Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 852575	(X3) Date Survey Completed 07/12/2022
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)
E0000	An onsite survey to investigate complaints #GA00224547 and #GA00225116 was initiated on July 6, 2022 and concluded on July 12, 2022. 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. A standard level deficiency was cited which resulted from the facility's noncompliance related to the survey.
E0028	Dialysis Emergency Equipment §494.62(b)(9) Condition for Coverage: [(b) Policies and procedures. The dialysis facility must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years. At a minimum, the policies and procedures must address the following:] (9) A process by which the staff can confirm that emergency equipment, including, but not limited to, oxygen, airways, suction, defibrillator or automated external defibrillator, artificial resuscitator, and emergency drugs, are on the premises at all times and immediately available. This STANDARD is not met as evidenced by: Based on observation, staff interview, and a review of the Food and Drug Administration (FDA) recommendations, it was determined that the facility failed to ensure expired medications were removed and not available for use. This deficient practice was observed in one of one medication cabinet. Findings include: During an inspection of the Medication Refrigerator with the Charge Nurse (RN AA) on 7/8/22 at 10:40 a.m., the following medications were expired, thus these were not suitable for use. - Flu Blok (Influenza Vaccine) = 8 vials expired 6/30/22. In the Crash Cart: - 50% Dextrose injection vials (6 boxes) expired 5/2022. RN AA stated on 7/8/22 at 10:40 a.m., that she was unaware that these medications were expired. According to FDA recommendation dated 2/8/21, drug expiration dates reflect the time period during which the product is known to remain stable, which means it retains its strength, quality, and purity when it is stored according to its labeled storage conditions. Several potential harms may occur from taking an expired medicine... Once the expiration date has passed there is no guarantee that the medicine will be safe and effective.
V0000	An onsite survey to investigate complaints #GA00224547 and #GA00225116, was initiated on July 6, 2022 and concluded on July 12, 2022. The complaint investigation revealed that two of three allegations (Unqualified Personnel and Infection Control) were substantiated; and one of three allegations (Quality of Care/Treatment) was unsubstantiated. However, additional Condition level and standard level deficiencies were identified which resulted from the facility's noncompliance related to the survey. The survey revealed that the facility was not in compliance with 42 CFR Part 494.80 - Patient Assessment, 42 CFR Part 494.90 - Patient Care Plans, 42 CFR Part 494.110 - Quality Assessment and Performance Improvement, 42 CFR Part 494.140 - Personnel Qualifications, 42 CFR Part 494.150 - Responsibilities of the Medical Director, and 42 CFR Part 494.180 - Governance, for End Stage Renal Disease Facilities. The facility census was 32.
V0117	IC-CLEAN/DIRTY;MED PREP AREA;NO COMMON CARTS CFR(s): 494.30(a)(1)(i) Clean areas should be clearly designated for the preparation, handling and storage of medications and unused supplies and equipment. Clean areas should be clearly separated from contaminated areas where used supplies and equipment are handled. Do not handle and store medications or clean supplies in the same or an adjacent area to that where used equipment or blood samples are handled. When multiple dose medication vials are used (including vials containing diluents), prepare individual patient doses in a clean (centralized) area away from dialysis stations and deliver separately to each patient. Do not carry multiple dose medication vials from station to station. Do not use common medication carts to deliver medications to patients. If trays are used to deliver medications to individual patients, they must be cleaned between patients. This STANDARD is not met as evidenced by: Based on observation and patient and staff interviews, it was determined that the facility failed to ensure that clean items/areas were kept clean and dirty supplies were promptly discarded in the appropriate bins or receptacles. This breach in infection control techniques had the potential for cross contamination and spread of infection to six of six patients (P#1, P#2, P#5, P#6, P#9, P#10), who were undergoing hemodialysis treatment at the time of this observation and four of four patients (P#8, P#11, P#12, and P#13) who were waiting for their hemodialysis treatment to be initiated. The facility census was 32. - During observation in the patients' treatment room on 7/6/22 between 11:40 a.m. and 1:30 p.m., the following was revealed: - There was a blood-stained gauze pad and a blood-stained Band-Aid on the floor between two empty dialysis chairs in Pod #4, and scattered, torn gauze and Band-Aid wrappers strewn on the floor next to these two chairs also. - The medication preparation area/counter had numerous