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 012501 (X3) Date Survey Completed 03/14/2019
Name of Provider or Supplier Gadsden Dialysis Street Address, City, State 409 South First Street, Gadsden, 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)
V0516 PA-FREQUENCY-INITIAL-30 DAYS/13 TX
CFR(s): 494.80(b)(1)

An initial comprehensive assessment must be conducted on all new patients (that is, all admissions to a dialysis facility), within the latter of 30 calendar days or 13 hemodialysis sessions beginning with the first dialysis session.


This STANDARD is not met as evidenced by:
Based on the review of the facility policy, medical records (MR), and interviews with the staff, it was determined the facility failed to ensure the patients Initial Plan of Care was completed within 30 calendar days or 13 treatments of admission for 1 of 1 newly admitted patient to the facility. This affected Patient Identifier (PI) # 2, and had the potential to affect all new patients served by this facility. Findings include: Title: Interdisciplinary Teams (IDT) Patient Assessment and Plan of Care (POC) Policy number: 1-14-01 Revise date: October 2018 Purpose: To provide guidance for the development of patient assessment and plan of care for IDT (Interdisciplinary Team) teammates. Policy: Assessment: ... A comprehensive assessment will be conducted on all new patients within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines... ... Plan of Care: 8. The facility's interdisciplinary team will develop and implement a written, individualized comprehensive plan of care that specifies the services necessary to address the patient's needs... 10. An initial Plan of Care, based on the findings from the comprehensive assessment, will be completed on all patients new to dialysis within 30 calendar days (or 13 outpatient dialysis sessions for hemodialysis) beginning with the first outpatient dialysis treatment or per state guidelines... 14. The patient's plan of car will be completed by the facility's interdisciplinary team, including patient or personal representative and be signed by the team members including the patient or the patient's personal representative..." ****** 1. PI # 2 was admitted to dialysis on 12/7/18 with a primary diagnosis of End Stage Renal Disease. Review of the Initial Interdisciplinary Care Plan meeting revealed it was dated 12/3/19 (future date) and was signed by the Physician, Nurse, Dietitian, Social Worker, and PI # 2. There was no way to determine if PI # 2's POC was completed within 30 calendar days or 13 outpatient dialysis treatments because of the 12/3/19 future date documented. The IDT failed to complete PI # 2's POC per facility policy. An interview was conducted on 3/14/19 at 10:04 AM with Employee Identifier # 1, Group Facility Administrator, who confirmed the above findings.