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Volume 2025 | No. 2
Quality Review Edition THE Accreditation Resource for Data Nerds SURVEYOR
Volume 2024 | No. 2
SURVEYOR
TABLE OF CONTENTS
03 Corner View
04 From the Program Director
05 Frequent Deficiencies in Renal Dialysis
BOARD OF COMMISSIONERS
LEADERSHIP TEAM
Brock Slabach, MPH, FACHE Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CEO, MSMP ANESTHESIA SERVICES, LLC
Leonard S. Holman, Jr., RPh Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES
John Barrett, MBA Officer-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM
Matt Hughes VICE PRESIDENT, COMMUNITY CARE SERVICES Jonathan Kennedy, CPA, MBA VICE PRESIDENT, FINANCE AND CORPORATE SERVICES
Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO
Mark S. Defrancesco, MD, MBA, FACOG Secretary WOMEN’S HEALTH CONNECTI CUT/PHYSICIANS FOR WOMEN’S HEALTH (RETIRED)
Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
Jennifer Burch, PharmD OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS
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Volume 2025 | No. 2
SURVEYOR
CORNER VIEW WITH PRESIDENT & CEO, JOS É DOMINGOS
You made a great decision when choosing ACHC to accredit your dialysis program. Whether you are new or have years of experience with us, I am confident that you have already felt first-hand our intense focus on customer service. Real support that builds your team ACHC doesn’t engage in “accreditation theatre” through complex scoring rubrics or punitive surveys that give an illusion of rigor without adding any true value for your organization. Instead, we focus on real support designed to close any gaps between your current state and full standards compliance. We are known as Accreditation Nerds for our genuine belief in— and passion for—the efficacy of accreditation to enhance quality and safety in healthcare organizations. But we know it works best when those organizations understand and embrace continuous performance improvement. The Quality Review edition of Surveyor is an excellent place to start. This publication is a resource demonstrating how ACHC program teams work to help you develop individual expertise within your organization, while recognizing that your staff may have varying levels of experience and current knowledge of accreditation standards. The standards covered are the most frequently cited on recent surveys and the compliance tips provided are divided into categories to make them useful for individuals across a range of roles and experience. “Accreditation Nerd Newbies” are just that: new to the process of demonstrating compliance with accreditation standards. ACHC uses a Plan- Do-Study-Act framework to organize standards. Even a “simple” standard may include multiple
elements for full compliance. Under Compliance tips for Nerd Newbies, we offer a clear summary of the expectations for each standard. “Accreditation Nerd Apprentices” understand the concepts of meeting and maintaining standards. Compliance tips for Nerd Apprentices focus on using data on hand to continuously assess how well your organization is performing. Finally, “Accreditation Nerd Trailblazers” are those individuals who are passionate about maximizing their organization’s capacity for excellence. They are enthusiasts who eagerly share their knowledge with colleagues to create a path forward. Nerd Trailblazers thrive on the goal of continuous improvement. Compliance tips for Nerd Trailblazers cover best practices designed to level up your organization. These tongue-in-cheek categories are our way of saying that it’s possible to approach accreditation seriously without being humorless. When we say that we want to help you develop your staff into a team of Accreditation Nerds, you immediately understand our goal. Partnership you can rely on Once your organization is ACHC-accredited, we become your partner, dedicated to meeting your needs. ACHC’s staff of Accreditation Nerds— account advisors, surveyors, clinical educators, quality and regulatory, and other experts— thrive on being helpful. Review the information on the pages that follow confident that we’re ready to dig in to answer questions, provide feedback, offer suggestions, and direct you to any additional resources you need.
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.
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Volume 2025 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
RENAL DIALYSIS
ACHC’s Renal Dialysis Accreditation Program covers in-center dialysis and home dialysis training and support. This report identifies 10 standards that were cited for noncompliance on at least 20% of the surveys conducted from June 1, 2024 to May 31, 2025. To achieve or maintain accreditation, each deficiency noted must be corrected. Some standards are perennially challenging; these are usually the ones with many required elements. Nonetheless, organizations should always strive to make sustainable corrections and to avoid repeat deficiencies on subsequent surveys.
