There are  13 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 7/15/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" and Policy 1-04-02B "Central Venous Catheter (CVC) with Clearguard HD Antimicrobial End Caps Procedure" with the emphasis on but not limited to: 1. Infection control: 1) Hand hygiene is to be performed upon entering the patient treatment area, prior to gloving, after removal of gloves, after contamination with blood or other infectious material, after patient and dialysis delivery system contact, between patients even if the contact is casual, before touching clean areas such as supplies and on exiting the patient treatment area. 2) Gloves are changed: ...When going from a "dirty" area or task to a "clean" area or task... 2. CVC care: 1) Step 4 - Remove old dressing and discard... 2) Step 7 - Remove gloves and discard. Perform hand hygiene per procedure and re-glove... 3) Step 8 -...clean exit site... 4) Step 10 - Remove gloves and discard, perform hand hygiene per procedure and re-glove. 4) Step 13 – Apply label to the dressing... 5) Step 14 - Remove gloves and discard, perform hand hygiene per procedure and re-glove. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet. The Facility Administrator or designee will conduct infection control audits with focus on proper glove wearing and hand hygiene during CVC care and treatment initiation: 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 audit results with teammates during homeroom meetings and with the Medical Director during 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 07/15/22. Surveyor observations were reviewed. Education included but was not limited to a review of Policy 1-05-01 "Infection Control for Dialysis Facilities" and Policy with emphasis on but not limited to: 1) 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. 2) 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. Verification of attendance at in-service will be evidenced by teammates signature on in-service sheet. The Facility Administrator or designee will conduct infection control audits to verify teammate compliance with disinfection of non-disposable thermometers per policy: 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 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 07/15/22. 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. NOTE: Shortened/Early Termination of the dialysis treatment includes all reasons the prescribed dialysis time is not met by 30 or more minutes. 2) Reasons why a patient's treatment may be terminated early include, but are not limited to: Facility emergency (power outages, weather-related emergencies, and other facility wide equipment failure... 3) 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.

On 07/15/22, a Governing Body meeting with the Medical Director, Facility Administrator, Director of Nursing and Regional Operations director to review results of the CMS survey ending 07/13/22. The Governing Body reviewed Policy COMP-DD-017 "Medical Director Qualifications and Responsibilities". The Medical Director acknowledges that he/she is responsible to ensure that all policies and procedures relative to patient admissions, patient care, infection control and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and non-physician providers. Plans of correction were developed and initiated to correct identified deficiencies and sustain compliance. Surveyor observations were reviewed and education for all teammates was conducted starting on 7/15/22. Education included but was not limited to a review of these facility policies: 1. Policy 1-03-08 "Pre- Intra- Post Treatment Data Collection, Monitoring and Nursing Assessment" with emphasis on but not limited to: 1) Purpose: To obtain and document baseline and ongoing information about the patient before, during and after the dialysis treatment through data collection and nursing assessment... 2) The PCT or licensed nurse will obtain and document basic data on each patient post dialysis and compare to pre dialysis findings. 3) 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. 4) 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 post treatment: a. If the patient can stand: Standing systolic BP greater than 140 mm/Hg or less than 90 mm/Hg; Standing diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg... b. If patient is not able to stand, document reason and sitting BP. c. Sitting BP for patient's that cannot stand: Sitting systolic BP greater than 140 mm/Hg or less than 90 mm/Hg; Sitting diastolic BP greater than 90 mm/Hg or less than 50 mm/Hg. 2. COVID-19 Response "Entrance Evaluation Tracker" with emphasis on but not limited to: 1) Evaluate one hundred percent (100%) of people entering your facility in a timely manner. 2) Document responses on the following pages (Entrance Evaluation Tracker)... 3. Policy 2-04-02 Daily Water Treatment System Monitoring" with emphasis on but not limited to: 1) All observations and test results will be within the limits specified on the Daily Water Treatment Log. If observations or test results are found outside the specified limits, follow the instructions given on the Daily Water Treatment Log for the parameter(s) in question. In addition to following the log form instructions, the teammate completing the log will notify the Facility Administrator/designee and Biomed teammate assigned to the facility of any observation or test result found outside the limit specified on the Daily Water Treatment Log. 4. Water Treatment: A. Policy 2-03-01 "Water Treatment Systems Minimum Component Requirement" and facility specific "Water Contingency Plan" (DaVita St. Luke's Quakertown #06928) with emphasis on but not limited to: 1) In the event of equipment failure of the dialysis quality water treatment system, follow the approved facility specific Water Contingency Plan. 2) DI tank(s) will not be used without the prior approval of the Area Biomed Supervisor, Facility Administrator and Medical Director. B. Water Contingency Plan with emphasis on but not limited to: 1) In the event the Reverse Osmosis (RO) water treatment system fails to provide dialysis quality water or you experience chlorine break through, immediately notify your Biomed Technician (BMT). 2) The BMT will then make the determination to make the repair themselves, or contact an outside vendor for assistance and or provide alternative water purification such as Deionized Water (D.I.). C. Policy 4-07-01 "Facility Emergency Management Plan (ICHD, Home)" Water Contingency Plan with emphasis on but not limited to: 1) In the event the RO system is found to be inoperable due to system failure or water product quality, the Medical Director, Facility Administrator/designee, local Biomed department and ROD will be notified. Local Biomed department will promptly make arrangements for RO repair. The Medical Director will decide if appropriate to switch to deionization (DI) as an alternate water treatment method until the RO system is repaired. If deemed appropriate by the Medical Director, local Biomed department will promptly make arrangements for DI to be used. Verification of attendance is evidenced by teammate's signature on the in-service sheets. The Facility Administrator or designee will conduct audits post education to verify sustained compliance with policies: 1. The Facility Administrator or designee will conduct flowsheet audits to verify proper documentation of data collection, appropriate notification of abnormal findings to nurse and response by nurse: 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. 2. The Facility Administrator or designee will audit one hundred percent (100%) of COVID-19 Entrance Evaluation forms to confirm complete documentation: daily for two (2) weeks, weekly for two (2) weeks, and monthly for two (2) months. 3. The Facility Administrator or designee will conduct an audit of the Daily Water Log to verify accurate and complete timely entries and appropriate notification of appropriate Biomed Technician, Facility Administrator or Medical Director as required by evidence of system failure: daily for two (2) weeks, weekly for two (2) weeks and monthly for two (2) months. Implementation of the Water Contingency Plan will be fully documented in Governing Body meetings until the emergency has been resolved and normal facility services have resumed. All instances of non-compliance will be addressed immediately. The Facility Administrator or designee will review audit findings with teammates during homeroom meetings. The Medical Director will review all audit results, and plan of correction progress, as well as any barriers to maintaining compliance, with supporting documentation included in the meeting minutes. Action plans will be evaluated for effectiveness, and new plans developed as applicable, in order to achieve compliance with teammates' adherence to policy and procedure. The Regional Operations Director or designee will validate that the survey findings and the plans of correction are being reviewed in Governing Body and Quality Assessment Performance Improvement meetings known as Facility Health Meetings, monthly for three (3) months. The Governing Body is responsible for the oversight of all activities of the dialysis center. The Medical Director is responsible to ensure teammates adhere to facility policies and procedures. The Facility Administrator is responsible for compliance with this plan of correction.