Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 852578	(X3) Date Survey Completed 04/12/2023
Name of Provider or Supplier Dialysis Care Center Pleasant Hill, Llc	Street Address, City, State 1425 Georgia Ave, Suite 101, Macon, 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 Dialysis Care Center Pleasant Hill, LLC from April 10, 2023 through April 12, 2023. The survey revealed that the facility was in 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	A Recertification Survey [CORE] was conducted at Dialysis Care Cenrer Pleasant Hill, LLC from April 10, 2023 through April 12, 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:
V0113	IC-WEAR GLOVES/HAND HYGIENE CFR(s): 494.30(a)(1) Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station. This STANDARD is not met as evidenced by: Based on observation, a review of policy and procedure, and staff interview, it was determined that the Infection Control Committee failed to ensure that and one of two Certified Clinical Hemodialysis Technician (CCHT BB) observed, performed hand hygiene (wash hands or use an alcohol-based hand sanitizer), after removal of contaminated gloves. This breach in infection control had the potential to cause the spread of infections, or bloodborne pathogens in the dialysis environment through cross contamination. The facility In-center Hemodialysis census was 42. Findings include: During observation in the patient treatment room on 4/12/23 between 9:30 a.m. and 11:00 a.m., the following was revealed: - CCHT BB was observed answering a machine alarm at Station 11. She removed her gloves and documented on the computer (clean) and then placed another pair of gloves on without sanitizing or washing her hands. A review of Policy titled, "Infection Control " dated 1/6/16 stated the following: - Hands are always washed after gloves are removed and between patient contact. According to CDC recommendations, even with glove use, hand hygiene is necessary after glove removal because hands can become contaminated through small defects in gloves and from the outer surface of gloves during glove removal ... During an interview on 4/12/23 at approximately 10:30 a.m., the Clinic Manager stated that CCHT BB should have performed appropriate hand hygiene.
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 4/10/23 between 1:30 p.m. and 2:30 p.m., the following was observed: - RN AA was observed during initiation of HD treatment on P#6 with a CVC at Station 4. He placed the used blood tubes (contaminated) on the blue liner that stored clean/sterile supplies such as Heparin-lock syringes, gauze pads, and 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 Clinic Manager on 4/10/23 at approximately 3:30 p.m., she stated that the nurse should have separated the clean supplies from the dirty/contaminated supplies to prevent cross contamination.
V0402	PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This STANDARD is not met as evidenced by: Based on observation and staff interview, it was determined that the facility failed to ensure that the Acid holding tank was maintained and cleaned to ensure the safety of the 42 patients who dialyzed at this facility. This deficient practice was observed in one of one Water Treatment Room. Findings were: During a tour of the water treatment room on 4/10/2023 at 11:45 a.m., the following was observed: - The hose attached to the holding tank was covered with crystallized substance. - The area under the holding tank was covered with rust colored stains. During an interview with the Clinic Manager on 4/10/23 at approximately 3:00 p.m., she stated that the crystallized substance and the rust should be cleaned and removed.
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 ensure that six of 16 dialysis machines were maintained in good condition. Findings were: During a tour of the facility on 4/10/2023 between 12:00 p.m. and 1:00 p.m., the following was observed: - The paint on the blood pump panels of the dialysis machines at Stations #2, #9, #10, #12, #14 and #16 were removed exposing the metal underneath. - During an interview with the Clinic Manager on 4/12/23 at approximately 11:30 a.m., she stated that the panels on the dialysis machines needed to be replaced.
V0552	POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This STANDARD is not met as evidenced by: Based on a review of records and staff interview, it was determined that the interdisciplinary team failed to ensure that a Kidney Disease Quality of Life (KDQOL) assessment was completed annually for one of one patient sampled for anemia (P#2), and for one of one patient sampled for bone/mineral outcomes (P#4). Findings were: A review of the medical records for P#2 and P#4 revealed that the last documented KDQOL was dated 11/3/20 and 8/20/19 respectively. There was no documentary evidence that an updated annual KDQOL assessments were completed on these patients. A review of policy titled, "Comprehensive Assessment and Plan of Care" dated 1/6/2016, stated the reassessment of the KDQOL will be conducted at least annually for stable patients. During an interview with the Clinic Manager on 4/12/23 at approximately 12:00 p.m., she stated that the KDQOL assessments should have been completed.
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#1) 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#1's care plan dated 11/11/22, was incomplete and was not signed by the IDT, nor by P#1 or a designee. - P#3's care plan dated 12/29/22, was incomplete and was not signed by the IDT, nor by P#3 or a designee. During an interview with the Clinic Manage on 4/11/22 at approximately 3:30 p.m.., she stated that the IDT should have completed the care plans with signatures from the patients.
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 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) and develop action plans and outcomes, to 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 (October 2022 - March 2023). This deficient practice had the potential to negatively affect the health and safety of the 42 patients who were receiving dialysis services at this facility. Findings were: A review of 2022 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 October 2022 - March 2023 revealed that the facility's average percentage for Hgb < 10 g/dL was 30.8 % for in-center dialysis patients. The Quality Improvement Meeting minutes revealed a lack of documented evidence that anemia management for 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 Clinic Manager on 4/12/23 at approximately 12:00 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.
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 (4/1/22 - 4/1/23). Failure to conduct periodic fire drills for each shift of patients, had the potential to negatively affect the health and safety of the 42 patients who were dialyzing at this facility. Findings were: A review of the facility fire drill records from 4/1/22 to 4/1/23, showed a lack of documented fire and evacuation drills for each shift of patients for the last twelve months. The last documented fire drill was completed on 12/1/22 for second shift patients only. A review of the policy titled, "Fire Emergency" dated 7/16/18 stated fire drills shall be performed quarterly for each shift of patients and staff. During an interview with the Clinic Manager on 4/11/23 at approximately 2:30 p.m., she stated that the fire drills should have been conducted quarterly.