| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852612 | (X3) Date Survey Completed 06/18/2025 |
| Name of Provider or Supplier Dialysis Care Center Troup County, Llc | Street Address, City, State 25 Patillo Rd, Lagrange, 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 Initial Certification survey was conducted at Dialysis Care Center Troup County, LLC from June 18, 2025 through June 18, 2025. 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 | An Initial Certification survey was conducted at Dialysis Care Center Troup County, LLC from June 18, 2025 through June 18, 2025. 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, a standard level deficiency was cited which resulted from the facility's noncompliance related to the survey: |
| 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 observation, 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 one of one Registered Nurse (RN BB), adhered to the facility's established P & P relative to pre-dialysis assessment of patient (P), (P#1). Failure to perform nursing pre-dialysis assessment (such as determining P#1's fluid status), had the potential to miscalculate fluid removal (incorrectly determining the amount of fluid to be removed during hemodialysis - either removing too much or too little compared to the patient's actual fluid overload status and dry weight) that could negatively affect the health and safety of P#1. The facility's current census was three. Findings include: - During observation in the Patient Treatment Room on 6/18/25 between 9:49 a.m. and 11:00 a.m., the following was revealed: - P#1 entered the Patient Treatment Room at 10:02 a.m., and hemodialysis treatment was initiated at 10:13 a.m. at station (S) 18 by RN AA. This surveyor requested to review P#1's pre-assessment documentation at 10:30 a.m., which was marked completed by RN BB. However, RN BB did not perform a thorough pre-dialysis assessment as mandated prior to initiating hemodialysis treatment even though he documented it as done. -On 6/18/25 at 11:18 a.m., RN AA stated that while she initiated hemodialysis treatment for P#1, RN BB was responsible for performing the pre-assessment and documenting the current findings of P#1. -On 6/18/25 at 11:25 a.m., RN BB acknowledged this observation and stated that he always performed patients' pre-assessments and documented the findings. - A review of the facility's Policy # HDS-IC-PC-300-002, titled, "Patient Assessment Pre-Treatment", with latest revision date of April 23, 2021, stated: V. Policy: A. A patient assessment will be conducted by the nurse and documented on all dialysis patients before initiation of the dialysis treatment. Any State that requires an assessment by the Registered Nurse (RN) during the first hour of treatment the RN will comply with the State rules and regulations. |