SURVEYOR Volume 2024 | No. 2 Quality Review Edition
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
BOARD OF COMMISSIONERS Brock Slabach, MPH, FACHE I Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CHIEF EXECUTIVE OFFICER, MSMP ANESTHESIA SERVICES, LLC Mark S. Defrancesco, MD, MBA, FACOG I Secretary PAST PRESIDENT, AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS Leonard S. Holman, Jr., RPh I Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT Roy G. Chew, PhD I Immediate Past Chair PAST PRESIDENT, KETTERING HEALTH NETWORK John Barrett, MBA I Board Member-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM Jennifer Burch, PharmD PHARMACIST/OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
02 CORNER VIEW
04 FROM THE PROGRAM DIRECTOR
05 FREQUENT DEFICIENCIES
IN RENAL DIALYSIS CENTERS
LEADERSHIP TEAM
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES Matt Hughes VICE PRESIDENT, CORPORATE STRATEGY Barbara Sylvester, RN, BBA, MSOLQ DIRECTOR, REGULATORY AFFAIRS AND QUALITY
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SURVEYOR
Welcome to the 2024 Surveyor Quality Review. Each year, program-focused editions of this CORNER VIEW publication analyze compliance with ACHC standards over 12 months of surveys. This year’s data span initial and renewal surveys conducted between June 1, 2023, and May 31, 2024. ACHC-accredited organizations use the data to benchmark their performance by comparing these frequently-cited standards against their own survey report. There is value for non-accredited organizations, too. Because ACHC standards are closely aligned with CMS requirements, the information is relevant regardless of how your organization achieves its Medicare certification. For programs outside the Medicare regulations, the value remains. ACHC standards represent an important risk management/quality improvement framework. Reviewing the kinds of issues that arise in your peer organizations is an opportunity to act preemptively to manage your own risks. This is a critical business function in all healthcare settings. We know that some standards consistently present more compliance challenges than others. Frankly, if we offered only a list of frequent deficiencies, this publication wouldn’t vary much from year to year. Instead, Surveyor Quality Review gives insight into trends by quoting findings and offering practical tips to avoid citations. Some standards appear almost annually because of a large number of required elements. Perhaps a policy needs clarification, or staff members were not fully trained on a revision that impacts their work. Perhaps new or contract employees were not adequately oriented to a requirement for documentation, or employees made a change in their workspace that compromises fire safety. For a complex standard, any of these examples represents a potential deficiency and a risk to the organization, its staff, or its patients.
By sharing the observations of ACHC Surveyors, we offer an expert’s perspective on the most current issues impacting organizations. Trends by Program Internally, we use these data to guide the development of educational resources. Organizations seeking to renew their ACHC accreditation in 2024 were also surveyed in 2021. This year, our leaders are including comparative comments as they introduce their program findings. When we experience a large uptick in the number of initial surveys, as we have for several programs in this period, those difficult standards are likely to be prominent as new organizations confront them for the first time. However, we hope to see at least incremental improvement in standards that appeared as frequent deficiencies for this cohort of organizations three years ago. If we don’t see triennial improvements for some of the most frequently cited standards, it means we need to give more educational focus to these in the resources (webinars, workshops, tools) we offer. It is never ACHC’s intention to leave clients wondering about what is expected. To the contrary, our goal is to provide a range of resources that engage and enrich the experience of continuous quality improvement in the healthcare markets we serve. In this year’s first issue of Surveyor , I wrote about team collaboration and handoffs. Remember that ACHC serves as an extension of your team, ready to confer and coach. With Surveyor Quality Review , we are passing an evidence-based guidance tool to you. I hope you grasp it firmly and run with it!
MISSION STATEMENT
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
José Domingos President & CEO
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FROM THE PROGRAM DIRECTOR
Overall, standards from Section 7: Risk Management: Infection and Safety Control dominated the list of challenges. New compared to 2021 are RD7-B , RD7-J , and RD7-T . A range of infection prevention risks were noted by ACHC Surveyors, many related to the environment of care in which clean and contaminated equipment and supplies were not adequately separated to avoid cross-contaminations. Safety risks related to emergency preparedness were also noted. While most organizations did have emergency plans, in many cases staff was inadequately trained to maintain consistent readiness. Expired supplies or inaccessible equipment were prevalent among Surveyor findings. An Additional Offering for Providers I also wanted to bring attention to Long-Term Care Dialysis Certification that launched this year to address the growing number of providers offering dialysis within LTC/SNF facilities. Achieving this certification as an addition to accreditation, demonstrates an elevated standard of care for patients in these settings, highlighting an organization’s commitment to go above and beyond the federal requirements. Please reach out for more information.