and scattered used/empty vials of Epogen injection (for anemia), Heparin injection vials (anticoagulant), syringes and a Ziploc bag of lab tubes (no blood inside the tubes). - The clean supply cabinet doors were left wide open, which had the potential for clean supplies to drop out or spill out onto the dirty floor. - Registered Nurse (RN AA) was observed performing pre-assessment on P#10 at Station (S18) and assessing his arterio-venous fistula (AVF) access with a stethoscope. RN AA placed the used, contaminated stethoscope around her neck without first disinfecting it. - RN AA stated that the staff had been really busy trying to get the patients started on hemodialysis today. She further stated that there were only two Licensed Practical Nurses (LPN AA and LPN BB) working with her today. She also acknowledged that the stethoscope should be disinfected after use and the used supplies discarded in their respective receptacles (trash can or biohazard box) promptly. - P#5 stated on 7/6/22 at approximately 12:00 p.m., that the treatment floor especially around her area has always been wet during her treatment time, but it was dry today.
V0500	CFC-PATIENT ASSESSMENT CFR(s): 494.80 This CONDITION is not met as evidenced by: Based on a review of facility records and staff interview, it was determined that the facility failed to ensure that comprehensive assessments and re-assessments were completed by the entire Interdisciplinary Team (IDT). This deficient practice had the potential to negatively affect the health and safety of all 32 patients who were under the care of this facility. Findings include: Cross reference the following deficiencies: V 501 - Failure of the facility to ensure that comprehensive assessments of patients were completed by the entire IDT. V 516 - Failure of the IDT to conduct initial comprehensive assessments on new patients within 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session.
V0501	PA-IDT MEMBERS/RESPONSIBILITIES CFR(s): 494.80 The facility's interdisciplinary team consists of, at a minimum, the patient or the patient's designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient's treatment plan and expectations for care. This STANDARD is not met as evidenced by: Based on facility record review and staff interview, it was determined that the facility failed to ensure that three of five (P#1, P#2, and P#3) sampled patients, had a current comprehensive Interdisciplinary Team (IDT) assessment that was used to develop the patient's treatment plan and expectations for care. This deficient practice had the potential to negatively affect the health and safety of three patients sampled and the other 29 patients who were under the care of this facility. Findings include: A review of the medical records of P#1 - P#3, revealed the following: - P#1 was admitted to this facility on 5/2/22. There was no documentary evidence that an Initial comprehensive assessment was completed by the entire IDT. - P#2 was admitted to this facility on 2/2/22. There was no documentary evidence that an Initial and 90-day comprehensive assessment completed by the entire IDT. - P#3 was admitted to this facility on 12/20/21. There was no documentary evidence that an Initial and 90-day comprehensive assessment was completed by the entire IDT. During an interview on 7/12/22 at approximately 11:15 a.m., the Chief Executive Officer (CEO)/Owner stated he could not find any of the missing documents.
V0516	PA-FREQUENCY-INITIAL-30 DAYS/13 TX CFR(s): 494.80(b)(1) An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session. This STANDARD is not met as evidenced by: Based on a review of medical records and staff interview, it was determined that the facility failed to complete a comprehensive interdisciplinary assessment that was conducted by the entire Interdisciplinary Team (IDT) within 30 calendar days of admission or after 13 dialysis treatments for two of two sampled new patients (P#1 and P#2), who were admitted in 2022. This failure had the potential to negatively affect the health and safety of P#1 and P#2. The facility census was 32. A review of medical records revealed the following: - P#1 was admitted to this facility on 5/2/22. There was no documentary evidence that a comprehensive IDT initial assessment was completed. There was only a Social Worker's initial assessment. There was no documentary evidence of an Initial Registered Nurse (RN) Assessment before P#1's initial hemodialysis treatment. - P#2 was admitted on 2/2/22. There was no documentary evidence that a comprehensive IDT initial assessment was completed. There was no documentary evidence of an Initial RN Assessment on P#2 before his initial hemodialysis treatment at this facility. In addition, there was no documentary evidence that a 90-day comprehensive assessment was completed by the entire IDT for P#2. The Chief Executive Officer (CEO)/Owner, stated on 7/12/22 at approximately 11:30 a.m., that he could not find any documentary evidences of P#1's and P#2's initial IDT comprehensive assessment, nor of an Initial RN assessment prior to P#1's and P#2's hemodialysis treatment.
