Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 852592	(X3) Date Survey Completed 07/16/2025
Name of Provider or Supplier Kidneyspa East Atlanta Dialysis, Llc	Street Address, City, State 2375 Metropolitan Pkwy Sw, Atlanta, 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 unannounced onsite survey to investigate Complaint # GA00255800 and # GA00255540, was conducted on July 16, 2025 and ended on July 16, 2025. Two of two allegations were substantiated. The following standard level deficiencies were cited:
V0684	PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This STANDARD is not met as evidenced by: Based on a review of facility records and staff interviews, it was determined that the Governing Body failed to ensure that this facility had a full-time Registered Nurse (RN), who was in charge of nursing services, to supervise the provision of patient care by fifteen of fifteen Direct Patient Care (DPC) Staff (three full-time Registered Nurses (RN BB , RN CC, AND RN DD), one part-time RN - RN AA, four full-time Patient Care Technicians (PCTs) - PCT AA, PCT BB, PCT CC, PCT DD, two part-time PCTs (PCT EE and PCT FF) and five PRN (as needed) PCTs, (PCT GG, PCT HH, PCT II, PCT JJ, and PCT KK), who were employed by this facility. This failure had the potential to negatively affect the health and safety of all 61 in-center hemodialysis patients who were receiving hemodiaysis services at this facility. Finding include : A review of the Governing Body Meeting Minutes revealed that on 4/25/25, RN AA (part-time nurse) was designated as Nurse in Charge of Nursing Services/Clinical Coordinator. The duties included: Overseeing clinical care delivery, support nursing staff, and ensure compliance with quality standards and patient care protocol. Assisting the Facility Administrator with a variety of team member and clinic program support functions. During an interview with the Facility Administrator on 7/16/25 at 09:44 a.m., the Facility Administrator explained that she was a Registered Dietitian (RD) by profession and currently served in a dual role as both Facility Administrator and RD at the facility. She stated that the Clinical Coordinator was responsible for assessing patients for medical dialysis-related issues. During an interview on 7/16/25 at 1:00 p.m., with RN AA (adopted as the Nurse in Charge of Nursing Services), the following was revealed: RN AA stated that she was not the clinical coordinator nor nurse in charge of nursing services at this facility. She explained that she worked part-time only, on Mondays, Wednesdays, and Fridays (MWF) schedule. RN AA also stated that she was never asked to take on the Clinical Coordinator role, never applied for the position, and was not being compensated for performing any responsibilities associated with it. She further stated that she recently saw her name listed on a form at the facility indicating she had been designated as the Clinical Coordinator. According to RN AA, this occurred after the previous Facility Administrator (who was a RN) resigned, and the position (Facility Administrator), was filled by a RD. She emphasized that someone assigned her the Clinical Coordinator role without her knowledge or consent and she made it clear that she was not accepting the position. - A copy of the job description for Clinical Coordinator/Nurse In-Charge of Nursing Services, was presented to this surveyor by the Facility Administrator, but was not signed and dated by RN AA. - There was no other RN designated as Clinical Coordinator/Nurse in charge of Nursing Services in the Governing Body Meeting Minutes, except RN AA.
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, patient and staff interviews, and a review of the facility's Policies and Procedures (P&P), it was determined that the Medical Director failed to ensure that all Direct Patient Care (DPC) staff (Registered Nurses - RNs, and Patient Care Technicians - PCTs), consistently adhered to prescribed hemodialysis orders relative to ultrafiltration rate (UFR-the speed at which excess fluid is removed from the body during hemodialysis treatment which is at or below 13 mL/kg/hr [milliLiter per kilogram per hour] - the maximum safe rate for fluid removal during treatment), of three of three patients (P) P#1, P#2, and P#3, sampled. Excessive ultrafiltration (UF) during hemodialysis can lead to serious complications, including intradialytic hypotension (low blood pressure during treatment), muscle cramping, dizziness, and long-term cardiovascular risks, potentially leading to increased morbidity and mortality. In addition, one of the three patients (P#1) sampled, did not receive the correct dialysate (dialysis fluid - specially prepared sterile solution of electrolytes, glucose, bicarbonate or lactate) and did not have hourly blood glucose checks performed as ordered. This deficient practice had the potential to negatively impact the health and safety of P#1, P#2, and P#3. The facility census was 61. Findings include: During a review of facility records, the following was revealed: P#1: - P#1 had a hemodialysis order to run on a 1.0 potassium bath (potassium component of the dialysate) for the first hour of treatment, followed by a 2.0 potassium bath for the remaining 2 hours and 45 minutes of hemodialysis treatment. P#1 also had an active order for hourly blood glucose monitoring during dialysis. A review of P#1's hemodialysis orders dated July 9, 2025, confirmed this prescription, along