ACHC has offered a CMS-approved program for Renal Dialysis Accreditation since 2019. Our program offers standards for in-center dialysis and for home dialysis training and support. For surveys included in the period from June 1, 2023 to May 31, 2024, the average number of standards noted as not compliant was six, although for some standards, multiple required elements may have been missed. Each deficiency noted must be corrected for an organization to receive accreditation. The Findings In 2021, there were seven standards cited on more than 20% of surveys. In 2024, a similar cohort of organizations was surveyed and all seven of these standards continue to be challenging for consistent compliance. I’m happy to report that five ( RD2-E, RD5-G, RD5-J, RD7-A, RD7-C ) were cited on fewer surveys in this cycle. Two others ( RD7-E, RD7-R ) appeared at a slightly elevated frequency compared to three years ago. Joining these seven are six additional standards that crossed the 20% frequency threshold. Standard RD4-M focuses on the accountability of the medical director. This individual is the liaison between those providing care and the governing body and as such, responsible for ensuring alignment of patient care with policy and procedure. The intent of standard RD5-L is to ensure equivalent quality of service between in-center and home-based dialysis. Surveyors noted missing documentation for home visit tasks. Standard RD6-A is the standard that drives continuous quality improvement for dialysis providers. It is essential that when performance monitoring data show opportunity for improvement, corrective action is taken. Documentation of the action and remeasurement provide evidence of its effectiveness.
RENAL DIALYSIS ACCREDITATION
In-Center Dialysis Home Dialysis Support Services
Distinction
Certification
Telehealth
Long-Term Care Dialysis
FREQUENT DEFICIENCIES FROM RENAL DIALYSIS SURVEYS
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% RD2-E RD4-M RD5-G RD5-J RD5-L RD6-A RD7-A RD7-B RD7-C RD7-E RD7-J RD7-R RD7-T
Teresa Hoosier Associate Program Director
Program/Service Operations
Provision of Care and Record Management
Risk Management: Infection and Safety Control
Human Resources Management
Quality Outcomes/ Performance Improvement
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RENAL DIALYSIS
SECTION 2: PROGRAM/SERVICE OPERATIONS RD2-E Overview of the requirement:
SECTION 4: HUMAN RESOURCES MANAGEMENT RD4-M Overview of the requirement:
Policies and procedures address patient rights and responsibilities. These rights are protected by the organization and communicated to each patient in writing. Evaluation of compliance comes from policy review, review of rights and responsibility statements and medical records, response to interviews, and direct observation. Surveyors noted specific required elements missing from patient rights statements, delays in providing the statement at the start of treatments, and missing documentation that the written statement was provided to each patient.
A qualified medical director is accountable to the governing body for the quality of patient care and outcomes. Compliance is assessed through personnel files review, direct observation, and response to interviews. Surveyors noted that a range of aspects of patient care were not aligned with policies and procedures.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
21%
Examples of surveyor findings:
n There is evidence of non-compliance with policies for patient admissions, patient care, infection control, and safety by individuals who treat patients in the facility, including attending physicians and non-physician providers. n The facility did not follow its policy for RN patient assessment within the first 30 minutes of dialysis. n The medical director did not ensure that a Quality Assessment and Performance Improvement Program was in place. The medical director’s employment began in 2021. The organization could not provide any QAPI meeting minutes prior to January 2024. n Ensure the medical director’s responsibilities include but are not limited to overseeing/approving staff education, training, and performance. n Educate staff on policy and procedure expectations. n Perform audits to ensure compliance.