V0540	CFC-PATIENT PLAN OF CARE CFR(s): 494.90 This CONDITION is not met as evidenced by: Based on a review of facility records and staff interview, it was determined that the facility failed to develop or complete an individualized plan of care in collaboration with the entire Interdisciplinary Team (IDT) for four of five patients sampled (P#1 - P#4). This deficient practice had the potential to negatively affect the health and safety of 32 patients who were under the care of this facility. Findings include: Cross reference: V 0542 - Failure of the facility to ensure that individualized plan of care was completed for each patient by the entire IDT.
V0542	POC-IDT DEVELOPS PLAN OF CARE CFR(s): 494.90(a) The interdisciplinary team must develop a plan of care for each patient. This STANDARD is not met as evidenced by: Based on medical record review and staff interview, it was determined that the facility failed to ensure that the Interdisciplinary Team (IDT) developed an effective, individualized plan of care for four of five sampled patients (P#1, P#2, P#3, and P#4). This deficient practice had the potential to negatively affect the health and safety of the four patients sampled. The facility census was 32. Findings include: - P#1 was admitted to this facility on 5/2/22. There was no documentary evidence that an Initial individualized plan of care was developed and completed by the entire IDT. - P#2 was admitted to this facility on 2/2/22. There was no documentary evidence that an Initial and 90-day individualized plan of care was developed and completed by the entire IDT. - P#3 was admitted to this facility on 12/20/21. There was no documentary evidence that an Initial and 90-day individualized plan of care was developed and completed by the entire IDT. - P#4 was admitted to this facility on 11/26/19. The last record for an IDT assessment was 10/7/21 however, there was no documentary evidence that an individualized Plan of Care was developed and completed by the entire IDT based on the comprehensive IDT assessment of 10/7/21. The Chief Executive Officer (CEO)/Owner stated on 7/12/22 at approximately 11:30 a.m., that he could not find any documentary evidence of the above patients' individualized plan of care.
V0625	CFC-QAPI CFR(s): 494.110 This CONDITION is not met as evidenced by: Based on a review of the Quarterly Update of the Fiscal Year 2022 Dialysis Facility Report (DFR: 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), a review of facility records, and staff interviews, it was determined that the Quality Assessment and Performance Improvement (QAPI) Committee failed to track, trend, analyze, and develop plans of action for the facility's Mortality, Hospitalization, Infection/Dialysis Access, Fluid Management, Anemia, Dialysis Adequacy, Nutrition and Influenza Vaccination and Transplant status for six of six months (January 2022 to June 2022) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of 32 in-center hemodialysis (ICHD) patients who were under the care of this facility. Findings include: Cross Reference: V 638 - Failure of the QAPI Team to consistently monitor, track and trend facility's performances and develop action plans to improve and sustain patient outcomes.
