Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 852575 (X3) Date Survey Completed 08/09/2023
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 A Recertification Survey was conducted at CC&D Services from August 7, 2023 through August 9, 2023. 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. However, the following deficiency was cited which resulted from the facility's noncompliance related to the survey:
E0039 EP Testing Requirements

§416.54(d)(2), §418.113(d)(2), §441.184(d)(2), §460.84(d)(2), §482.15(d)(2), §483.73(d)(2), §483.475(d)(2), §484.102(d)(2), §485.68(d)(2), §485.542(d)(2), §485.625(d)(2), §485.727(d)(2), §485.920(d)(2), §491.12(d)(2), §494.62(d)(2). *[For ASCs at §416.54, CORFs at §485.68, REHs at §485.542, OPO, "Organizations" under §485.727, CMHCs at §485.920, RHCs/FQHCs at §491.12, and ESRD Facilities at §494.62]: (2) Testing. The [facility] must conduct exercises to test the emergency plan annually. The [facility] must do all of the following: (i) Participate in a full-scale exercise that is community-based every 2 years; or (A) When a community-based exercise is not accessible, conduct a facility-based functional exercise every 2 years; or (B) If the [facility] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required community-based or individual, facility-based functional exercise following the onset of the actual event. (ii) Conduct an additional exercise at least every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [facility's] emergency plan, as needed. *[For Hospices at 418.113(d):] (2) Testing for hospices that provide care in the patient's home. The hospice must conduct exercises to test the emergency plan at least annually. The hospice must do the following: (i) Participate in a full-scale exercise that is community based every 2 years; or (A) When a community based exercise is not accessible, conduct an individual facility based functional exercise every 2 years; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospital is exempt from engaging in its next required full scale community-based exercise or individual facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (3) Testing for hospices that provide inpatient care directly. The hospice must conduct exercises to test the emergency plan twice per year. The hospice must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual facility-based functional exercise; or (B) If the hospice experiences a natural or man-made emergency that requires activation of the emergency plan, the hospice is exempt from engaging in its next required full-scale community based or facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop led by a facilitator that includes a group discussion using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the hospice's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the hospice's emergency plan, as needed. *[For PRFTs at §441.184(d), Hospitals at §482.15(d), CAHs at §485.625(d):] (2) Testing. The [PRTF, Hospital, CAH] must conduct exercises to test the emergency plan twice per year. The [PRTF, Hospital, CAH] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the [PRTF, Hospital, CAH] experiences an actual natural or man-made emergency that requires activation of the emergency plan, the [facility] is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an [additional] annual exercise or and that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [facility's] response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the [facility's] emergency plan, as needed. *[For PACE at §460.84(d):] (2) Testing. The PACE organization must conduct exercises to test the emergency plan at least annually. The PACE organization must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or (B) If the PACE experiences an actual natural or man-made emergency that requires activation of the emergency plan, the PACE is exempt from engaging in its next required full-scale community based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or individual, a facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the PACE's response to and maintain documentation of all drills, tabletop exercises, and emergency events and revise the PACE's emergency plan, as needed. *[For LTC Facilities at §483.73(d):] (2) The [LTC facility] must conduct exercises to test the emergency plan at least twice per year, including unannounced staff drills using the emergency procedures. The [LTC facility, ICF/IID] must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise. (B) If the [LTC facility] facility experiences an actual natural or man-made emergency that requires activation of the emergency plan, the LTC facility is exempt from engaging its next required a full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the [LTC facility] facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the [LTC facility] facility's emergency plan, as needed. *[For ICF/IIDs at §483.475(d)]: (2) Testing. The ICF/IID must conduct exercises to test the emergency plan at least twice per year. The ICF/IID must do the following: (i) Participate in an annual full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise; or. (B) If the ICF/IID experiences an actual natural or man-made emergency that requires activation of the emergency plan, the ICF/IID is exempt from engaging in its next required full-scale community-based or individual, facility-based functional exercise following the onset of the emergency event. (ii) Conduct an additional annual exercise that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the ICF/IID's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the ICF/IID's emergency plan, as needed. *[For HHAs at §484.102] (d)(2) Testing. The HHA must conduct exercises to test the emergency plan at least annually. The HHA must do the following: (i) Participate in a full-scale exercise that is community-based; or (A) When a community-based exercise is not accessible, conduct an annual individual, facility-based functional exercise every 2 years; or. (B) If the HHA experiences an actual natural or man-made emergency that requires activation of the emergency plan, the HHA is exempt from engaging in its next required full-scale community-based or individual, facility based functional exercise following the onset of the emergency event. (ii) Conduct an additional exercise every 2 years, opposite the year the full-scale or functional exercise under paragraph (d)(2)(i) of this section is conducted, that may include, but is not limited to the following: (A) A second full-scale exercise that is community-based or an individual, facility-based functional exercise; or (B) A mock disaster drill; or (C) A tabletop exercise or workshop that is led by a facilitator and includes a group discussion, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (iii) Analyze the HHA's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the HHA's emergency plan, as needed. *[For OPOs at §486.360] (d)(2) Testing. The OPO must conduct exercises to test the emergency plan. The OPO must do the following: (i) Conduct a paper-based, tabletop exercise or workshop at least annually. A tabletop exercise is led by a facilitator and includes a group discussion, using a narrated, clinically relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. If the OPO experiences an actual natural or man-made emergency that requires activation of the emergency plan, the OPO is exempt from engaging in its next required testing exercise following the onset of the emergency event. (ii) Analyze the OPO's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the [RNHCI's and OPO's] emergency plan, as needed. *[ RNCHIs at §403.748]: (d)(2) Testing. The RNHCI must conduct exercises to test the emergency plan. The RNHCI must do the following: (i) Conduct a paper-based, tabletop exercise at least annually. A tabletop exercise is a group discussion led by a facilitator, using a narrated, clinically-relevant emergency scenario, and a set of problem statements, directed messages, or prepared questions designed to challenge an emergency plan. (ii) Analyze the RNHCI's response to and maintain documentation of all tabletop exercises, and emergency events, and revise the RNHCI's emergency plan, as needed.