with the blood sugar monitoring instructions. A review of P#1's hemodialysis treatment flowsheets revealed that on 6/17/25, 6/19/25, and 7/12/25, P#1 was dialyzed using a 2.0 potassium / 2.5 calcium bath or dialysate for the entire treatment, which was not in accordance with the prescribed staggered potassium bath order. Additionally, there was no documented evidence that hourly blood glucose checks were performed on any of the above mentioned dates as ordered. - A review of P#1's recent potassium lab values showed that P#1 has had consistently elevated potassium levels: 7.2 mEq/L on 6/19/25, 6.9 mEq/L on 6/26/25, and 6.0 mEq/L on 7/3/25 (normal range: 3.5-5.5 mEq/L). - A review of P#1's weight history from 6/24/25 to 7/15/25 showed an average weight of 79.23 kg (kilogram), while P#1's estimated dry weight (EDW) remained 73.0 kg. - On 6/19/25, P#1 weighed 81.5 kg, with a pre-BP of 201/116 mmHg and post-BP of 198/91 mmHg. The UFR was 16.34, no clonidine (treatment for high BP, as needed) was administered, and there was no documentation of physician notification. - On 7/12/25, P#1's weight was 84.6 kg, with a pre-BP of 216/107 mmHg and a post-BP of 188/92 mmHg. Clonidine 0.1 mg was given at 9:45 a.m., and the UFR was 14.28. No documentation was found indicating physician notification of elevated BP readings or of UFR (greater than) >13 mL/kg/hr. - On 7/17/25, P#1's pre-dialysis weight was 81 kg, with a blood pressure (BP) reading of 224/113 mmHg (millimeters of mercury) pre-hemodialysis treatment and 221/109 mmHg post-hemodialysis treatment. - The UFR was 19.81, and 0.1 mg of clonidine was given at 10:30 a.m. There was no documentation that the physician was notified of the elevated BP reading or high UFR. - On July 3, 2025, the Nurse Practitioner (NP- who made rounds in addition to the Nephrologist's monthly rounds) documented that the patient was stable and without complaints. In addition, the NP documented that the prescription, vital signs, and labs were reviewed, and the plan was to continue hemodialysis as instructed. The NP did not address the high BP readings, excessive weight gain, high UFR and high potassium levels. During an interview on 7/17/25 at 4:00 p.m., P#1 stated: The doctor walks in, gives us cookies, and walks out. I know some of this is my fault, but I only started feeling bad and cramping when they tried to pull all the fluid off of me. I can't remember the last time someone adjusted my dry weight, and the doctor seemed too overwhelmed with patients to really pay attention. I have not received a nutritional report from the dietitian in over three months, and I had to stop the dietitian (also the Facility Administrator) just to ask a question. I think the staff are doing the best they can with what they have, but they need better training. P#2: - On 7/1/25, P#2's pre-treatment weight was 89.4 kg. P#2's EDW was 86.6 kg. The ordered fluid removal for the treatment was 2.9 kg, with a scheduled dialysis session of 3 hours and 30 minutes. However, documentation showed that the treatment started at 8:53 a.m. and ended at 11:03 a.m., lasting only 2.0 hours and 4 minutes. Despite the shortened treatment time, the UFR for this session was 23.04 mL/kg/hr (well above the recommended maximum of 13 mL/kg/hr). - A review of P#2's weight history from 6/5/25 to 7/15/25 showed an average weight of 88.3 kg. During hemodialysis treatment, P#2's BP readings ranged from 127/77 to 159/92, and the pulse ranged from 115 to 105 beats per minute. - 0n 7/5/25 the NP documented: "Patient was stable and without complaints. Perscription, vitals and labs have been reviewed. Continue HD as instructed". - During an interview on 7/16/25 at 11:15 a.m., P#2 stated: I kept telling the nurse that I was being pulled too hard. I was cramping, and the staff did nothing. I made them take me off the dialysis machine (on 7/1/25). The doctor only cared about cookies. I was so sick when I got home that day-my heart was racing, and I told them that. They treat us like cattle-get us in and get us out. I can't remember the last time anyone sat down and talked to me about adjusting my dry weight or helping me understand the medications I'm taking. P#3: - On 6/17/25, P#3's pre-treatment weight was 81 kg. P#3's EDW was 78 kg. P#3's prescribed treatment time was 3 hours and 30 minutes, but the patient only dialyzed for 2 hours and 54 minutes. UFR was 14.18 mL/kg/hr, exceeding the recommended safe limit of 13 mL/kg/hr. P#3's post dialysis weight was 77.8 kg, which was slightly below the prescribed EDW. - On 6/19/25, P#3's UFR was 17 mL/kg/hr. Pre-hemodialysis treatment BP was 127/78 mmHg and post-treatment BP was elevated at 162/112 mmHg, and post-treatment weight was 78 kg. During an interview on 7/16/25 at 12:00 p.m., P#3 stated: "On 6/19/25, I made them take me off the dialysis machine because I started feeling bad, and I knew my blood pressure would go up These dumb people didn't know what to do. I was angry because I asked them to give me some fluid, and they just turned my UF off. On 6/16/25, they pulled me below my dry weight, and I was tired and sick all day. The doctor is a joke-if you don't take his cookies, he won't talk to you . He'll walk past you like he didn't even see you. Some of the techs (patient care technicians) are really good. They're the ones who actually go get what I need from the doctors and nurses". - On 7/3/25 the Nurse Practitiner documented: Patient is stable and without