Volume 2025 | No. 2
SURVEYOR
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)
achc.org | (855) 937-2242 | 19
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