Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 852575	(X3) Date Survey Completed 05/25/2022
Name of Provider or Supplier Cc&D Services	Street Address, City, State 5040 Snapfinger Woods Dr, Ste 108, Decatur, 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)
V0000	An onsite survey to investigate complaint #GA00223758 was conducted at CC&D Services from May 25, 2022 through May 25, 2022. The complaint investigation revealed that the facility was in substantial compliance with 42 C.F.R. Part 494 for End Stage Renal Disease facilities. The allegations were substantiated and the following standard level deficiencies were cited:
V0122	IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL CFR(s): 494.30(a)(4)(ii) [The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment. This STANDARD is not met as evidenced by: Based on observations, staff interview, and a review of Centers for Disease Control and Prevention (CDC) guidelines, it was determined that the facility failed to ensure that three of three Patient Care Technicians (PCT AA, PCT BB and PCT CC), and one of one Registered Nurse (RN AA), who were present during these observations, immediately and thoroughly cleaned and disinfected blood-contaminated surfaces between patient use. This failure could lead to the transmission of dangerous pathogens through cross contamination. This deficient practice had the potential to negatively affect the health and safety of 15 of 15 Patients (P#1 - P#15), who were undergoing hemodialysis (HD) treatment at the time of this observation. The facility had a total census of 34 in-center hemodialysis patients. Findings include: During observation in the patients' treatment room on 5/25/22 between 12:05 p.m. and 1:40 p.m., the following was revealed: - There were five dried blood stains (thin and light pinkish-red colored) measuring approximately 2 cm in diameter on the floor between Stations (S) 6 and 7. - There were also five dried blood stains (thin and light pinkish-red colored), that appeared splattered (different shapes and sizes) measuring approximately 1 cm - 2 cm in diameter on the floor next to S5. According to CDC guidelines, failure in environmental cleaning and disinfection have led to transmission of bloodborne pathogens (e.g., Hepatitis B virus) and other infections from one patient to another in hemodialysis units. Correct cleaning and disinfection of environmental surfaces (including floors, patient chair or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces, etc., especially with blood splatters) must be performed between patient uses to prevent transmission of dangerous pathogens. The Facility Administrator (in training) was present during this observation and acknowledged the presence of these blood stains. The Outgoing Facility Administrator was notified of these observations on 5/25/22 at 4:17 p.m. and she stated that the blood stains should be cleaned immediately. A review of facility personnel education and audit records pertaining to Bloodborne Pathogens and Infection Control was dated 1/7/19.
V0401	PE-SAFE/FUNCTIONAL/COMFORTABLE ENVIRONMENT CFR(s): 494.60 The dialysis facility must be designed, constructed, equipped, and maintained to provide dialysis patients, staff, and the public a safe, functional, and comfortable treatment environment. This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to ensure that there was a safe environment for all 15 of 15 patients (P#1 - P#15) who were undergoing hemodialysis treatment at the time of this observation and that three of three Patient Care Technicians (PCT AA, PCT BB and PCT CC), and one of one Registered Nurse (RN AA), who were present at the time of this observation, as evidenced by the presence of standing water on the floor and a crack on the floor's surface in the patients' treatment room. Failure to keep the floor clean and dry had the potential for slips and fall accidents. The patient census was 34. Findings include: During observation in the patients' treatment room on 5/25/22 between 12:05 p.m. and 1:40 p.m., the following was revealed: - There was a straight crack in the middle of the floor that ran in front of Station (S) 2 through to S12. - There were four wet blue chuck pads that covered a wet area on the floor between the machine at S9 and the wall chase box behind it, and the floor was wet behind the machines at S11 and S12. There were no "Caution Signs" to alert others about the wet floors. P#6 at S26 stated on 5/25/22 at 1:00 p.m., that she had noticed some wet areas on the floor of the treatment room at times. The Facility Administrator stated on 5/25/22 at approximately 2:30 p.m., that the wet floors was due to the plumbing issues in the building and the chase boxes, and not from the dialysis machines. The Biomed Technician (BMT) was not available for an interview and record review.
