|Survey Date: 7/31/2007|
Regulation Title: PATIENT CARE POLICIES: DEVELOPMENT/REVIE
Regulation Description: Policies concerning the provision of dialysis and other ESRD services to patients are developed by the physician responsible for supervising and directing the provision of ESRD services, or the facility's organized medical staff (if there is one), with the advice of (and with provision for review of such policies from time to time, but at least annually by) a group of professional personnel associated with the facility, including, but not limited to, one or more physicians and one or more registered nurses experienced in rendering ESRD care.
Based on policy and procedure review and staff interview, the facility failed to review their policies and procedures on an annual basis. The findings were:
The policy and procedure manual for patient care policies was reviewed on 7/30/07. There was a cover sheet in front of the manual which stated: "This Acute Policies and Procedures Manual has been reviewed and accepted. Any additions, updates, or deletions will be noted on this sheet and date entered. This manual will be reviewed annually." The last date these policies and procedures were updated and reviewed was 5/27/05.
The director of nursing (DON) was interviewed on 7/31/07 at approximately 9:30 a.m. The DON stated they had fallen behind in this process and agreed an annual review should be done.
In summary, the failure to annually review and update patient care policies had the potential to affect all patients served by the facility.
Facility Plan of Correction:
The policy and prodedure manual has been reviewed and verified by the Medical Director, DON, PD Nurse and Biomed Technician on 8/21/07.
The Board of Directors will annual review the P & P manual.
Note new policies that have been added.
Policies added: Policy of Bicarb System, Facility Cleaning Policy, and an Emergency preparedness Quarterly summary.
Quarterly Emergrency Preparednes in-service/training will be completed by all dialysis staff members. This will be monitored by quarterly QA audit conducted by the DON.