Frequency of citation:
32%
Examples of surveyor findings:
n Client records did not include evidence that the facility informed the patient of the facility’s policies and procedures for transfer, routine or involuntary discharge, and discontinuation of services to patients. n Records did not include evidence that the organization provided a statement of rights and responsibilities at the time treatment was started. n There was no evidence that patient rights were honored with regard to information about and participation in their care. Patients were not invited to participate in interdisciplinary team meetings or to share information with the IDT. n The patient’s right to respect and dignity was compromised by observed rude and aggressive behavior by a staff member toward a patient with documented cognitive issues. n Ensure that at least each element of the standard is covered in the statement of rights and responsibilities. n Educate staff about the need to document provision of the written statement to each patient at the time service is initiated.
Tips for compliance:
Tips for complianc e:
The protection of patient rights is a critical part of compliance. Ensure that staff are trained to implement rights as well as to distribute them as a document.
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RENAL DIALYSIS
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT RD5-G Overview of the requirement: Policies and procedures define the components each patient’s individualized assessment and the interdisciplinary approach used to complete the assessment. Comment on deficiencies: Evaluation of compliance comes from review of policies and procedures, review of patient records, and response to interview. Surveyors noted non-compliance with guidelines, poor documentation practices, and delays in patient assessments and care plan updates.
RD5-J Overview of the requirement:
The comprehensive assessment drives an individualized plan of care. Minimum requirements for the plan of care are detailed in the standard. Evaluation of compliance comes from review of policies and procedures, review of client/patient records, and response to interviews. Many findings related to an inadequate level of detail in the plan of care, or treatment that failed to follow the organization’s policies.
Comment on deficiencies:
Frequency of citation:
68%
Examples of surveyor findings:
n Records did not demonstrate that the plan of care adequately addresses the patient’s dialysis blood flow rate (BFR) and/or dialysate flow rate (DFR). BFRs were reduced during treatment without a documented reason. n Plans of care were not signed by the patient. If the patient chooses not to sign the plan of care, this choice must be documented. n Records did not contain evidence that blood pressure and fluid management needs were addressed. Multiple medical records noted blood pressure fluctuations without evidence of interventions including notification of the MD per facility policy. n There was no evidence that home dialysis patients were evaluated by the facility for the ability to safely, aseptically, and effectively administer erythropoiesis- stimulating agents and store this medication under refrigeration, if necessary. Per interview with the CNM, the patients have been evaluated and trained, however there is no evidence of documentation of the evaluation or training. n Ensure the plan of care for each patient reflects a current assessment and is adjusted as needed. n Audit care notes against orders for consistency and alignment with organizational policies. Reeducate staff on the individualized nature of plans of care. If the expectation is that care is standardized within the center, individual variations are less likely to be noted.
Frequency of citation:
47%
Examples of surveyor findings:
n Assessments lacked evaluation of current health status, co-morbidities, nutritional status, psychosocial needs, and/or physical activity levels. n Assessment documentation did not include immunization history. n Policies related to addressing care protocols (e.g., hypertension, dysrhythmias, and patient falls) were not followed. n There were delays in reassessing and updating the plan of care for unstable patients. n Patient assessments did not include evidence of involvement by an interdisciplinary team (social workers, dietitians, physicians). n Review policies for patient assessment to ensure all required participants and all required elements are identified. n Create templates for patient assessments to ensure each required element is addressed in every patient record.
Tips for compliance:
Tips for compliance:
Complete initial assessments within 30 days or 13 treatments.
n Conduct reassessments for unstable patients at least monthly. n Audit patient records for inclusion of complete assessments. n Reeducate staff as needed to ensure full documentation is completed.
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RENAL DIALYSIS
SECTION 6: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT RD6-A Overview of the requirement:
The facility must develop, implement, maintain, and evaluate an effective, data- driven, QAPI program that reflects the complexity and scope of the services provided and demonstrates participation by the professional members of the interdisciplinary team. Surveyors evaluate compliance through review of policies and procedures and the QAPI plan, observation and response to interviews. Surveyors cited missing evidence of corrective actions.
