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)
V0520 PA-FREQUENCY REASSESSMENT-UNSTABLE Q MO
CFR(s): 494.80(d)(2)

In accordance with the standards specified in paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each patient and a revision of the plan of care must be conducted- At least monthly for unstable patients including, but not limited to, patients with the following: (i) Extended or frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis.


This STANDARD is not met as evidenced by:
Based on review of medical records (MR), facility policy, and interview with the staff it was determined the agency failed to ensure the Interdisciplinary Team completed monthly care plans for all unstable patients. This affected patient identifier (PI) # 5, 1 of 3 unstable in-center hemodialysis MRs reviewed and had the potential to negatively affect all in-center hemodialysis patients served by the facility. Findings include: Policy: Interdisciplinary Teams (IDT) Patient Assessment and Plan of Care (POC) Policy Number: 1-14-01 Revision Date: October 2018 "Assessment: 1. The facility's IDT consists of, at a minimum, the patient or the patient's personal representative, a registered nurse, a physician or allied health professional, if allowed by state End Stage Renal Disease (ESRD) licensure regulations, treating the patient for ESRD, a social worker, and a dietitian. 2. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment documenting his/her needs. The comprehensive assessment will be used to develop the patient's treatment plan and expectations for care... 7. A comprehensive re-assessment of each patient and revision in the plan of care will be conducted: ... At least monthly for unstable patients including, but not limited to, patients with the following: Extended or frequent hospitalizations, marked deterioration in health status, significant changes in psychosocial needs, concurrent poor nutritional status, and unmanaged anemia and inadequate dialysis... Plan of Care ... 12. Subsequent interdisciplinary re-assessments should be completed within the 30 days following the initiation of the re-assessments. The Plan of Care following re-assessments must be completed within 15 days of completing the re-assessment. This process would occur monthly for unstable patients and annually for stable patients... 14. The patient's plan of care will be completed by facility's interdisciplinary team, including patient or personal representative..." 1. PI # 5 was admitted to the facility on 5/9/18 with a diagnosis of ESRD. Review of MR on 3/13/19 revealed documentation that PI # 5 was deemed unstable on 9/24/18. Further review of the MR revealed there was no documented unstable POC for 10/2018 and the next POC was completed on 11/7/18. The IDT failed to document an unstable POC monthly per facility's policy. An interview was conducted on 3/14/19 at 10:00 AM with Employee Identifier # 1, Group Facility Administrator, who verified the above findings.