| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852579 | (X3) Date Survey Completed 06/07/2023 |
| Name of Provider or Supplier Home Dialysis Services Norcross, Llc | Street Address, City, State 3780 Holcomb Bridge Road, Suite E, Norcross, 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 Home Dialysis Services Norcross , LLC from June 5, 2023 through June 7, 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 Home Dialysis Services Norcross, LLC from June 5, 2023 through June 7, 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: |
| 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 two of two patients (P) sampled for anemia (P#1 and P#5). Findings were: A review of the medical records for P#1 and P#5 revealed that the facility was not able to produce the last documented KDQOL 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 Facility Administrator on 6/6/23 at approximately 2:00 p.m., she stated that the KDQOL assessments should have been completed. |
| V0587 | H-FAC RECEIVE/REVIEW PT RECORDS Q 2 MONTHS CFR(s): 494.100(b)(2),(3) The dialysis facility must - (2) Retrieve and review complete self-monitoring data and other information from self-care patients or their designated caregiver(s) at least every 2 months; and (3) Maintain this information in the patient ' s medical record. This STANDARD is not met as evidenced by: Based on a review of records and staff interview, it was determined that the facility failed to ensure that two of two sampled peritoneal dialysis (PD) patients (P#2 and P#3) treatment flowsheets were reviewed at least every two months, to determine if the patients were following their prescribed treatment plan and/or having problems with dialysis at home. Failure to monitor home patient's status by reviewing dialysis treatment records, could negatively affect the health and safety of the 27 PD patients who were receiving PD services at this facility. Findings include: A review of P#2 and P#3's treatment records dated 2/1/23 through 5/30/23 , revealed the following: There was no documentation to confirm that the patient's home treatment flowsheets were reviewed by a nurse, to determine if P#2 and P#3 were following the prescribed treatment plan or having any documented problems with home dialysis. During an interview with the HomeTraining Nurse on 6/6/23 at approximately 3:00 p.m., she stated that the treatment flowsheets were reviewed however should have been signed. |
| V0632 | QAPI-INDICATOR-ANEMIA MANAGEMENT CFR(s): 494.110(a)(2)(iv) The program must include, but not be limited to, the following: (iv) Anemia management. 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 (December 2022 - May 2023). This deficient practice had the potential to negatively affect the health and safety of the six home hemodialysis patients who were receiving home dialysis support 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 hemodialysis patients. A review of Quality Improvement Meeting reports for six of six months (December 2022 - May 2023) revealed that the facility's average percentage for Hgb < 10 g/dL was 28% for home hemodialysis patients. The Quality Improvement Meeting minutes revealed a lack of documented evidence that anemia management for home 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 Clinic Manager on 6/7/23 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 the home hemodialysis patients with Hgb <10. |