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)
V0542 POC-IDT DEVELOPS PLAN OF CARE
CFR(s): 494.90(a)

The interdisciplinary team must develop a plan of care for each patient.


This STANDARD is not met as evidenced by:
Based on the review of medical records (MR), facility policy and interview, it was determined the facility failed to ensure the interdisciplinary team developed the patients' plan of care in 2 of 2 records reviewed for admissions to the facility within the last 30 days and the last 90 days. This affected Patient Identifier's (PI) # 1 and PI # 3 had the potential to negatively affect all patients served by this facility. Findings Include: Facility Policy: Comprehensive Interdisciplinary Assessment and Plan of Care Published: 04/24/2019 Version: 5 ...The Comprehensive Interdisciplinary Assessment (CIA) and Plan of Care (POC) must be developed and implemented by an interdisciplinary team (IDT) consisting of at a minimum, the patient or patient's designee (if patient desires), a registered nurse, the patient's attending physician (and physician extender where allowed by State regulations), qualified social worker and qualified registered dietitian. The CIA and POC and for New Patients must be completed electronically in the patient's MR. The POC must be signed at the time of the IDT meeting for those attending in person or if remotely attending within 30 days of the IDT meeting... CIA and POC for New Patients to Dialysis ...Implementation of monthly or annual updates of the POC must be performed within 25 days of completion... A follow up CIA must occur within 90 days. The POC should be adjusted as appropriate and implemented within 15 days of reassessment. 1. PI # 1 was admitted to the facility 7/24/21 with diagnoses including End Stage Renal Disease (ESRD). MR review revealed the IDT POC Meeting date was 8/26/21. There was no reason for the meeting documented, no list of attendees and no signature of any IDT members. An interview was conducted on 9/16/21 at 9:02 AM with Employee Identifier (EI) # 1, Clinic Manager, who confirmed there was no documentation of the IDT team members who attended the 8/26/21 New Patient POC meeting and no date the POC was approved/implemented by the IDT. 2. PI # 3 was admitted to the facility 6/3/21 with diagnoses including ESRD. MR review revealed the IDT POC Meeting date was 8/26/21. There was no reason for the meeting documented, no list of attendees and no signature of any IDT members. An interview was conducted on 9/16/21 at 9:42 AM with EI # 1, who confirmed there was no documentation of the IDT team members who attended the 8/26/21 POC 90 Day Follow up meeting and no date the POC was approved/implemented by the IDT.