SOS
When the surveyor walks into your clinic who do you notify?
Notify Medical Director, ROD, MCS. Ask surveyors for their business cards and send to MCS.
What should I have ready at all times to be prepared for my survey?
Three hour binder
Updated at least monthly
Entrance Evaluation - Can I screen myself?
No
Each TM must be screened by another TM. First opener can screen themselves and when 2nd opener gets to facility then TM can re-screen 1st opener.
Please make sure Surveyors get screened.
FA Question - How does this facility promote a facility-wide culture of safety, including encouraging staff to report errors/near misses, or safety risks they identify? What action(s) does this facility take with staff when an error/near miss or safety risk is reported? How does the facility address these to reduce and prevent problems in the future?
See it, Say it, Solve it.
REM - report errors and near missess.
Actions taken - we have homerooms, Core meetings, FHM to discuss errors, how we can prevent it, and avoid future problems.
When is water tested?
Total chlorine testing prior to first shift after system has been operating for at least 15 minutes, and at least every 4 hours thereafter per policy.
Survey Ready information. Where do I get more information?
SOS - Survey Outcomes Support
Where can I get an updated report that is needed for the 3 hour binder.
FHM - go to the FHR Reports tab and go to Core Survey Report.
Infection Control - Top Citation
Wear gloves and washing hands per CDC recommendations.
Cleaning and Disinfection of Contaminated Surfaces.
Review policies with team.
FA Question - What is your system for handling patient complaints, including reporting complaint resolution to the patient?
Grievance procedure
What is needed by Medical Director?
Medical Director is board certified in nephrology, pediatric nephrology, internal medicine.
DEA, License, Insurance.
Back up Medical Director.
Besides an Initial Visit and Recertification, why would we get a State Visit.
Grievances
Low PRD score or QIP score
What is needed in the 3 Hour binder that I will not get from the report in FHM - ESRD Core Survey.
List of facility key personnel: Medical Director, FA, CC, SW, RD.
Staff Schedule, Patient schedule, REM 6 months, Grievance Log 6 months
Copy of QAPI 6 months
The prescription components are confirmed by an RN within ____ of treatment initiation along with the nursing assessment.
One hour of Tx.
Flowsheet Audits. Please check prescriptions and assessments that is competed within 1 hr on initiation.
FA Question - How do you appoint the medical staff (physicians, advanced practice registered nurses, and physician assistants)?
MSOW
Governing Body
Medical records -When are patients taught on emergency disconnection?
During admission and every quarter.
Who is Dream Team SOS Director and and Survey Response Manager?
SOS Director - Nancy Wagner
SOS Survey Response Manager - Vickie Rickords
What policies do I need in my 3 hour binder? And a copy of a protocol.
Policy and procedure manuals for patient care, water treatment, dialysate preparation and delivery, infection control, and dialyzer reprocessing/reuse, if applicable
Anemia management protocol
Unstable Care Plans - how many times do I have to complete an assessment. Frequency
Monthly - until patient is determined by IDT to be stable.
Charge RN Question - What training do you have in dealing with patient emergencies and cardiac arrest? What are patients taught about emergency disconnection and evacuation from the facility, and about preparing for disasters? How do you determine and keep track of which patients need more help with evacuation?
CPR
Every quarter we teach our patients about emergency disconnection, fire drills, and where to meet.
Patients that need more help - look at schedule
4 breaches infection control patient care practices:
o Poor hand hygiene & glove use practices (V113)
o Supplies taken to station not disposed, disinfected or dedicated (V116)
o Clean dialysis supplies not protected from potential contamination (V119)
o Breaches in aseptic practices for CVC (V147) or AVF/AVG care (V550)
A) What do I have to send to the SOS- Survey Response Manager after the surveyors leave my facility.
B)How long do I have to work on my Statement of Deficiencies after the Surveyor exits.
A) Exit Interview Form
B) Do not wait until you receive the statement of deficiencies to get started on your plan as our time frame of 30 days starts when they exit.
Materials needed by noon on Day 2 of survey.
Completed “Personnel File Review” Worksheet
Completed CMS 3427-End Stage Renal Disease Application and Survey and Certification Report - email Stephanie King from DaVita.
Hemodialysis Care - What is normal range for PH and Conductivity?
Not testing dialysate pH/conductivity w/ independent method or staff unaware of parameters.
PH 6.9- 7.6
Conductivity - 13 - 15.5
[Infection control] What training did you receive about infection prevention and control? How to you monitor the infection control practices of the direct care staff? What precautions do you and direct care staff take when caring for an HBV+ patient? How are staffing assignments made when HBV+ patients are scheduled?
Infection training yearly - Star Learning SAF
Monthly Audit - Infection Control Audits
Hep B precautions - buffer zone, we check Hep Ag monthly for pt with Antibodies less than 10. Vaccines are offered to pt with Antibodies less than 10.
Newly admitted patients <90 days: review documentation in first weeks at facility: Looking for 3 items?
Looking for initial nursing evaluation & orders prior to 1st tx, surveillance for TB, HBV, offered vaccinations.