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 Quarterly Update of the Fiscal Year 2022 Dialysis Facility Report (DFR: 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), a review of facility records, and staff interviews, it was determined that the Quality Assessment and Performance Improvement (QAPI) Committee failed to track, trend, analyze, and develop plans of action for the facility's Mortality, Hospitalization, Infection/Dialysis Access, Fluid Management, Anemia, Dialysis Adequacy, Nutrition and Influenza Vaccination and Transplant status for six of six months (January 2022 to June 2022) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of 32 in-center hemodialysis (ICHD) patients who were under the care of this facility. Findings include: - A review of the Quarterly Update of the Fiscal Year 2022 DFR for calendar year 2020, revealed that the facility was missing their Mortality, Hospitalization, Infection/Dialysis Access, Fluid Management, Anemia, Dialysis Adequacy, Nutrition and Influenza Vaccination and Transplant status, since Quarter (Q) 3 (July-September 2020) and Q4 (October - December 2020) reports. The only report recorded in the Quarterly Update of the Fiscal Year 2022 DFR for calendar year 2020 from this facility were: 1. Vascular Access: Central Venous Catheter (CVC) only greater than (>) 90 days/3 months was 81.8 %. The U.S. threshold was 61.7%. 2. Transplant Waitlist less than (<) 70 years old was 5.3%. The U.S. threshold was 17.4%. - A review of the facility's QAPI meeting minutes from January 2022 - June 2022 revealed the following: 1. Adequacy < 1.2 (not meeting acceptable range): U.S. threshold was 1.6% This facility: - January 2022 - 25% - February 2022 - 13.64% - March 2022 - 0% - April 2022 - 7.41% - May 2022 - 4.3% - June 2022 - 25% 2. Anemia - there was no documentation regarding anemia outcomes for the months of January - June 2022. 3. Phosphorus (P04) > 7.0 - the QAPI minutes only showed the % of patients whose PO4 were greater than 5.5. The Registered Dietitian was not available to provide percentage of patients who had PO4 greater than 7.0. Percentage of patients whose PO4 were > 5.5 (U.S. threshold for PO4 > 7.0 was 15.3%): January 2022 - 62.5% February 2022 - 44% March 2022 - 44.4% April 2022 - 34.5% May 2022 - 51.5% June 2022 - 46.4% 4. Albumin < 4.0. U.S. threshold was 56.3%. This facility: January 2022 - 75% February 2022 - 75% March 2022 - 80.8% April 2022 - 82.8 % May 2022 - 75.8% June 2022 - 75% There were no available records of the QAPI teams' tracking and trending of Bloodstream infections, CVCs, Hospitalizations and re-admissions, Fluid Management (UFR - Ultrafiltration Rate >13 mL/kg/hour), and Mortality Analysis. According to the Social Worker on 7/11/22 at approximately 1:00 p.m., there was one patient on the transplant list, and one patient who was referred for transplant evaluation in April of 2022. There was one who transplanted last year. The Chief Executive Officer (CEO)/Owner stated on 7/12/22 at approximately 11:30 a.m., that he couldn't find other QAPI records and the former Facility Administrator (FA) had left employment last June 17, 2022.
V0680	CFC-PERSONNEL QUALIFICATIONS CFR(s): 494.140 This CONDITION is not met as evidenced by: Based on a review of facility records and staff interviews, it was determined that the facility failed to ensure that one of one Facility Administrator (FA) and four of four Patient Care Technicians (PCTs AA, BB, CC, and DD) were competent to perform assigned duties, and responsibilities in providing safe and effective patient care. This deficient practice had the potential to negatively impact the health and safety of 32 in-center hemodialysis patients who were under the care of this facility. Findings include: Cross references: V 681 - Failure of the facility to ensure that FA, was duly licensed to perform skilled nursing care to hemodialysis patients and PCT AA was certified or had documentary evidence of PCT training and skills competencies to perform the duties and responsibilities of safe hemodialysis patient care. V 693 - Failure of the facility to ensure that all PCTs (AA, BB, CC, and DD) were competent to perform their assigned tasks. V 695 - Failure of the facility to ensure that all PCTs (AA, BB, CC, and DD) had a documentary evidence that they were certified under a State certification program or a national commercially available certification program.