complaints. Prescription, Vitals, and labs have been reviewed. Continue HD as instructed. (The same exact wording as above for the other two patients). During an interview with the Facility Administrator on 7/16/25 at 9:44a.m., the Facility Administrator stated that she was a Deititian by profession, and any clinical issues must be addressed by Registered Nurse (RN AA) because she was adopted by the Governing Body on 4/25/25 as the Clinicical Coordinator and Nurse in Charge of Nursing Services. During an interview on 7/16/25 at 1:00 p.m., RN AA, (who was listed in the Governing Body meeting minutes as the nurse in charge of nursing services), stated: I work part-time. I am not the nurse in charge of nursing services. No one asked me, and I did not accept that responsibility. A review of policy #02.103, dated 10/20/20, titled, "Nursing Assessment Before, During, and after Hemodialysis", stated: Before beginning hemodialysis each patient should be evaluated by a registered nurse for the following data and sign and symptoms which, if abnormal, SHOULD be document and may need to be REPORTED to the patient's nephrologist as needed. A review of policy # 02.419, dated 5/22/22, titled " Utrafiltration (UF) Rate Verification" states: -The UF rate entered into the dialysis machine (in ml/hr) must be manually verified by the clinical team prior to the start of each treatment. -UF rate and removal accuracy must also be re-verified during every routine blood pressure and machine safety check throughout the treatment session.
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 patient and staff interviews, a review of facility records, and a review of the facility's Policies and Procedures (P&P), it was determined that the Facility Administrator failed to ensure that patient (P) #1, was treated with respect and dignity, and was provided with support and resolution regarding P#1's concerns and complaints/grievances. Additionally, it was determined that the Facility Administrator and the Medical Director failed to ensure appropriate assessment and follow-up was conducted regarding P#1's repeated reports of adverse medication reactions related to Mircera (a medication used to treat anemia caused by chronic kidney disease [CKD], by stimulating red blood cell [RBC] production). The Facility Administrator and the Registered Nurse (RN AA), identified as responsible for Clinical Coordination failed to follow the facility's established P & P regarding patient complaints and grievances. This lack of action deprived the patient of her right to be heard and to receive timely resolution of her concerns, which could negatively affect the health and safety of P#1 and the other 60 patients who were receiving hemodialysis services at this facility. Findings include: During a telephonic interview with P#1 on 7/15/25 at 5:00 p.m., P#1 stated that on 7/10/25, she was informed by the Facility Administrator that the facility would be discontinuing the use of Epogen (also a medication used to treat anemia caused by CKD, by stimulating RBC production) and will be using Mircera instead. P#1 expressed concern, stating that Mircera had caused blisters on both of her lower legs (while on Mircera), so she refused to resume treatment with Mircera. P#1 also added that since February 2025, she had spoken to the Medical Director (P#1's primary Nephrologist), regarding the blisters on her legs, but the Medical Director did not respond when she spoke to the Medical Director about it and did not examine/assess her legs. P#1 also stated that she told the Nurse Practitioner (NP AA) during weekly rounds about the blisters on her legs but NP AA did not examine her legs either. P#1 further stated that she requested the Facility Administrator to file a grievance on her behalf. P#1 further explained that when her medication was changed from Mircera to Epogen, the blisters on her legs dried up and improved. So when the Facility Administrator informed P#1 on 7/10/25 that Epogen will be discontinued and Mircera was to be resumed, P#1 was very concerned that the blisters on her lower legs will get worse again. - A review of P#1's medical records revealed the following: P#1 was admitted to this facility on 7/9/24. An order for Mircera 225 mcg (micrograms) was to be administered to P#1 via intravenous push during dialysis treatment every 14 days (on Tuesdays), and was initiated on August 20, 2024. Mircera was discontinued on February 27, 2025, when P#1 refused Mircera due to complaints of blisters on her lower legs. P#1's hemoglobin count on 5/16/25 was 6.8 g/dL (grams per deciLiter), while the hemoglobin's acceptable range was between 10-12 g/dL for adults with End Stage Renal Disease (ESRD). P#1 was then started on Epogen (also for the treatment of anemia) 5,000 units three times per week on 5/6/25 and was currently being used as P#1's anemia management medication. During a review of the Complaint and Grievance Logs between January 2025 and July 2025, there were no documented complaint/grievances regarding P#1 or in behalf of P#1's complaints of blisters, by the Facility Administrator. During an interview with the Facility Administrator on 7/16/25 at 9:44 a.m., the following information was disclosed: The Facility Administrator stated that on 7/3/25, she received a call from the corporate office informing her that the company would be discontinuing the use of Epogen. On 7/10/25, she communicated this decision to P#1 and informed her that she would