RENAL DIALYSIS SERVICES Services In-Center Dialysis Home Dialysis Training & Support
Distinctions Telehealth
Certifications Long-Term Care Dialysis
The findings Using the 20% threshold, we can compare this year’s report to 2022, the last triennial survey cycle for this cohort of organizations. The overall count of standards was seven in 2022 and ten in 2025. Six standards were repeated this year: RD5-J, RD5-G, RD7-A, RD7-C, RD7-E, and RD7-J . These fall into two groups, section 5: Provision of Care/Record Management and section 7: Risk Management: Infection and Safety Control where maintaining cleanliness, water quality, and avoiding cross contamination for infection prevention are prevalent citations. Standards from section 5 focus on individualized assessments and care plans with robust and accurate documentation regarding the care delivered and the patient’s progress toward goals. Many of these standards require a high level of detail and the primary challenge is current, complete, authenticated documentation. Standards from section 7 focus on mitigating risk to patients, especially those associated with infection and safety hazards. Deficiencies clustered around lapses in infection prevention practice and observable issues in the environment of care, for example, inadequate separation of clean and contaminated equipment and supplies to avoid cross-contamination.
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. Observation of expired supplies and inaccessible equipment were prevalent findings for emergency preparedness. A number of deficiencies were identified across long-term care settings. For providers delivering dialysis services within LTC/SNF facilities, collaboration between the dialysis facility’s staff and the LTC/SNF staff is paramount to ensure continuity of care and maintain compliance with the standards. How can we help? The ACHC Renal Dialysis Accreditation team is passionate about safe, high-quality care for dialysis patients. Don’t hesitate to reach out with your questions. We’re here to support your success!
FREQUENT DEFICIENCIES FROM RENAL DIALYSIS SURVEYS
60%
50%
40%
30%
20%
Teresa Hoosier Associate Clinical Director
10%
0%
RD5-G
RD5-7
RD5-P.01
RD6-A
RD7-A
RD7-C
RD7-E
RD7-J
RD7-R
RD7-T
Provision of Care and Record Management
Quality Outcomes/ Performance Improvement
Risk Management: Infection and Safety Control
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RENAL DIALYSIS
Compliance tips for:
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT RD5-G Frequency of the citation: 48% Overview of the requirement: Within a defined time frame, an interdisciplinary team prepares a comprehensive assessment of each patient admitted for dialysis. Written policies and procedures include the required components of each initial and subsequent assessment to ensure the adequacy of the dialysis prescription. Comment on deficiencies: Evaluation of compliance comes from reviewing policies and procedures, reviewing patient records, and responses to interviews. Surveyors noted a range of deficiencies related to required elements of the comprehensive assessment that were not included. Failure to act on monthly data for unstable patients was also an issue. Examples of ACHC Surveyor findings: ■ Patient records did not include evidence of a physician evaluation of health status or history and physical in the comprehensive assessment. All patient visits with the physician were confirmed to be conducted via telehealth, and there was no evidence of an initial physical assessment and review of systems conducted. ■ Comprehensive assessments did not include history of standard immunizations (pneumococcal, influenza, TB screening). ■ Organization policy requires monthly evaluation of nutritional status by the dietitian. This documentation was missing in some client records. ■ Comprehensive reassessments for stable patients, due at least annually, and conducted by the IDT were noted to be incomplete. MD and RN sections were completed on time, however the MSW did not complete the psychosocial portion until eight months later and the registered dietitian assessment was not completed. ■ There was no evidence that the facility revised the plan of care at least monthly for unstable patients. Patients with documentation of ongoing unmanaged anemia/frequent hospitalizations were not identified as unstable and assessed monthly as required. ■ For a patient hospitalized in December for a GI bleed, the nursing sections of monthly assessments in January and February did not address the hospitalization. Additionally, weekly Hgb results were not within acceptable range throughout January with ESA dosing on hold and no reason noted for the hold. ■ On reassessment, an RN documented the day of the IDT round, however the nursing portion of the assessment was blank in relation to lab work, goals, and head to toe assessment of the client.
