| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852553 | (X3) Date Survey Completed 10/31/2024 |
| Name of Provider or Supplier Flint River Dialysis | Street Address, City, State 700 Gordon Avenue, Bainbridge, GA | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| E0000 | An unannounced Recertification Survey was conducted at Flint River Dialysis from October 30, 2024 through October 31, 2024. The survey revealed that the facility was in substantial compliance with 42 CFR Part 494.62, Conditions for Coverage for Emergency Preparedness Plan for End Stage Renal Disease facilities. No deficiencies were cited. |
| V0000 | {CORE} An unannounced Recertification survey was conducted at Flint River Dialysis from October 30, 2024 through October 31, 2024. The survey revealed that the facility was in substantial compliance with 42 CFR Part 494 Conditions for Coverage for End Stage Renal Disease Facilities. However, the following standard level deficiencies were cited which resulted from the facility's noncompliance related to the survey: |
| V0403 | PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU CFR(s): 494.60(b) The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer's recommendations. This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to maintain a safe environment as evidenced by torn leather upholstery in three of 19 patient treatment chairs in Station (S) 4, S6, and S18. This failure could hinder effective cleaning and disinfection of the surfaces and could negatively affect the health and safety of all patients who used these hemodialysis chairs. Findings include: During observation in the Patient Treatment Room on 10/30/24 between 8:57 a.m. and 10:59 a.m., the following was observed: The hemodialysis chairs at S4, S6, and S18 had torn upholstery ranging from approximately 2 inches to 8 inches in length and diameter, along the sides and top of the armrests, on the seats, and/or on the back rests. During an interview with the Facility Administrator on 10/30/24 at 3:47 p.m., the Facility Administrator stated that chairs have been on back order since August 2023. |
| V0638 | QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This STANDARD is not met as evidenced by: Based on a review of the Fiscal Year 2025 Dialysis Facility Report (QDFR: A report prepared by the Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients), Quality Assessment and Performance Improvement (QAPI) minutes, and staff interview, it was determined that the QAPI Committee failed to track, trend, analyze and develop plans of action to improve and sustain the facility's anemia management and mineral metabolism/bone disorder, for six of six months (April 2024 - September 2024) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of 65 patients who were receiving dialysis services at this facility. Findings include: A review of the FY 2025 Pre-Survey DFR (third quarter 2023), revealed that the facility was above the United States (US) threshold in: 1. Mineral Metabolism and Bone Disorder - (Phosphorus greater than (>) 7.0) - facility was 22 %, whereas US was 12.6 %. The % of patients with Phosphorus >7.0 was 24.6 % in April 2024, 17.5 % in May 2024, 23 % in June 2024, 20.3 % in July 2024, 17.7 % in August 2024, and 25 % in September 2024. 2. Anemia - Hemoglobin (Hgb) (a protein containing iron that facilitates the transport of oxygen in red blood cells)<10.0 facility was 22 %, whereas, US was 16.8 %. The facility was not monitoring the percentage of patients with Hgb less than (<)10.0; the facility was monitoring the percentage of patients with a Hgb of < 9. A review of the facility's QAPI meeting minutes from April 2024 - September 2024 revealed documentary evidence that the interdisciplinary team (IDT) conducted a review of anemia and mineral/bone. However, no changes were made to the action plans to achieve and sustain improvements in anemia. |