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 012508 (X3) Date Survey Completed 12/12/2019
Name of Provider or Supplier Birmingham East Dialysis Street Address, City, State 1105 East Park Drive, Birmingham, 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 2 records of newly admitted patients to the facility. This affected Patient Identifier (PI) # 1, and had the potential to affect all patients dialyzed at this facility. Findings include: Facility Policy: Interdisciplinary Teams (IDT) Patient Assessment and Plan of Care (POC) Policy Number: 1-14-01 Revision Date: October 2019 Purpose: To provide guidance for the development of patient assessment and plan of care for IDT teammates. Policy: ... 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... Modality Change: Within 30 days of change in modality (or 13 treatments)... 1. PI # 1 was admitted to the facility on 9/23/19 with the diagnosis of End Stage Renal Disease (ESRD). Review of the medical record (MR) revealed the Comprehensive Assessments were completed on 12/6/19 by the Registered Nurse, Dietitian, and Social Worker. The new patient POC was scheduled for 12/16/19. In an interview conducted on 12/12/19 at 9:36 AM, Employee Identifier (EI) # 1, Facility Administrator, confirmed the facility failed to complete the new patient POC within 30 days or 13 treatments per policy.