■ Initial assessments must include all required elements and be performed within 30 days or 13 treatments by the interdisciplinary team that includes, at least, a physician, a registered nurse, a social worker, and a dietitian. ■ Comprehensive reassessment of unstable patients is conducted monthly, at minimum. ■ Comprehensive reassessment of stable patients is conducted annually, at minimum. ■ Create templates for patient assessments to ensure each required element is addressed in every patient record. ■ Audit patient records for inclusion of complete assessments. ■ Reeducate staff as needed to ensure full documentation is completed. ■ Communicate monthly assessment data for unstable patients to the interdisciplinary team for revisions in the plan of care.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
RD5-J Frequency of the citation: 52%
Overview of the requirement: The comprehensive assessment drives an individualized plan of care developed by the interdisciplinary team and implemented within 30 days of admission or 13 outpatient hemodialysis treatments. Minimum requirements for the plan of care are detailed in the standard. Dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician assistant providing ESRD care at least monthly. Comment on deficiencies: Evaluation of compliance comes from reviewing policies and procedures, reviewing client/patient records, and responses to interviews. This standard includes many elements, each of which is required for compliance. Surveyor citations can be summarized as noting that monthly, interdisciplinary plan of care review and revision was insufficient. Examples of ACHC Surveyor findings: ■ Monthly progress notes were missing from patient records. ■ Home dialysis patient records did not include evidence of training for administration and refrigerated storage of erythropoiesis-stimulating agents. ■ Initial plans of care did not have signatures of all members of the interdisciplinary team as evidence of review.
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RENAL DIALYSIS
■ The SNF reported to the dialysis facility the patient’s Hgb results ranging from 6.3g/dl - 6.8g/ dl between July and October, which resulted in the SNF sending the patient to the hospital for transfusions on five occasions. Interview with the CNM revealed that the patient has a diagnosis of Alport syndrome which can lead to hemolytic anemia, however this has not been documented as a reason for not meeting the anemia goal on the plan of care. There is no evidence that the IDT conducted an evaluation of the patient's comorbidities in order to identify a reason/diagnosis for consistently low hemoglobin levels. There is no note in the physician or nursing monthly progress notes related to the unmanaged anemia, requiring five blood transfusions in a five month period. The nursing and physician portion of the plan of care addressed only the ESA dose and stated “continue with anemia management” on the initial start of care assessment and again on the 90- day follow up assessment. There is no evidence of plan of care revisions after the follow up.
RD5-P.01 Frequency of the citation: 33%
Overview of the requirement: Storage, handling, labeling, and administration of drugs and biologicals is in accordance with written policies and procedures. Comment on deficiencies: Compliance is evaluated by direct observation, response to interviews, and document review. Surveyors frequently noted missing or insufficient policies for disposal of expired drugs and the presence of expired medications. Examples of ACHC Surveyor findings: ■ The facility did not have a policy regarding appropriate administration, storage, handling, labeling, and dispensing of drugs and biologicals. ■ Policy states that multi-dose vials will be labeled with the date that they are first opened. An opened multi-dose vial of heparin was not labeled with its open date. ■ The facility did not have a process for recall of drugs and biologicals or current drug references and antidote information available onsite. ■ The dialysis supply closet stored multiple packs of lab tubes with expiration dates ranging from 1/2022 - 1/2025. ■ The facility did not dispose of expired drugs. A vial of heparin (10,000 units) with an expiration date of 10/2023 was present. Compliance tips for:
Compliance tips for:
Patient needs identified by the comprehensive assessment are used to develop and implement an individualized plan of care. The plan includes measurable and expected outcomes and estimated time frames to achieve them. Required elements of the plan are defined in the standard. Monthly progress notes reflect that a physician, nurse practitioner, clinical nurse specialist, or physician’s assistant providing ESRD care sees the patient at least monthly.