V0681	PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY CFR(s): 494.140 All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility's staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility's staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions. This STANDARD is not met as evidenced by: Based on a review of facility records, a review of personnel file, and patient and staff interviews, it was determined that the facility failed to ensure that one of one Patient Care Technician (PCT AA) sampled, who was specifically mentioned in the complaint investigation, and one of one Facility Administrator (FA), were certified and licensed and able to demonstrate and sustain the skills necessary to perform the duties that were assigned to them or refrain from performing nursing skills without being duly licensed. Findings include: A review of all PCTs and licensed personnel records at the facility revealed the following: - PCT AA was hired by this facility on 11/20/20. There were no records of PCT AA's certification status, no records of CPR training(CPR - Cardiopulmonary Resuscitation, is a lifesaving technique that's useful in many emergencies, such a a heart attack or near drowning, in which someone's breathing or heartbeat has stopped), there were no records of PCT AA's skills competency checks both for initial and annual competencies and check offs, no records of Emergency Preparedness Plan training and testing, Infection Control, Water and Dialysate, and Machine Training, nor any health records since she was hired at this facility on 11/20/20. -A review of PCT AA's Time Card or schedule of hours worked from June 3, 2022 through July 11, 2022 revealed that PCT AA continued to work at this facility on 6/3/22, 6/6/22, 6/8/22, and on 6/10/22, with an average of 11.93 hours per work day. The complainant (C#1), on 7/6/22 at approximately 11:40 a.m., stated that PCT AA told her and several other patients on 5/25/22 (when a State Surveyor came to investigate a complaint), that if the surveyor ask for PCT AA's name, she was to be called another PCT's name (PCT VV), who had left employment in September of 2021. According to the Chief Executive Officer (CEO/Owner) on 7/6/22 at approximately 1:30 pm., he could not find any of PCT AA's personnel records on file. He stated that both FA and PCT AA left employment at about the same time. A review of personnel records revealed that FA's personnel file was missing. The CEO stated on 7/6/22 at approximately 3:00 p.m., that he could not find FA's personnel file and FA was a Certified Clinical Hemodialysis Technician but went back to attend nursing school and graduated last year but he was told by FA that she was only given a temporary license as a Registered Nurse last year due to the pandemic (COVID 19). This surveyor looked up FA's licensure status in the Georgia State's Licensure website but FA's name was not listed. This was confirmed by the CEO on 7/7/22 at approximately 2:30 p.m. that FA was not a licensed nurse. - A review of the FA's Time Card or schedule of hours worked from June 3, 2022 through July 11, 2022, revealed that FA worked at this facility every Monday, Wednesday, and Friday through 6/17/22; and was hired as the Facility Administrator on 9/22/19. - A review of patients' (P#1, P#5, P#6, P#7, and P#8) Flowsheets revealed the following: - P#1's hemodialysis treatment on 5/27/22 using a central venous catheter (CVC) was initiated and terminated by FA, including pre and post assessment. Only licensed nurses in this state are allowed to initiate and terminate hemodialysis treatment on a patient with a CVC. - P#5 was given on 5/25/22 the following medications by FA: Heparin (anticoagulant) bolus of 1500 units via intravenous push (IVP) and maintenance dose of 1000 units every hour for 3 hours; Epogen 8000 units (Erythropoietin Stimulating Agent for anemia) via IVP; and Promethazine 25 mg (for the treatment of allergy or allergic reactions) via IVP. FA also performed the pre- and post-assessment of P#5 (which included lung sounds), to be performed by a licensed nurse. - P#5 was again given by FA, the same