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5/25/2010 Survey Tag 0750 Detail for:
PRINTERS PLACE DIALYSIS CENTER
Wednesday, October 23, 2019 12:20 AM

Survey Date: 5/25/2010

Regulation Number:0750

Regulation Title: CFC-GOVERNANCE

Regulation Description:

Surveyor Findings:


Based on the number and nature of the deficiencies cited, staff interviews, and review of patient records, policies/procedures, personnel/credential files, meeting minutes and other facility documents, the governing body (as the entity ultimately responsible for the governance and operation of the facility and responsible for the health care and safety of patients) failed to ensure that the facility maintained complete medical records, and that facility staff followed facility policies/procedures, and that the Medical Director was involved in the oversight of providers adherence to facility policies/procedures and with the quality improvement process for ensuring that medical errors were not repeated. The Governing Body failed to provide a comprehensive and proactive leadership to ensure the facility met the requirements for the health and safety of the patients.

The findings were:

1. Cross Reference to the QAPI Standard Tags V626 and V634 for findings related to the facility's failure to "identify and correct deficiencies in the completeness of medical records as part of the QAPI program" and "implement process changes to ensure that a different patient's dialyzer would not be used on another patient."

2. Cross Reference to the Medical Director Condition Tag V710 and Standard Tags V711 and V715 for findings related to the Medical Director's failure to "ensure that providers practicing in the facility were adhering to facility policies in regards to security, completeness, and centralization of medical records" as well as the Medical Director's failure to "be involved in the quality improvement process in ensuring that medical errors were not repeated."

3. Cross Reference to the Medical Record Condition Tag V725 and Standard Tags V726, V727, V729 and V730 for findings related to the facility's failure to "maintain complete and accurate records and protect them against loss and unauthorized use".

Facility Plan of Correction:

V750
The Governing Body will provide
comprehensive and proactive leadership to
ensure the facility meets the requirements for
the health and safety of the patients. An inservice
on the Governing Body process and
documentation of said meeting was conducted
by the Regional Operations Director (ROD) on
06/15/2010. The Governing Body will ensure
the facility maintains an effective, data driven,
quality assessment and performance
improvement program (QIFMM) that is
led by the Medical Director and ensures the
security of medical records, includes the
evaluation and prevention of medical errors, to
include but not be limited to dialyzers being
used by the wrong patients, and ensures
teammates adhere to policies and procedures.
Policy #3-02-01Medical Record Maintenance
has been reviewed with the facility team with
emphasis on the need for ensuring the
confidentiality of the medical record and for a
monthly review of 10% of the medical records
and that medical records are to remain in the
facility at all times, until such time they are
archived in an approved medical records
storage company.
Pt. charts have been secured by
placing a locked bar across the medical
records shelf, so they cannot be removed from
their slots. The patient chart labels were
changed from full names to initials to protect
patient identity. A fabric covering will be
placed over the charts so they will not be
visible by 07/01/2010. A letter was written to
XXX Nephrology Associates on May 20,
2010 by the Medical Director, stating that no
documents are to be removed from the facility
from that date forward. Policy #3-02-02
Medical Record Preparation Charting
Guidelines has been reviewed with the
teammates with the emphasis that all
entries are to be timed, dated, and signed at
the time of entry. FA and Medical Director are
responsible for ongoing compliance with
POC. AA's are to complete all filing and audit
100% of the patient charts by 6/21/10,
followed by monthly audits of 10% of the
charts. In addition compliance will be
evidenced by random audits conducted by the
FA of monthly physician Rounding Reports X
3 months. Results of audits will be reported in
QIFMM and addressed as necessary. FA and
Medical Director are responsible for ongoing
compliance with POC.
Adverse occurrences will be reviewed in
QIFMM meeting with action plans developed
and implemented as needed. Policy changes
will be made if indicated. After internal
review of cited incidents a plan of action was
put in place that required that the teammate
not sign off dialyzer until the patient is in their
chair. Policy # 01-03-02 “Prescription
Verification and Safety Checks” was revised
to include written verification on the dialyzer
while the patient is present, by 2 teammates.
A governing body meeting which included
the Medical Director was held on 05/20/2010
approving the new policy. Documentation of
this meeting is on file in the facility. All
teammates were in-serviced on this policy on
05/21/2010 and 05/22/2010. The Charge
Nurse/Clinical Coordinator is observing the
PCT's for compliance with verification while
the patient is in the chair. In addition, audits
will be conducted on 100% of reuse dialyzers
X 1 month followed by auditing of 50% of
reuse dialyzers X 1 month, to ensure
compliance. The dialyzer audits were
implemented on 06/08/2010. These audits
are being conducted by the reuse technician
and given to the FA for review daily. Results
of audits will be reported in QIFMM and
addressed as necessary. FA is responsible for
ongoing compliance with POC.
The Governing Body will meet monthly x 3
to ensure compliance with POC. Further
compliance to the POC will be reviewed
during monthly QA meetings and reported to
the Governing Body no less than semiannually.
The Facility administrator (FA)
representing the GB will be responsible for
ensuring implementation and ongoing
compliance with this POC.


Back to Survey Tag Summary for:PRINTERS PLACE DIALYSIS CENTER

Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
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