Nerd Newbies (understand the requirement)
■ Audit care notes:
Nerd Apprentices (audit for excellence)
ٝ against orders to ensure consistency and alignment with organizational policies. ٝ for inclusion of all required elements. ٝ for evidence that a qualified clinical professional has seen the patient/ reviewed the plan of care at least monthly. ■ Create templates to ensure all required measurements are captured. ■ Educate staff on the importance of individualized plans of care. A standardized approach increases the risk of patient-specific needs being overlooked.
Nerd Trailblazers (prepare the path for others)
Policies related to medication management are designed to ensure safety for patients and compliance with laws and regulations for dispensing scheduled drugs. ■ Audit storage areas and rotate dated medications and supplies to ensure that those closest to expiration are used first.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Dispose of expired drugs. ■ Monitor for drug recalls.
■ Review policies to ensure that all required elements are included. ■ Conduct staff training related to storage, labeling, and administration, and disposal of medications.
Nerd Trailblazers (prepare the path for others)
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RENAL DIALYSIS
Compliance tips for: Nerd Newbies
SECTION 6: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT RD6-A Frequency of the citation: 22% Overview of the requirement: The facility measures, analyzes, and tracks quality indicators to assess processes of care, services, and operations. Facility-wide performance improvement efforts focus on improving health outcomes and reducing medical errors. Comment on deficiencies: Surveyors evaluate compliance by reviewing documentation, direct observation, and response to interviews. Surveyors noted that QAPI was not sufficiently comprehensive of services provided and that when measured results indicated opportunity for improvement, there was no evidence of corrective action. Examples of ACHC Surveyor findings: ■ The organization did not present a written policy and procedure for a QAPI Program. ■ The facility did not track the incidence of infections to establish baseline information and identify trends. Additionally, there was no evidence of recommendations and action plans to minimize infection transmission. The only immunization information noted in the QAPI documentation was a column labeled “influenza” which contained the number of patients who had received a vaccine. There were no action plans noted to promote immunizations nor were there any other immunizations included in the data. ■ There was no evidence of medical record audits, patient satisfaction surveys, direct observation in a care setting or interviews with patients and personnel. ■ Identified goals were not met over the last six months and action plans had not been changed in the past four month for any of the unmet goals. ٝ Adequacy goal of 98% was not met with a percentage ranging from 75% to 87%. ٝ Catheter > 90 days goal of <30% was not met with percentage ranging from 33%-58%. ٝ A goal is not included in the QAPI vascular access section for AVFs or AVGs. The AVF percentage ranged from 22%-39% and AVGs from 3%-13%. ٝ The facility’s anemia goal for at least 50% of patients to have an Hgb between 9g/dl-11g/dl, has not been met with results ranging from 40%-48%. ٝ Transplant referrals do not have an established goal, and there is no evidence that referrals have been addressed over the last six months.
The intent of a QAPI Program is continuous quality improvement. The organization begins by identifying what and how it will measure important aspects of care. These metrics provide a performance baseline. Comparing initial results to industry norms gives an external benchmark for goal-setting. Tracking performance over time reveals internal trends. Use the data to identify and guide improvement efforts. ■ Audit QAPI documentation to ensure inclusion of expected metrics on a defined schedule. ■ Establish priorities for improvement projects that impact patient outcomes and safety. ■ Communicate the start and the goal of QAPI projects across the organization. Provide updates as each corrective action and remeasurement cycle is completed. Engaging staff in continuous improvement will build it as a cultural norm for your organization.
(understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL RD7-A Frequency of the citation: 48% Overview of the requirement: Written policies and procedures are established and implemented to include accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions. 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 were the result of observed infection control breaches by staff when managing supplies and equipment. Examples of ACHC Surveyor findings: ■ The facility did not present an infection control policy that addresses the surveillance, identification, prevention, control and investigation of infectious and communicable diseases. ■ The exposure control plans did not include a current prevalence rate of TB in the communities
served or the rate of TB in patients serviced by the facility. ■ Some personnel records lacked evidence of TB testing.
