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12/5/2007 Survey Tag 0150 Detail for:
RELIANT RENAL CARE RRC TRINIDAD
Wednesday, October 23, 2019 12:20 AM

Survey Date: 12/5/2007

Regulation Number:0150

Regulation Title: PERSONNEL RECORDS: HEALTH

Regulation Description: The governing body, through the chief executive officer of the ESRD facility, is responsible for maintaining and implementing written personnel policies and procedures that ensure that complete personnel records are maintained on all personnel including health status reports.

Surveyor Findings:


Based on personnel records, employee health file review and staff interview, it was determined that the governing body, through the chief executive officer of the ESRD facility failed to ensure that:
1. Complete employee health files were maintained for five (#1, #2, #3, #4 and #5) of 5 employee files reviewed and;
2. Complete personnel records were maintained for two (#4 and #5) of 5 personnel records reviewed. The findings were:

The health file for employee #1 was reviewed on 12/5/07. Employee #1, a registered nurse (RN) and clinical supervisor, was hired on 10/6/06. There was no documentation of Hepatitis B screening in the employee's file.

The health file for employee #2 was reviewed on 12/5/07. Employee #2, a licensed practical nurse (LPN), was hired on 11/1/06. There was no documentation of Hepatitis B screening in the employee's file.

The health file for employee #3 was reviewed on 12/5/07. Employee #3, a patient care technician (PCT), was hired on 10/5/05. There was no documentation of Hepatitis B screening in the employee's file.

The personnel and health file for employee #4 was reviewed on 12/5/07. Employee #4, a social worker, was hired in 11/07. There was no documentation of tuberculosis or Hepatitis B screening in the employee's health file. Furthermore, the personnel file did not contain any documentation of in-services performed.

There was no personnel or health file for employee #5. Employee #5, a dietitian, was hired sometime in 2007. The exact date could not be determined by documentation or interviews.

The clinical supervisor was interviewed on 12/5/07 at 2:00 p.m. The supervisor stated that s/he was not aware that Hepatitis B screening was required for employees in the dialysis facility.

The Director of Nursing (DON) was interviewed via telephone on 12/5/07 at 2:30 p.m. The DON was aware that personnel and health files for employees #4 and #5 were incomplete. The DON stated that it would be taken care of.

In summary, the facility failed to ensure that employees were free from communicable diseases, specifically tuberculosis and/or Hepatitis B, and that complete personnel files were maintained. Employees #1, #2 and #3 were working in direct patient care.

Facility Plan of Correction:

1. Summit Kidney Centers policy is that all employee files will be reviewed annually in Januaray to ensure they are complete.
New employee files will be completed and reviewed upon start date.

QA at this time states that all employee files will be reviewed annually. A data base that monitors and flag dates and requirments has been started in the computer, a designated person will monitor and update files. The results will be reported to the DON and upward to the Medical Director.

The review will include Hep b screening (titer), Tb, CPR, Osha training, Emergency Preparedness, Job description,and skills check list.

The medical parts, Tb and Hep b, will be kept in the OSHA Medical Health Records. Other parts of the review will be kept in the employee files.

2.
After auditing employee files it was determined that Hep screens should be performed and non reactive results would require HepB vaccination. Will continue to verify Hep screen yearly.

Result of Hep Screens and Tb testing when required:
Emloyee #1 -Hep screen performed 12/17/2007...results are 103 MIU/ML...reactive.
Employee #2 - Hep screen performed 12/17/07...results are 70 MIU/ML...reactive.
Employee #3 - Hep screen performed 12/17/07...results are 226 MIU/ML...reactive.
Employee #4 - Declination of Hep B vaccine notice signed. Employee refuses vaccination 12/18/07. Tb . Infection control In-service will be provided within the first quarter of 2008.

Employee #5 - Previous dietician no longer employed at Summit Kidney Centers. Copy of previous dieticians license sent.
Newly hired dietician, started 12/27/07-license # 00810059, see attachment. Employee and Health files are being compiled. Hep b screen and Tb test to be performed 12/31/07. Infection control In-service will be provided within the first quarter of 2008.

In service was provided to clinical supervisor regarding requirments of health screen on 12/13/07.

Personnel records are being reviewed and compiled on Employee #4 and #5. see attachments.

A policy will be implemented that all employee files will be reviewed annually in Januaray to ensure they are complete. The files will be completed and reviewed upon start date for new employees. The review will include Hep b screening (titer), Tb, CPR, Osha training, Emergency preparedness, Job description,and skills check list.




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Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
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Denver CO 80246-1530
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