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 conduct an annual exercise to test the facility emergency plan. This deficient practice had the potential to negatively affect the health and safety of 17 patients who were receiving dialysis services at this facility. Findings were: A review of the facility Emergency Preparedness Plan revealed that the facility failed to maintain documents of all tabletop exercises (emergency events that included emergency scenarios) annually, and to revise emergency plans as needed. The facility was unable to obtain a documented tabletop exercise. During an interview with the Facility Administrator on 8/6/23 at approximately 1:00 p.m., she stated that the exercises should have been completed.
V0000 A Recertification Survey [CORE] was conducted at CC&D Services from August 7, 2023 through August 9, 2023. 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 deficiencies resulted from the facility's noncompliance related to the survey:
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, a review of the Centers for Disease Control and Prevention (CDC) guidelines, and staff interview, it was determined that the Infection Control Committee failed to ensure that one of one Registered Nurse (RN AA) observed, utilized appropriate infection control techniques to prevent cross contamination. This breach in infection control techniques could negatively affect the health and safety of one of one patient (P#6), who was undergoing hemodialysis (HD) treatment with central venous catheter (CVC - dialysis access) at the time of this observation. Findings include: During observation in the patient treatment room on 8/9/23 between 9:00 a.m. and 10:00 a.m., the following was observed: - RN AA was observed during initiation of HD treatment on P#6 with a CVC at Station 3. She placed the used syringes, gauzes and alcohol wipes (contaminated) on the blue liner that stored clean/sterile supplies such as Heparin-lock syringes, clean gauze pads, and clean alcohol pads. According to the CDC, measures to prevent contamination of clean or sterile items include not storing potentially contaminated (used) supplies in areas where clean (unused) supplies are handled. During an interview with the Facility Administrator on 8/9/23 at approximately 1:30 p.m., she stated that the nurse should have separated the clean supplies from the dirty/contaminated supplies to prevent cross contamination.
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 have a system in place to ensure that 17 of 17 hemodialysis machines (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17 ) were maintained and free of unsanitary substances. Findings were: During a tour of the facility on August 7, 2023 between 11:00 a.m. - 12:00 p.m., the following was observed: - Machines #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, and #17 had peeling paint and rust colored stains covering the lower surfaces of the machines. During an interview with the Administrative Assistant on 8/7/23 at approximately 2:00 p.m., she stated that the machines needed to be painted.
V0556 POC-COMPLETED/SIGNED BY IDT & PT
CFR(s): 494.90(b)(1)

The patient's plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient's designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided.