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RENAL DIALYSIS AMBULATORY SURGERY CENTER
■ A common supply cart stocked with gallon jugs of bicarb solutions was positioned within the treatment station where a patient was actively dialyzing. ■ One staff member did not remove her gloves when leaving the patient’s station, nor did she wash her hands before obtaining a clean bleach rag from the clean bleach container. One staff member did not don gloves when moving patients from their wheelchairs to their dialysis chairs or when touching their belongings to prepare them for dialysis. ■ During initiation of treatment, a staff member was observed placing a used vacutainer and a tube of blood alongside clean supplies designated for cannulating the access and normal saline infusion. ■ While initiating treatment with a CVC, one staff member placed used syringes on the clean drape where alcohol preps were in place to be used to scrub the hub. Another staff member, initiating treatment using an AVF, placed a blood filled syringe on a clean pad with other clean syringes and alcohol pads. The staff member continued to use the supplies from the clean pad that became soiled with blood leakage from the AVF site while initiating treatment. ■ A staff member’s cell phone was placed on a counter designated for clean supplies.
RD7-C Frequency of the citation: 26%
Overview of the requirement: Based on the services provided, the organization provides infection control education and training to its employees, contracted providers, patients, and their family members. Clinical staff demonstrate competence and compliance with infection control principles. Comment on deficiencies: Written policies and procedures, personnel files, medical records, direct observation and response to interview are used to assess compliance with the standard. Most noncompliance was failure to follow the organization’s policies for preventing catheter-related infection, noted by direct observation. Examples of ACHC Surveyor findings: ■ The policy, “Dialysis Catheter Care,” requires visual inspection and a dressing change with each treatment. Two of six patient records reviewed did not have evidence of catheter care on one treatment date. Another record, for an assisted treatment in the patient’s home, included no evidence that the catheter site was visually inspected and a dressing change completed. ■ Three of six personnel records reviewed did not include evidence of infection control training. ■ A staff member initiating care of a CVC did not remove his gloves, perform hand hygiene, and don clean gloves to minimize cross contamination at three risk points: after removing the old CVC dressing, prior to placing the new CVC dressing, and prior to initiation of treatment. ■ During observation of care, a staff member opened up all the supplies used to initiate treatment for a patient with a CVC. The caps were removed from the heparin filled syringes, the normal saline filled syringes, and the packaging was removed from two 10 cc syringes. The staff member then proceeded to move over and care for another patient for more than 15 minutes, leaving all previously opened supplies exposed and unprotected from potential contamination. As the staff member began the process of removing the CVC dressing to initiate a change, they opened a sterile swab taking it out of the package and placing it on the pad with the other supplies. Once the dressing was completely removed, the staff member then picked up the swab from the pad and proceeded to clean the skin around the outer area of the CVC site with the contaminated swab.
Compliance tips for:
The intent of this standard is to highlight the details critical to effective infection prevention and control. Policies and procedures are expected to be developed and rigorously implemented. ■ Evaluate clean and dirty storage locations and ensure adequate separation between them. ■ Disinfect equipment between patients.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Hold regular infection prevention training.
Nerd Trailblazers (prepare the path for others)
ٝ Segment training for avoiding cross-contamination into before, during, and after treatment modules. ٝ Engage staff with “spot-the-error” scenarios.
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RENAL DIALYSIS
■ The facility did not ensure that reverse osmosis systems were meeting the requirements of AAMI 5.2.2, Table 1 when tested with the typical feed water. ٝ Location 1 - The RO 2 product conductivity range is 1-20 mS. On several dates it was documented out of range (22- 24). Additionally, the rejection range is >90%, however on several dates there is no documentation of this parameter. ٝ Location 2 - The RO prefilter differential delta pressure range is <10. It was noted as “10” on nine occasions in June, nine occasions in July, and 10 occasions in August with no documentation at either location of trending analysis or interventions regarding the documented out of range measurements.