V0754	GOV-ADM RESP FOR FISCAL OPERATIONS CFR(s): 494.180(a)(2) The governing body or designated person responsible must appoint an individual who serves as the dialysis facility's chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to- (2) Fiscal operations; This STANDARD is not met as evidenced by: Based on patient and staff interviews and facility record review, it was determined that the facility failed to ensure that patients did not miss their prescribed hemodialysis treatments when the facility had to close due to power outages and water leakage. This failure had the potential to negatively affect the health and safety of 34 of 34 patients (P#1 - P#34) who dialyzed at this facility. Findings include: During patient interviews while patients were undergoing hemodialysis in the treatment room between 12:05 p.m. and 1:40 p.m., the following was revealed: P#2 at Station (S) 5 stated that the facility had closed three times. Once in October 2021 and twice this year. The most recent closure was two weeks ago. She was notified by the Transport personnel (not the facility staff) on the Sunday before her Monday scheduled dialysis treatment about the closure, and was advised by the Transport personnel to go to the hospital if she had health issues. P#4 at S11 stated that the facility had closed a few times due to power outage and water leakage. P#5 at the Isolation Room (not currently used for Hepatitis B+ patients), stated that she was admitted to this facility last January 2022, and had experienced closure of the facility once on a Monday, since she had been here. She was re-scheduled for treatment the following day (Tuesday), but she had to work so she waited to come for her regular dialysis treatment the following Wednesday. P#6 at S26 stated that the facility closed twice and she was notified via phone call regarding the closure on the day of the incident, but it was too late, she had already arrived at the facility. She also stated that she tried to go to the hospital but was told at the hospital that she did not need an emergency treatment. She further stated that the facility staff re-scheduled her to come for treatment the following day (Tuesday). P#7 at S13 stated that he had been a patient at this facility for two years. The clinic had closed twice. He was not notified ahead of time but was re-scheduled the following day, however, he was late the following day due to transportation issues. He further stated that he had to "fix" his own transport because it was not his regular scheduled transportation day and when he arrived at the facility, he was late and was not dialyzed because the last patient ahead of him was almost done with his treatment. A review of facility records revealed that out of 28 scheduled patient treatments on 3/23/22 (Wednesday), only 18 patients dialyzed the following day, 3/24/22 (Thursday). The Facility Administrator stated on 5/25/22 at 2:30 p.m., that there was a water leak in the building (not at the facility), but the whole water system was turned off. When they re-scheduled the patients for treatment the following day, some patients refused to come back for treatment. The Facility Administrator also stated on 5/25/22 at 2:30 p.m., that on 5/2/22, there was a County Power Outage so they couldn't open the facility for patient treatment. The facility re-scheduled patient treatments the following day, 5/3/22. Out of 29 scheduled treatments, only 18 patients dialyzed at the facility. Six patients were "No Shows", two patients were in the hospital, one patient was on vacation, and one patient (P#7), did not have treatment because he came in late. The Facility Administrator further stated on 5/25/22 at 2:30 p.m., that the facility was also closed on 5/16/22 (Monday), due to Power Outage in the building. Patient treatments were re-scheduled the following day, 5/17/22 (Tuesday). Facility record review revealed only 18 patients were dialyzed, two were in the hospital, four patients did not answer the facility's phone call, one missed treatment, one patient was working and one patient refused. The Facility Administrator further stated when asked by this surveyor, that the facility's back up dialysis facility had their own patients to dialyze that day and they re-scheduled their own patients' treatments the following day. A review of the Governing Body (GB) Meeting minutes, with latest date (5/6/22), did not show any documentation about the facility closures and Plans of Action to avoid future closures or improve patients' re-scheduled treatments in an emergency or contingency plan. During an interview with Patient Care Technician (PCT AA) on 5/25/22 at 3:45 p.m., she stated that she has been working at this facility for one year. She confirmed that there was a power outage in the whole building which happened toward the end of the first shift patients. Two of the patients she called did not have an updated phone number so she couldn't reach them. Failure to update patients' contact numbers will result in the facility's inability to communicate with their patients in a timely manner.
V0765	GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility's internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient's designated representative will be informed of steps taken to resolve the grievance. This STANDARD is not met as evidenced by: Based on a review of facility records and patient and staff interview, it was determined that the facility failed to ensure that Patient's(P#7's) complaint and grievance was followed through. This failure had the potential to negatively affect the health and safety of P#7 and the other 33 patients who dialyzed at this facility. Findings include: A review of the Complaint and Grievance logs revealed a lack of documentation of complaints and grievances. There was one grievance in 2/2020, one in 3/2020 and one in 12/1/21, not related to clinic closures. The only documented grievance for 2022, was dated on 5/3/22 by nursing staff and on 5/4/22, by the Social Worker, both regarding P#7 who was denied make up treatment on 5/3/22 because P#7 was late coming to the facility. According to the grievance records, P#7's scheduled treatment was at 10:00 a.m. and he arrived at approximately 1:55 p.m. P#7 requested the facility staff to call the ambulance for him to be transported to the hospital for dialysis treatment because the facility refused to provide him his make up dialysis treatment due to his late arrival. The staff refused to call the ambulance because according to the report, P#7 did not exhibit signs and symptoms of distress. However, P#7 became irate and hostile, so the Administrative Assistant called the police instead. P#7 called the ambulance himself and was transported to the hospital. According to the Social Worker's documentation, the Plan of Action was for the Social Worker to discuss the issue with all involved and the owners and get back with P#7 on findings, within one week, 5/11/22, but there were no further updates about any discussions with all involved including the owners mentioned. The Social Worker also added that P#7 had requested that his dialysis care be transferred to another facility. There were no other documentation on further updates since the initial Social Worker documentation dated 5/4/22. The Social Worker was not available for interview. During an interview with P#7 on 5/25/22 at approximately 1:00 p.m., he stated that he had to arrange for his own transport on the scheduled make up treatment because it was not his regular transport day and he was late getting to the facility. Although he may not have exhibited signs and symptoms of distress, he still felt sick that's why he wanted the facility to call the ambulance to take him to the hospital for dialysis treatment that day, 5/3/22, since he had not had dialysis treatment since Friday, 4/29/22. The Facility Administrator stated on 5/25/22 at approximately 2:45 p.m., that P#7 had a history of missing treatments and sometimes did not answer the facility's phone calls.