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 012500 (X3) Date Survey Completed 09/16/2021
Name of Provider or Supplier Fmc Capitol City Street Address, City, State 255 South Jackson Street, Montgomery, AL
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)
V0540 CFC-PATIENT PLAN OF CARE
CFR(s): 494.90



This CONDITION is not met as evidenced by:
Based on review of medical records (MR), facility policies and interviews, it was determined the facility failed to ensure staff provided care according to facility policies and procedures, physician orders and the patient's Plan of Care (POC) during care delivery. This had the potential to negatively affect all patients who dialyzed at this facility. Refer to: V 542, V 543, V 544, V 545, V 550 and V 551.