Comment on deficiencies:
Frequency of citation:
32%
Examples of surveyor findings:
n The facility did not show evidence of continuous performance monitoring. Outcomes reported were not producing positive results and there was no evidence of corrective action to promote improvement for: nutritional status, mineral metabolism, renal bone disease, anemia management, vascular access or hospitalization rate. n The facility did not show evidence of priorities set for performance improvement based on prevalence and severity of identified problems. The QAPI minutes provided for two quarters and included no improvement activities related to clinical outcomes or patient safety. n The QAPI Program did not include a measure to address medical injuries and errors. n The QAPI Program states that the facility will analyze and document the incidence of infections, identify trends and establish baseline information on infection incidents. The documentation noted an action plan to promote immunization to reduce further incidents. There was no immunization data included in subsequent documentation. Identifying opportunities and taking action toward improvement is the essence of the QAPI Program. Initial measurement establishes baseline performance, then specific actions must be taken, and remeasurement used to assess improvement over time. n Identify items to be measured, based on the standard and the services provided. n Set priorities for improvement and take one corrective action at a time. Simultaneous changes make it hard to identify what drove improvement.
RD5-L Overview of the requirement:
For organizations that support home dialysis patients, the services must be equivalent to those provided in-center. Note: This standard is only applicable to home dialysis services. Compliance is evaluated by review of contracts and patient records, direct observation of home visits, response to interviews. Most prominent in Surveyor finds was a lack of documentation for quarterly bacteriological and endotoxin testing in patient homes.
Comment on deficiencies:
Frequency of citation:
24%
Examples of surveyor findings:
n Missing documentation that a nurse made a home visit prior to the patient’s first treatment per organization policy. n Quarterly evaluation and testing to ensure water and dialysate quality meets AAMI quality limits was not documented. n The plan of care was not completed by all members of the interdisciplinary team. n Ensure equivalence between home-based and in-center services. n Create checklists for scheduled activities to be performed during home visits. n Audit files for compliance.
Tips for compliance:
Tips for compliance:
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RENAL DIALYSIS
SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL RD7-A Overview of the requirement: Written policies and procedures govern an infection prevention and control program designed to protect patients and personnel from communicable disease and infection.
RD7-B Overview of the requirement:
Policies and procedures follow CDC recommendation and OSHA mandates for Hepatitus B vaccination of patients and staff. Compliance is evaluated through review of policy and procedure, other records, and response to interviews. Surveyor findings came from document review and most deficiencies were a result of noncompliance with the organization’s policy for testing and vaccination.
Comment on deficiencies:
Comment on deficiencies:
Compliance is evaluated based on review of policies and procedures, direct observation, response to interviews, and review of personnel files. Most citations noted a failure to distinguish between clean and dirty areas when managing supplies and equipment. Improper use of PPE (especially gloves) also was frequently observed.
Frequency of citation:
32%
Examples of surveyor findings:
n During review of the facilities hepatitis vaccination tracker, it was noted that an admitted patient signed a consent to receive the Hepatitis B vaccine two days after admission and was scheduled to receive the first vaccine four days later but it had not been administered at the time of survey (14 days after consent was received). n The organization is not following its patient hepatitis testing and vaccination policy. Six of ten patient records reviewed did not include evidence that the vaccine series had been offered, nor was a document declining the vaccination present. n Not all personnel files included evidence of hepatitis B antigen titer being drawn, vaccine administered, or vaccine declined. n Identify the HBV serological status of all patients before admission to hemodialysis. n Routinely test patients for hepatitis B vaccine and should seroconversion occur, investigate possible sources of infection against unit practices and procedures. n Segregate HBsAg positive patients from others for treatment.
Frequency of citation:
62%
Examples of surveyor findings:
n A staff member was observed placing a used face shield on top of the clean supplies and medication preparation counter. n Staff stores clean supplies behind the treatment station while a patient is on dialysis. These supplies were not discarded at the end of treatment. n Staff members were observed wiping down each dialysis machine, but did not disinfect the RO machine and the computer within the station. n Clean and dirty areas are not clearly separated. Used supplies and equipment are handled and clean supplies are stored in the same area. The PD training room had a centrifuge used for spinning lab tubes sitting beside a clean sink, with no barrier separating the clean/dirty area. Clean supplies were stored above and below the centrifuge. The emergency eye wash station was installed onto the dirty sink. n Staff members placed used CVC caps, gauze, and alcohol pads on the barrier pad where clean gauze and saline syringes were located. n The physician assessing patient heart and lung sounds at the initiation of treatment did not don gloves. n Staff on the treatment floor were observed donning gloves that they were carrying in their pockets. n Evaluate clean and dirty storage locations. Ensure adequate separation between the two. n Educate staff on processes to avoid cross contamination before, during, and after procedures. n Disinfect equipment between patients. n Reeducate staff on required hand hygiene and gloving protocols.
