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SAMPLE ELEMENTS
SELF-SURVEY CHECKLIST: PREPARING FOR THE NEW CONDITIONS OF COVERAGE
 

Condition

ID #

Subject

Type

Comment

494

.30

114

Infection Control: Items taken into the dialysis station.

Policy

Use CDC language in policy to indicate that items taken to a patient's dialysis station, including those placed on top of dialysis machine, should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being returned to a common clean area or used for other patients. This includes BP cuffs. Unused medications or supplies should not be returned to a common clean area or used on other patients.

494

.30

115

Multiple Dose Vials

Policy

Use CDC language to indicate that individual patient doses will be prepared in a clean and centralized area away from dialysis stations and delivered separately to each patient.  Residual meds from 2 or more vials will not be pooled, in other words you cannot re-enter single use vials.

494

.30

115

Multiple Dose Vials

Observation

Clearly separated dirty/clean areas.
Meds delivered separately to each patient, incl. heparin and xylocaine. Medication carts may not be used to travel between pt. stations.

Condition

ID #

Subject

Type

Comment

494.30

114

Infection Control: Items taken into the dialysis station.

Policy

Use CDC language in policy to indicate that items taken to a patient's dialysis station, including those placed on top of dialysis machine, should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being returned to a common clean area or used for other patients. This includes BP cuffs. Unused medications or supplies should not be returned to a common clean area or used on other patients.

494.30

115

Multiple Dose Vials

Policy

Use CDC language to indicate that individual patient doses will be prepared in a clean and centralized area away from dialysis stations and delivered separately to each patient.  Residual meds from 2 or more vials will not be pooled, in other words you cannot re-enter single use vials.

494.30

115

Multiple Dose Vials

Observation

Clearly separated dirty/clean areas.
Meds delivered separately to each patient, incl. heparin and xylocaine. Medication carts may not be used to travel between pt. stations.

494.70

468

Patient Rights: Discharge & Transfer Policies

Documentation

Proof of information given, esp. as it relates to involuntary discharge. Facility must define situations under which a pt. could be transferred or discharged or when dialysis could be discontinued. Facility will need a clearly defined Involuntary Discharge policy.

 

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