Common Findings in Hemodialysis (Noted during monitoring)

Common Findings in Hemodialysis Facilities(Noted during monitoring)Dr. TEODORA M. EUGENIOMedical Officer VBHFS- QAMDTotal of Hemodialysis Facilities Monitored As of August 2014n=56TOTAL NO. OF HDF MONITOREDn=56

40TOTAL NO. OF HDF MONITOREDn=56

TOTAL NO. OF HDF given Notice of Violationn=40

Most Common Findings

Physical Plant

A. Space/Area Measurement less than the required ex. Water treatment area less that 12 sq. mm

B. Designated area utilized for other purposes ex. Water treatment area also the storage area reprocessing area also the storage area

C. Absence of required/specific area vs approved PTC ex. janitor closet with slop sink waiting area business area storage area toilet/urinal reprocessing area

D. Documentary Requirements

No evacuation/disaster plan; evidence of emergency/disaster drill conductedImproper used of colored plastic bags for infectious wasteNo waste management/treatment for disposal of hazardous wasteNo record of water tank flushing

Personnel

A. No dialysis technician B. No duty physician C. No fulltime nurse (dual functions)

D. Documentary Requirements

- contract of employment/appointment/memorandum of agreement/ = none/not updated - training certificates = none/not updated ex. For ACLS/BLS for dialysis technician Specialty Board - PRC ID Card = expired/none - Record of vaccination -= none/not updatedIII. Equipment, supplies & medicines:

A. No available/incomplete/expired emergency medicines (E-cart) B. No basic equipment EENT Diagnostic set Nebulizer TDS meter Defibrillator Minor Surgical Set Safety hasp for oxygen tank Pulse oximeter Cardiac/ECG leads Suction machines Exhaust fan (reprocessing area) HD machines more than 30,000 hrs. usedDocumentations:

A. No Policies/Procedures on:

Referral/Transfer of patient to other Health FacilitiesTreatment of water for hemodialysis Reprocessing of Dialyzer Sterilization technique Preventive maintenance (of equipment) Prevention of Control of Hepatitis & other infections Management of Infectious waste Pest and Vermin Control HousekeepingHiring, recruitmentSecurity

Incomplete Patients Chart: ex. Nursing Chart

Result of water testing analysis none/not updatedRecord/logbook of TDS of Product Water performed none/not updatedRecord/logbook of HD complication none/not updatedPT Registry/REDCOP Certificate of complianceV/M/organizational chartQAP

IV. Service Capability

- Operating more than the authorized HD Stations without applying for PTC

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