Compliance tips for:
The standard focuses on infection prevention training with the goal of consistent implementation of infection prevention practices across the organization. ■ Audit 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. ٝ define expectations for dressing changes. ٝ identify signs and symptoms of infection that should be reported – by staff, patients, caregivers. ■ Monitor personal for compliance with infection prevention practices. ■ Conduct regular refresher trainings on infection prevention topics. ٝ Engage staff with “spot-the-error” scenarios.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Compliance tips for:
The facility must be able to demonstrate that water and equipment used for dialysis meets quality standards and requirements from in the Association for the Advancement of Medical Instrumentation publication “Dialysate for hemodialysis,” ANSI/AAMI RD52:2004. ■ Audit water and dialysate logs for full and accurate documentation of requirements. ■ Conduct semi-annual training with relevant staff. ■ Hang laminated reminder signage in the appropriate areas to prompt staff on acceptable ranges and documentation requirements.
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
RD7-E Frequency of the citation: 26%
Nerd Trailblazers (prepare the path for others)
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.
RD7-J Frequency of the citation: 33%
Comment on deficiencies: Compliance is assessed through review of written policies and procedures, monitoring and testing records, response to interview, and observation. The elements of the standard are lengthy and detailed. Surveyors cited a range of specific deficiencies. The only concern repeated on multiple surveys was unrestricted access to the purification and storage system. Examples of ACHC Surveyor findings: ■ The facility did not provide evidence that it follows the manufacturer guidelines for system disinfection per AAMI 5.3.3. There was no documentation of hot water disinfection of machines on the required schedule. ■ There is no documentation of dialysate cultures being obtained for the month of November. ■ The water purification and storage system was not located in a secure area with access to the purification system restricted to individuals responsible for monitoring and maintenance of the system.
Overview of the requirement: The treatment environment is designed, equipped, and maintained to be safe, functional, and comfortable for patients, staff, and visitors. Comment on deficiencies: Compliance is assessed primarily through direct observation. Surveyor comments focused on the layout of patient care areas and deferred maintenance of equipment that compromised safety. Examples of ACHC Surveyor findings: ■ Patient rooms in this LTC facility are semi-private with two to three patients located in each room. During the survey, there were two patients dialyzing at the same time in each room. The waste lines/tubing were run from the machine into the restroom, then were taped to the toilet seat for waste disposal. Facility staff entering and exiting the rooms multiple times were carefully watching their footing. The tubing is not taped or secured to the floor creating a clear tripping hazard.
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RENAL DIALYSIS
RD7-R Frequency of the citation: 37%
■ The facility did not have available any preventative maintenance documentation since Oct 2023 for the 14 machines. The weight scale was due for maintenance/calibration in May 2024 and there is no evidence it has been completed. There is no documentation of the three eyewash stations being checked monthly since July 2024. ■ The home training facility was not maintained to provide a safe, functional, and comfortable environment. The staff restroom toilet would not flush. During interview it was confirmed the toilet had been broken for an extended amount of time. Both the patient and staff restroom toilets were found to contain mold, and it was evident they had not been cleaned in some time. Overall observation of cleanliness indicates that there is no routine cleaning schedule. There was no fire extinguisher located in the building, no maps to show the exit routes, and no evidence of an annual fire inspection conducted either by the local fire department, or the State Fire Marshall. ■ The side tables for all five dialysis chairs have scratches that have disrupted the integrity of the surface. There is increased risk for cross contamination as the deep scratches may not allow proper disinfection to remove all blood and/or body fluids from the spaces. ■ The facility did not ensure patients were in view of staff during the hemodialysis treatment to ensure visibility of the patient access. A staff member covering three patients in POD 2 and one patient in POD 1, left the POD area, moving to the charge nurse desk. Another staff member located in POD 3 walked out of the POD to the area where the scale and ice machine are located, leaving the POD unattended. ■ A patient’s AVG was wrapped in a chux pad preventing visibility of the access during the dialysis treatment. However, vital sign documentation by staff indicates the access is visible.
