis treatment will be developed by the Dialysis Director.
3. The dialysis clinical staff will complete the e-Learning module by March 15, 2023. The information in the e-Learning module will be reinforced during daily Patient Safety Huddles and will continue until the end of March.
4. The Director of Dialysis, or designee, will conduct a monthly audit of all outpatient hemodialysis initial treatments for a minimum 3 months for compliance with timing of the assessment and components of assessment. Audits will begin March 15, 2023.
5. Audit results will be submitted monthly to the Vice President Patient Care Services, Vice President Patient Care Services Chief Nursing Quality & Patient Safety Officer, and every other month during the Division of Nephrology meeting. The audit results will also be reviewed at the monthly outpatient dialysis QAPI meeting.
6. The Dialysis Director queried ESRD Network #4 Quality Insights and Dialysisdata.org to inquire about the Dialysis Facility Report quarterly data entry and reporting. A response was received on 2/21/23 from Teamdynamix@umich.edu on behalf of dialysisdata.org. This Facility does not enter into the CrownWeb system as these outpatients are not primary ESRD patients of this facility. This Facility does not receive a Dialysis Facility Report (DFR).
With the assistance of ESRD Network #4/Quality Insights, Dialysisdata.org and CMS, Lehigh Valley Hospital will investigate the origins of the data reported on the Dialysis Facility Report. Based on the information provided by the forementioned agencies, a summary of the investigation and determination regarding the data will be submitted by April 15, 2023.
7. The VP Patient Care Services is responsible for implementation of this plan of correction.

LVH: Medicare Recertification Survey of ESRD Facility) Plan of Correction Dialysis

V0726 494.170 MR-COMPLETE, ACCURATE, ACCESSIBLE
CITED FOR: FAFILED TO ENSURE PATIENT CONSENT FOR DIALYSIS TREATMENT WAS OBTAINED. THE DEFICIENCY REFERENCED THE ADMIN POLICY – REQUIRNG GENERAL CONSENT.

1. As of 2/21/23, a general consent to treat is obtained by the dialysis facility prior to initial treatment.
2. A mandatory learning module will be developed by the Dialysis Director which addresses obtaining general consent to the dialysis facility prior to initiation of initial treatment. Dialysis clinical staff will complete the education by 3/15/23 and the information will be reinforced during the Patient Safety Huddle through the end of March.
3. The Director, or designee, will conduct a medical record audit for presence of consent documentation prior to initial dialysis treatment. The medical records of all initial outpatient dialysis treatment patient will be audited daily for 2 weeks, then weekly for 2 weeks, and then monthly for a minimum of 3 months. Audits will begin 3/15/23 for a minimum of 3 months.
4. Audit results will initially be submitted weekly to the Vice President of Patient Care Services, and then monthly to the CNO Council, Vice President of Patient Care Services Chief Nursing Quality & Patient Safety Officer, bimonthly during the Division of Nephrology meeting, and reviewed monthly at the outpatient dialysis QAPI meeting
5. The VP Patient Care Services is responsible for implementation of this plan of correction.