Tips for compliance:
Tips for compliance:
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RENAL DIALYSIS
RD7-E Overview of the requirement:
RD7-C Overview of the requirement:
The organization must achieve standards set by AAMI for water and dialysate quality. Note: This standard is only applicable to in-center dialysis. Compliance is assessed through review of written policies and procedures, monitoring and testing records, response to interview, and observation. Most deficiencies noted inconsistency between AAMI requirements or the organization’s policies and actual practice.
The organization provides infection control training specific to hemodialysis units that enables personnel to demonstrate competence and compliance with infection control principles. It also educates patients and caregivers to report signs and symptoms of infection to healthcare personnel. Written policies and procedures, personnel files, medical records, direct observation and response to interview are used to assess compliance with the standard. Most instances of non-compliance noted a failure to follow organizational policies for preventing catheter-related infection.
Comment on deficiencies:
Comment on deficiencies:
Frequency of citation:
32%
Frequency of citation:
26%
Examples of surveyor findings:
n Electronic logs for documenting chlorine/chloramine checks showed that the facility failed to ensure all checks are performed prior to each patient’s treatment initiation. n Although all pipes, valves and tanks are labeled, the facility did not have a schematic diagram posted that provides a convenient means of identifying pipe content and flow components for valves, sample ports, and flow direction. n Operators do not follow the manufacturer’s instructions regarding dialysate conductivity. The pH must be measured with an independent meter prior to each patient treatment and at any time there is a change in the concentrate (dialysate.) The facility documents the conductivity prior to each patient’s treatment, but there is no evidence of pH being measured. n The softener brine tank requires daily monitoring to ensure a saturated salt solution with salt pellets filling the tank to the level of at least one half full. The brine tank was only filled one fourth of the way with salt pellets. n Ensure testing for free chlorine, chloramine, or total chlorine is performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every four hours. n When ultrafilters are used in a water purification system for hemodialysis applications, the pressure drop across the ultrafilter (PSI) should be measured using simple inlet and outlet pressure gauges. Ultrafilters operated in the cross- flow mode should also be monitored in terms of the flow rate of water being directed to drain (concentrate.) Results of pressure measurements and bacteria and endotoxin levels are recorded in a log. n Educate staff on water and dialysate requirements. Audits to ensure compliance. n Monitor the softener brine tank daily to ensure that a saturated salt solution exists. Salt pellets should fill at least half the tank. Salt designated as rock salt should not be used for softener regeneration since it is not refined and typically contains sediments and other impurities that may damage O-rings and pistons and clog orifices in the softener control head.
Examples of surveyor findings:
n Facility policy describes appropriate technique when performing catheter and catheter-site care which includes cleaning the hub with a 15 second scrub whenever the TEGO connector is removed from the CVC. Each time a staff member was observed removing the TEGO caps and scrubbing the hub it was for less than 10 seconds. n Personnel records did not show evidence of training and education in infection control practices appropriate to the responsibilities and task assignments of the staff at the time of hire and at least annually thereafter. n There was no specific training and education for practices regarding the appropriate infection control measures to prevent intravascular catheter- related infections, nor was there evidence of an assessment for knowledge of and adherence to guidelines periodically for all persons who manage intravascular catheters for home hemodialysis patients. n During a CVC dressing change, a staff member answered a machine alarm during the process of cleaning the access site. The staff member did not remove the dirty gloves, wash hands or don new gloves, after touching the machine, but instead resumed cleaning the catheter site and applying the clean dressing while wearing the same gloves. n Monitor all personnel for demonstrated compliance with infection control practices while providing care and services to patients in the dialysis facility. n Review policies and procedures for catheter and catheter-site care to ensure they: ٝ Define appropriate cleaning/disinfections of the caps used to close the catheter between uses. Require patient/patient care giver education on signs and symptoms that should be reported.