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 ensure that one of one patient sampled for anemia (P#2) and one of one patient sampled for bone/mineral outcomes (P#3), had an annual patient care plan completed by the Interdisciplinary Team (IDT), signed by the IDT, and by the patient or designee to acknowledge that the information in the plan of care was discussed with the patient or designee, or documentation of the patients' refusal if they chose not to sign. Findings include: During a review of medical records, the following was revealed: - P#2's care plan dated 5/5/23, was incomplete and was not signed by the IDT, nor by P#2 or a designee. - P#3's care plan dated 2/15/23, was incomplete and was not signed by the IDT, nor by P#3 or a designee. During an interview with the Facility Administrator on 8/7/23 at approximately 1:30 p.m.., she stated that the IDT should have completed the care plans with signatures from the patients.
V0633 QAPI-INDICATOR-VASCULAR ACCESS
CFR(s): 494.110(a)(2)(v)

The program must include, but not be limited to, the following: (v) Vascular access.


This STANDARD is not met as evidenced by:
Based on a review of the 2023 Dialysis Facility Report (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), facility records review, and staff interview, it was determined that the facility failed to track, measure, and analyze vascular access (access used for dialysis) for six of six months (February 2023 to July 2023) of Quality Improvement Program/Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed, to decrease the use of catheters. This deficient practice increased the risk for incidence of infection related to catheter use for 26% of patients, who used catheter as their only vascular access for dialysis. The facility census was 17. Findings were: A review of the 2023 Dialysis Facility Report revealed that the US average for Central Venous Catheters (CVC) only, that had been in place for 90 days or more, should not exceed 10.3%. - The facility had 27% of patients who had CVC only, as their dialysis access. A review of the QAPI meeting minutes from February 2023 - July 2023 revealed no documentary evidence that the QAPI team conducted a comprehensive review of the patients with vascular access to decrease the use of catheters. - The QAPI meeting minutes revealed a lack of documented evidence that aggregate data had appropriate action plans, root cause analysis, and follow-up evaluations to ensure improvement and decrease the use of catheters. During an interview with the Facility Administrator on 8/9/23 at approximately 1:30 p.m., she stated that the information was reviewed. However, root causes, action plans, and evaluations should have been completed for the reduction of catheters.
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 Dialysis Facility Report (DFR) and facility records and staff interview, it was determined that the facility failed to track and trend anemia rates (low red blood cell counts), develop action plans and evaluate the effectiveness of the facility's management of patients with a Hemoglobin (Hgb - protein in red blood cells that carries oxygen) of less than (<) 10 g/dL, for six of six months of Quality Improvement Meeting Minutes reviewed (February 2023 - July 2023). This deficient practice had the potential to negatively affect the health and safety of 17 patients who were receiving dialysis services at this facility. Findings were: A review of 2023 DFR (A report prepared by Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients of this facility, as compared to other facilities in the U.S.) revealed that the average Hgb < 10 g/dL should not exceed 16.8 % for in-center hemodialysis patients. A review of Quality Improvement Meeting reports for six of six months (February 2023 - July 2023) revealed that the facility's average percentage for Hgb < 10 g/dL was 28.9% % for in-center hemodialysis patients. The Quality Improvement Meeting minutes revealed a lack of documented evidence that anemia management for hemodialysis patients with a Hgb < 10 g/dL had appropriate action plans, root cause analysis, and follow-up evaluations to ensure improvement. During an interview with the Facility Administrator on 8/9/23 at approximately 1:30 p.m., she stated that the anemia management for patients with Hgb <10 were being reviewed. However, the action plans, root cause analysis and follow-up evaluation needed to be completed for hemodialysis patients with Hgb<10.
V0715 MD RESP-ENSURE ALL ADHERE TO P&P
CFR(s): 494.150(c)(2)(i)

The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;


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 conduct regular fire drills at least every six months for 12 of 12 months of fire drill records reviewed (7/30/22 - 7/30/23). Failure to conduct periodic fire drills for each shift of patients, had the potential to negatively affect the health and safety of 17 patients who were dialyzing at this facility. Findings were: A review of the facility fire drill records from 7/30/22 to 7/30/23, showed a lack of documented fire and evacuation drills for each shift of patients for the last twelve months. A review of the policy titled, "Disaster and Fire Drill Procedure" with no date stated fire drills shall be performed quarterly for each shift of patients and staff. During an interview with the Facility Administrator on 8/7/23 at approximately 2:30 p.m., she stated that the fire drills should have been conducted quarterly.