doses of Heparin and Epogen via IVP on 6/1/22; and in addition, Doxercalciferol (used to treat secondary hyperparathyroidism) 2 mcg via IVP; as well as performing pre and post assessments on P#5. - P#6's pre and post assessments were conducted by FA on 5/25/22. IVP of Heparin Bolus 1500 units, Heparin maintenance dose of 1000 units per hour for three hours; Epogen 8000 units; and Doxercalciferol 2 mcg were also administered IVP by FA. The same medications were also administered by FA via IVP on 5/27/22, 6/1/22, 6/3/22, and 6/29/22, as well as pre and post assessments. - P#7 was given Heparin Bolus of 2000 units IVP by FA on 6/29/22, as well as Benadryl (antihistamine) 25 mg IVP. FA also performed pre-assessment. - P#8's pre and post assessments were conducted by FA and medications such as Heparin Bolus 3000 units and maintenance dose of 1500 units per hour for three hours; Epogen 4000 units; and Doxercalciferol 2 mcg were administered via IVP by FA on 5/25/22, 5/27/22, 6/1/22 and 6/3/22. In addition, FA also gave P#8 Parsabiv (additional dose?), also for the treatment of hyperparathyroidism via IVP on 5/27/22. The CEO could not find doctor's order changes or records at the time of this investigation and he stated on 7/7/22 at approximately 1:00 p.m. that he had tried to contact FA several times via phone calls or text messages but FA did not return calls nor text messages. During patient interviews on 7/6/22 between 11:45 a.m. and 12:15 p.m., the following was revealed: - P#2 stated that FA had given him medications before while on the machine. - P#6 stated that FA had initiated her hemodialysis treatment before. P#6 had an arterio-venous fistula (AVF). - P#9 at Station (S9) stated that he could not remember if FA had given him medications before but remembered that FA had initiated his treatment in the past, but unsure of date. P#9 had a CVC.
V0693	PQ-PCT-COMPLETE TRAINING PROGRAM CFR(s): 494.140(e)(3) Patient care dialysis technicians must- (3) Have completed a training program that is approved by the medical director and governing body, under the direction of a registered nurse, focused on the operation of kidney dialysis equipment and machines, providing direct patient care, and communication and interpersonal skills, including patient sensitivity training and care of difficult patients. This STANDARD is not met as evidenced by: Based on a review of personnel records and staff interview, it was determined that the facility failed to provide documentary evidences that four of four Patient Care Technicians (PCTs AA, BB, CC, and DD), completed an orientation and training program that was approved by the facility's Medical Director (MD) and Governing Body (GB). This deficient practice had the potential to negatively impact the health and safety of all 32 patients who were under the care of this facility. Findings include: A review of personnel records for PCTs AA, BB, CC, and DD revealed no documentary evidences that they completed an orientation and training program at the facility, nor a documentary evidence that they had training at other dialysis facilities. There were no skills competency check offs, no water and dialysate training and skills check records, no CPR, no Infection Control and Emergency Preparedness Plan Training and Testing. There were no orientation records of newly hired PCTs and no health records except for PCT BB. A review of the hire dates of the following PCTs revealed the following: - PCT AA was hired by this facility on 11/20/20. - PCT BB was hired on 3/15/21. - PCT CC was hired on 5/1/22. - PCT DD was hired on 6/4/22. A review of PCT AA's last work day at the facility revealed that she worked at this facility until 6/10/22. An interview with the Chief Executive Officer (CEO) on 7/6/22 at 3:45 p.m., revealed that there were no documentary evidences available to confirm that the staff completed the facility's orientation and training program. The CEO further stated that some of them had worked here before, but confirmed that there were no orientation and training records available, nor any competency skills checks initially and annually.
