Volume 2024 | No. 2
SURVEYOR
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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