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 852538 (X3) Date Survey Completed 10/10/2024
Name of Provider or Supplier Jesse Jewell Dialysis Street Address, City, State 1475 Jesse Jewell Pkwy Ne, Ste 110, Gainesville, GA
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)
V0696 PQ-H20 TREATMENT SYSTEM TECHS TRAINING
CFR(s): 494.140(f)

Technicians who perform monitoring and testing of the water treatment system must complete a training program that has been approved by the medical director and the governing body.


This STANDARD is not met as evidenced by:
Based on a review of personnel records and staff interview, it was determined that the facility failed to ensure that one of one Patient Care Technician (PCT DD), who was responsible for the operation of the water/dialysate system equipment and new to dialysis, completed a training program that was accurate and that was approved by the Medical Director and the Governing Body. Findings were: A review of PCT DD's personnel records revealed the following: - PCT DD was hired on 3/25/24, with no prior PCT experience. - A review of PCT DD's training of the facility's CEC 4012 ICHD (In-center Hemodialysis, sic) Multi-Station Basic Components & Monitoring of Dialysis Quality Water Treatment Systems (Procedural Skills Verification Checklist for Teammates Who Perform Water Monitoring & Testing), showed that each of the procedural skills checklist was dated 1/10/24 with the initials of the PCT Preceptor (PCT PP) under the column, "Demonstration of skills by teammate. Date and Preceptor Initial". Under the column, "Satisfactory Performance of skill by teammate. Date and Initial of RN or Biomed Trainer", each skill was also dated 1/10/24 and initialed by the Registered Nurse Trainer (RN AA). This document was also signed by PCT DD with the same date, 1/10/24. There was no signature of approval by the Medical Director. - A review of PCT DD's training for "PCT Procedural Skills Verification Checklist" showed that PCT DD's initiation of the skills checklist started on 3/25/24 and ended on 5/13/24. However, the "PCT Procedural Skills Verification Checklist Completion", was dated 4/30/24 and signed by PCT DD, RN Trainer (RN AA), and by the Facility Administrator. There was no signature of approval by the Medical Director. - The Facility Administrator acknowledged and confirmed this discrepancy when notified by this surveyor on 10/9/24 at approximately 11:00 a.m.