| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852556 | (X3) Date Survey Completed 07/11/2019 |
| Name of Provider or Supplier Thomas County Home Training | Street Address, City, State 708 South Broad Street, Thomasville, 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 | A recertification survey was conducted at Thomas County Home Training from July 9, 2019 through July 11, 2019. The survey revealed that the facility was in compliance with 42 CFR Part 494.62, Conditions for Coverage for Emergency Preparedness Plans for End Stage Renal Dialysis Facilities. No deficiencies were cited. |
| V0000 | (Core) A recertification survey was conducted at Thomas County Home Training from July 9, 2019 through July 11, 2019. The recertification survey revealed that the facility was in substantial compliance with 42 CFR Part 494 Condition for Coverage for End Stage Renal Disease Facilities. However, the following standard level deficiencies were cited which resulted from the facility's non compliance related to the survey: |
| V0506 | PA-IMMUNIZATION/MEDICATION HISTORY CFR(s): 494.80(a)(3) The patient's comprehensive assessment must include, but is not limited to, the following: Immunization history, and medication history. This STANDARD is not met as evidenced by: Based on a review of the Center for Disease Control and Prevention (CDC) recommendations, patient medical records, and staff interview, it was determined that the facility failed to ensure that one of one sampled patient (P) P#1, was screened for Tuberculosis (TB - an infectious bacterial disease that usually attacks the lungs and can spread to other parts of the body). This deficient practice had the potential to negatively affect the health and safety of P#1 who received peritoneal home dialysis services at this facility. Findings include: A review of the CDC recommendation stated that all dialysis patients, be tested at least once for baseline tuberculin (TB) skin test results (TST) and re-screened if TB exposure is detected. Chest x-rays may be used for individuals for whom the TST is not an option. A review of medical records revealed that P#1 was admitted to this facility on 5/23/19. A TB testing was administered on 5/28/19. There was no documentary evidence of the result nor a record of chest x-ray was done. During a discussion with the Facility Administrator on 7/11/19 at 1:30 p.m., she stated that the TB result of P#1 was not documented therefore, TB testing should be repeated. |
| V0597 | H-PROVIDE ORDERED SUPPLIES/EQUIPMENT CFR(s): 494.100(c)(1)(vi) Services include, but are not limited to, the following: (vi) Purchasing, leasing, renting, delivering, installing, repairing and maintaining medically necessary home dialysis supplies and equipment (including supportive equipment) prescribed by the attending physician. This STANDARD is not met as evidenced by: Based on a review of facility records and staff interview, it was determined that the facility failed to maintain records of preventative maintenance and repairs performed by the manufacturer; on 17 of 17 home hemodialysis(HHD) machines and equipment. This deficient practice had the potential to negatively affect the health and safety of all 17 patients (P#1-P#17) who were receiving HHD services at this facility. Findings include: A review of the facility's equipment maintenance logs and patient records revealed no documented evidence of repairs and maintenance of the the equipment used in the patients homes. During an interview with the Facility Administrator on 7/10/19 at 11:30 a.m., she stated that there was no documented evidence to show that the facility monitored the repairs and maintenance of the patient's equipment. |
| V0628 | QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS CFR(s): 494.110(a)(2) The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves. This STANDARD is not met as evidenced by: Based on a review of facility records, review of the fiscal year (FY) 2019 Dialysis Facility Report [DFR: A report prepared for this facility per Centers for Medicare and Medicaid Services (CMS)], and staff interview, it was determined that the facility failed to analyze the causes of hospitalizations and infections of all patients, and develop action plans in six of six months (January 2019 - June 2019) of Quality Assurance Performance Improvement (QAPI) meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of all 77 home peritoneal dialysis patients and 17 home hemodialysis patients who were receiving home services at this facility. Findings include: A review of the hospitalization and infection records on 7/10/19 between 10:50 a.m. and 11:04 a.m. revealed 39 total hospitalizations and 18 total infections, from January 2019 to June 2019. A review of the facility's DFR for FY 2019 showed hospitalization with septicemia was 16.2%. The U.S. average was 11.2%. A review of the QAPI meeting minutes from January 2019 to June 2019 revealed that the facility had no documentation that hospitalizations and infection episodes were discussed, reviewed, evaluated, and analyzed to ensure that clinical outcomes were met. The Group Facility Administrator, Facility Administrator and Clinical Service Specialist were informed of the above findings on 7/11/19 at 1:30 p.m. The Facility Administrator stated on 7/11/19 at 1:30 p.m., that hospitalizations and infections data were not analyzed in their QAPI meetings. |