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. Comment on deficiencies: The standard is assessed through review of policies and procedures, observation, and response to interviews. Deficiencies were focused on in-center sites of service, noting expired and missing supplies and inaccessible emergency equipment. Examples of ACHC Surveyor findings: ■ Location A: The oxygen tank on the crash cart had maximum percentage of 8% which does not meet the 15% guidelines for use of an ambu bag during CPR. ■ Locations B and C: The agency did not have access to the LTC crash cart and oxygen. There was no emergency take out bag at either location to ensure emergency equipment is available to the staff inside the LTC during the dialysis treatments. ■ Location A: Emergency equipment is not immediately available, being located at a distance, down two hallways from dialysis patients. Additionally, the code cart does not include an AED. ■ The facility did not have any oxygen cylinders on the premises. A concentrator was present with no preventive maintenance noted. ■ The AED log has not been checked since August 2023. The crash cart and emergency take out box have not been checked since March 2025. Expired items observed in the emergency take out box: ٝ 4 normal saline syringes (expired Oct 2024) ٝ 4 butterfly blood collection sets (expired May 2024) ٝ 5 IV catheter sets (expired May 2023) ٝ .1 packet of Leur lock cap Set (expired Nov 2024) ٝ Heparin 10,000 units (expired Oct 2023) ٝ Inventoried as checklist items but not present in the emergency take out box: · 4 of 5 Leur lock cap sets · paper tape · hand sanitizer · Alcavis disinfectant · Gloves
Compliance tips for:
The intent of this standard is that the physical environment be organized and maintained to support safe, high quality care. Equipment is maintained in good working order. All areas are clean. Patients are in view of staff throughout treatment. ■ Conduct regular surveillance rounds for general environmental conditions and infection and safety risks (blood residue, rust, expired items, clutter, accessibility). ■ Tape down lines and tubes that create temporary tripping hazards. ■ Schedule equipment maintenance per manufacturer’s instructions. ■ 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. Train staff on the requirement to maintain visibility of patients, including vascular access sites.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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RENAL DIALYSIS
RD7-T Frequency of the citation: 26%
ٝ Inventoried on the crash cart checklist but not present: · AED pads · Glucometer and insta-glucose tablet ■ The monthly log for the emergency take out bag confirmed seven rolls of tape however, the bag did not contain any tape.
Overview of the requirement: The emergency plan requires testing at least annually, staff training at least every two years and appropriate patient orientation. Comment on deficiencies: The standard is assessed through review of training logs, observation, and response to interviews. The deficiencies were evenly split across lack of staff training, lack of patient training and lack of participation in emergency drills. Examples of ACHC Surveyor findings: ■ The facility did not ensure emergency preparedness training for patients located in the LTC facility. ■ There was no evidence of staff training on the emergency plan. ■ There was a policy regarding patient emergency preparedness training but no documentation that patients received the training. ■ There was no evidence that the facility participated in either a full-scale community- or facility- based exercise, a mock disaster drill, or a tabletop exercise to test the emergency plan. Compliance tips for:
Compliance tips for:
The goal of this standard is to ensure that emergency equipment, including oxygen and emergency drugs are on the premises at all times and immediately available. ■ Audit the inventory of immediately available emergency equipment (e.g., oxygen, airway and suction devices, defibrillator or AED, artificial resuscitator, and emergency drugs) and supplies. ٝ Remove and replace expired items. ■ Run “mock code” scenarios, to evaluate that all equipment is present, readily available, and include timing of how quickly staff can access the emergency supplies/equipment. ■ Promote peer to peer education/review of emergency preparedness plan with rotating roles for responsibilities during an emergency situation.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Continuity of care in the face of an emergency is the goal of this standard. It is achieved through training and testing.
Nerd Newbies (understand the requirement)
■ Ensure that the new admission patient orientation checklist includes training on the emergency preparedness plan. ■ Audit patient files for documentation of initial and ongoing emergency preparedness training. ■ Conduct emergency preparedness training for all staff. ■ Ask patients if they know what to do in the event of an emergency. ■ Coordinate with community resources to conduct an annual emergency exercise.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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RENAL DIALYSIS
NOTES
NOTES
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 .
achc.org | (855) 937-2242 | 21
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THE Accreditation Commission for Health Care
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Cary, NC | achc.org ©2025 Accreditation Commission for Health Care, Inc.
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