|Survey Date: 12/9/2009|
Regulation Title: PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY
Regulation Description: The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public.
Based on observations and staff interviews, the facility failed to maintain the integrity of the surfaces in the treatment area. Specifically, one of the countertops and doors at the handwashing sink were not intact.
The findings were:
Observations were made throughout the facility during the survey on 12/8/09 and 12/9/09. It was noted that the handwashing sink located next to the medication counter had lost the surface integrity. The formica countertop was pitted and very worn from what appeared to be damage done from bleach. There was also a chip on the bottom of the front door of the sink.
The facility was informed of the observation during the exit conference. The area manager stated there were a number of countertops repaired in various facilities but was not aware that one in this facility had been overlooked.
Facility Plan of Correction:
Kevin Lindsey, licensed contractor, hired by the
facility on December 23, 2009, to complete repairs on
the hand washing sink located next to the medication
counter. New Formica countertop scheduled to be
placed on January 12, 2010. The cabinets to the
counter below the sink scheduled are to be replaced at
the same time as the countertops. Clinical Manager will complete Physical Environment Audit quarterly
(January, April, July and October) with a second staff
member. The Director of Operations / Operations
Manager will complete an AM Regulatory Review
semi-annually (April and October) to ensure the
physical environment is intact and in good repair.
Completion of the repairs and plan for monitoring will
be documented in the QAI Meeting Minutes. Results
of the stated audits when completed will be discussed
and documented in the appropriate QAI Meeting