need to resume treatment with Mircera. According to the Facility Administrator, the patient expressed concern, stating that Mircera had previously caused blistering on her legs and that her condition had improved since switching to Epogen. P#1 expressed her concern and wished to file a complaint because she believed that returning to Mircera would again cause the blistering on her lower legs. When asked whether the complaint had been officially documented, the Facility Administrator stated that instead of recording it in the designated Complaint and Grievance Log, she wrote it on a piece of paper and left it on her desk since the Social Worker (SW), who was responsible for managing patient complaints, had been off work for several days at the time. When asked if the Medical Director had been informed of the corporate's decision to discontinue Epogen, the Facility Administrator stated that she had not spoken to the Medical Director about it. Regarding P#1's prior complaints about Mircera and the development of blisters, the Facility Administrator recalled that in February 2025, P#1 had voluntarily discontinued some of her anemia-related medications, citing the development of blisters on the lower parts of both legs. When asked if she had personally examined the patient's legs to verify the blisters, the Facility Administrator explained that she was a Registered Dietitian (RD) by profession and currently served in a dual role as both Facility Administrator and RD at the facility. She stated that the Clinical Coordinator was responsible for assessing patients for dialysis-related issues. When asked whether the Interdisciplinary Team (IDT) was aware of P#1's concerns, she responded that this question should be directed to the Clinical Coordinator (will be referred to as Registered Nurse (RN AA). During an interview with the Medical Director on 7/16/25 at 10:30 a.m., he stated that he was not aware corporate had made the decision to discontinue the purchase of Epogen. He added, however, that if necessary, he had the authority to override corporate decisions related to medications. When asked if he was aware that P#1 had complained about blistering on her legs, which she believed was caused by the use of Mircera, the Medical Director responded that P#1 was non-compliant, frequently refused dialysis treatments and medications, and had a history of signing out of the hospital against medical advice. When asked whether he (Medical Director), had assessed P#1's legs during his monthly rounds, whether P#1's concerns were discussed during Interdisciplinary Team (IDT) meetings following discontinuation of P#1's anemia medications in February 2025, and whether he had met with P#1 to address her concerns, the Medical Director stated that some patients prefer not to be awakened during rounds and he believed P#1 was one of them. He also added that a Nurse Practitioner made rounds at the facility three times a week to assist with patient care needs and assessments. - During an interview with RN AA on 7/16/25 at 11:30 a.m., she stated that she was not the Clinical Coordinator at this facility. She explained that she worked part-time only, on Mondays, Wednesdays, and Fridays (MWF), while P#1's scheduled dialysis treatments were on Tuesdays, Thursdays, and Saturdays (TTS). RN AA stated that she was never asked to take on the Clinical Coordinator role, never applied for the position, and was not being compensated for performing any responsibilities associated with it. She further stated that she recently saw her name listed on a form at the facility indicating she had been designated as the Clinical Coordinator. According to RN AA, this occurred after the previous Facility Administrator (who was a RN, resigned, and the position was filled by the current Facility Administrator (who was a RD). She emphasized that someone assigned her the Clinical Coordinator role without her knowledge or consent, and she made it clear that she was not accepting the position. A review of Policy # 04.113, titiled, "Internal Geievance Process", last revised 4/19/23, stated: Procedure for the Submission of Grievances: 1. Step 1: A grievant (person who wishes to file a grievance) should address thier question, complaint, or concern to the Facility Administror. If the grievant does not wish to provide the grievance to the Facility Administrator, they may enter into step 2 and contact the social worker. Timeframes for Reviewing Grievance: 1. The grievant shall recieve a response within 5 business days of the initial grievance being filed acknowledging the recept of the grievance. A review of "Patients Rights" stated: The following PATIENT RIGHTS will be observed by all person affecting care: 1. Quality Care You have the right to : a. Receive high quality healthcare that meets reconized professional goals. b. Be a part of a healthcare team, along with a social worker, nurse, physician, and dietitian 2. Information You have the right to: d. Be informed of any possible side effects of medications you are taking. 3. Individual Treatment You have the right to: a. Be treated with dignity, respect, and consideration. b. Suggest a change in the type of treatment you are receiving. c. Expect your kidney doctor and other members of your healthcare team to listen to you when you suggest changes in your dialysis treatment. 6. Treatment Options You have the right to: f. receive follow up care by dietary, social work, and nursing services.