Tips for compliance:
Tips for compliance:
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RENAL DIALYSIS
RD7-R Overview of the requirement:
RD7-J Overview of the requirement:
An emergency preparedness plan is developed and reviewed every two years to ensure the safety of patients and staff in the event of an emergency. The standard is assessed through review of policies and procedures, observation, and response to interviews. Deficiencies for in-center services noted expired and missing supplies and lack of access to emergency equipment. Deficiencies for home dialysis support focused on lack of communication with patients regarding an alternate site of care in the event of an emergency.
The facility provides a safe, functional, comfortable treatment environment.
Comment on deficiencies:
Compliance is assessed primarily through observation. Surveyor comments focused on environmental issues related to maintenance and the layout of patient care areas that compromised safety.
Comment on deficiencies:
Frequency of citation:
26%
Examples of surveyor findings:
n In one pod/bay, the laminate flooring was observed to be damaged and buckling in front of patient stations creating a significant trip or fall hazard to patients and staff. n The facility did not ensure that all equipment is monitored and maintained to ensure it is operating in accordance with the manufacturer’s guidelines. There was no evidence of temperature monitoring for the laboratory refrigerator where specific laboratory specimens are to be stored at a certain temperature range. n The space for treating each patient must be sufficient to provide needed care and services, prevent cross-contamination, and to accommodate medical emergency equipment and staff. Four patient chairs are arranged side by side with no machine between them, causing the chairside tables to be less than one inch apart making it difficult to accommodate medical emergency equipment if needed, and posing a risk for cross contamination. n Evaluate the space for function and make needed adjustments. All patients must be in direct line of sight throughout treatment but with adequate space to accommodate emergency equipment and to mitigate risk of cross contamination. n Conduct regular surveillance rounds for general environmental conditions and infection and safety risks (blood residue, rust, expired items, clutter, accessibility). n Schedule equipment maintenance per manufacturer’s instructions.
Frequency of citation:
32%
Examples of surveyor findings:
n Patients interviewed did not know what to do about missing treatments if there was an emergency and they could not make contact with the dialysis facility. They denied being notified regarding a back-up facility if the disaster/ emergency involved their clinic’s ability to provide treatment. n The emergency plan did not include a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. n Drugs and supplies earmarked for emergency use had expired. This conflicted with the organization’s emergency plan. n The emergency plan states that emergency equipment, including a defibrillator or automated external defibrillator and artificial resuscitator, are on the premises at all times and immediately available for use. There are no expired supplies. Logs show that the required AED check was not completed daily. The emergency evacuation box monthly checklist was not completed for two months and the box in was missing supplies and included expired items. The patient roster, contact information and dialysis orders in the Emergency take-out box had not been updated in the past three years. n Develop a process to confirm that emergency equipment (e.g., oxygen, airway and suction devices, defibrillator or AED, artificial resuscitator, and emergency drugs) is immediately available and includes appropriate inventory of unexpired drugs and supplies. n Advise patients of emergency precautions.
Tips for compliance:
Tips for compliance:
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RENAL DIALYSIS
NOTES
RD7-T Overview of the requirement:
The emergency plan requires testing at least annually, staff training at least every two years and appropriate patient orientation. The standard is assessed through review of training logs, observation, and response to interviews. Surveyors noted inconsistency in staff training and patient orientation.
Comment on deficiencies:
Frequency of citation:
26%
Examples of surveyor findings:
n Staff did not provide appropriate orientation to patients. n The patient education and information checklist states that the emergency orientation should occur with in the first three treatments. Two of ten patient records reviewed showed no emergency orientation for patients admitted for one- and two-years to date. n The organization did not have documentation of exercises to test the emergency plan. n There was no evidence of staff training on the emergency plan at least every two years.
Tips for compliance:
n Educate staff on the emergency plan.
Consistency is key. The three components of this standard are annual emergency exercises (testing), staff training (every two years), and patient orientation. Schedule the testing and training. Add patient orientation to an admission checklist.
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
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ACHC Redefining the Culture of Accreditation
We’re here to help. To learn more, visit our website at achc.org , call us at (855) 937-2242 , or email customerservice@achc.org .
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SURVEYOR 2024, NO. 2
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