V0695	PQ-PCT CERTIFIED CFR(s): 494.140(e)(4) Patient care dialysis technicians must- (4) Be certified under a State certification program or a national commercially available certification program, as follows- (i) For newly employed patient care technicians, within 18 months of being hired as a dialysis patient care technician; or (ii) For patient care technicians employed on October 14, 2008, within 18 months after such date. This STANDARD is not met as evidenced by: Based on facility record review and staff and patient interviews, it was revealed that the facility failed to ensure that one of one Patient Care Technician (PCT AA) sampled, who was specifically mentioned in the complaint allegation, and three of three other PCTs (PCT BB, PCT CC, and PCT DD), who were currently employed at this facility, had records of their certification status, nor PCT training. This deficient practice had the potential to negatively impact the health and safety of all 32 patients who were under the care of this facility. Findings include: A review of all certified and licensed personnel records at the facility revealed the following: PCT AA was hired by this facility on 11/20/20. There were no records of PCT AA's certification status. -A review of PCT AA's Time Card or schedule of hours worked from June 3, 2022 through July 11, 2022 revealed that PCT AA continued to work at this facility on 6/3/22, 6/6/22, 6/8/22, and on 6/10/22, with an average of 11.93 hours per work day. - The complainant (C#1), on 7/6/22 at approximately 11:40 a.m., stated that PCT AA told her and several other patients on 5/25/22, when a State Surveyor came to investigate a complaint, PCT AA told them that her name was another PCT's name, (PCT VV) who had left employment since September of 2021. - According to the Chief Executive Officer (CEO/Owner) on 7/6/22 at approximately 1:30 pm., he could not find any of PCT AA's personnel records on file. He stated that both the Facility Administrator (FA #1) and PCT AA left employment at about the same time. - A review of the personnel records of PCT BB, PCT CC, and PCT DD, who were currently working at this facility, also revealed no records of Hemodialysis certification status nor PCT training. The Chief Executive Officer/Owner could not find any documentary evidence of PCT BB, PCT CC, and PCT DD's certification records nor PCT training. The CEO was not able to provide any of the PCTs certification status, nor PCT training as of 7/18/22.
V0710	CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR CFR(s): 494.150 This CONDITION is not met as evidenced by: Based on a review of facility records and staff interviews, it was determined that the Medical Director (MD) failed to demonstrate responsibility for the operations of the facility. This failure had the potential to negatively impact the health and safety of 32 patients who were receiving hemodialysis at this facility. Findings include: Cross Reference the following cited deficiencies: V 681 - Failure of the facility to ensure that the Facility Administrator (FA), was duly licensed to perform skilled nursing care to hemodialysis patients and PCT AA was certified or had documentary evidence of PCT training and skills competencies to perform the duties and responsibilities for safe hemodialysis patient care. V 693 - Failure of the facility to ensure that all PCTs (AA, BB, CC, and DD) were competent to perform their assigned tasks. V 695 - Failure of the facility to ensure that all PCTs (AA, BB, CC, and DD) had a documentary evidence that they were certified under a State certification program or a national commercially available certification program. During an interview with the Medical Director on 7/12/22 at approximately 1:00 p.m., he stated that the facility needed stability of staff and that it was being addressed.
V0712	MD RESP-QAPI PROGRAM CFR(s): 494.150(a) Medical director responsibilities include, but are not limited to, the following: (a) Quality assessment and performance improvement program. This STANDARD is not met as evidenced by: Based on a review of the facility's Quality Assessment and Performance Improvement (QAPI) meeting minutes, and staff interviews, it was determined that the Medical Director failed to demonstrate operational responsibility for the facility's QAPI program for six of six months (January - June 2022) of QAPI meeting records reviewed. This deficient practice had the potential to negatively impact the health and safety of all 32 in-center hemodialysis patients who were under the care of this facility. Findings include: Cross Reference: V 638 - Failure of the QAPI Team to consistently monitor, track and trend facility's performances and develop action plans to improve and sustain patient outcomes.
V0750	CFC-GOVERNANCE CFR(s): 494.180 This CONDITION is not met as evidenced by: Based on patient and staff interviews and facility record review, it was determined that the Governing Body (GB) failed to demonstrate responsibility and accountability for the operations of the facility. This failure had the potential to negatively affect the health and safety of 32 in-center hemodialysis patients who were receiving dialysis treatment at this facility. Findings include: Cross references: V 681 - Failure of the facility to ensure that the Facility Administrator (FA), was duly licensed to perform skilled nursing care to hemodialysis patients and PCT AA was certified or had documentary evidence of PCT training and skills competencies to perform the duties and responsibilities of safe hemodialysis patient care. V 693 - Failure of the facility to ensure that all PCTs (AA, BB, CC, and DD) were competent to perform their assigned tasks. V 695 - Failure of the facility to ensure that all PCTs (AA, BB, CC, and DD) had a documentary evidence that they were certified under a State certification program or a national commercially available certification program.