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 852539 (X3) Date Survey Completed 06/10/2021
Name of Provider or Supplier Eatonton Kidney Center Street Address, City, State 103 N Washington Avenue, Eatonton, 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)
V0519 PA-FREQUENCY REASSESSMENT-STABLE 1X/YR
CFR(s): 494.80(d)(1)

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- (1) At least annually for stable patients;


This STANDARD is not met as evidenced by:
Based on a review of patients' medical records and staff interview, it was determined that the facility failed to ensure that four of five sampled patients (P#1, P#3, P#4, and P#5) received an annual comprehensive reassessment from each member of the interdisciplinary team (IDT), prior to the development of the patients' plan of care. This failure had the potential to negatively affect the health and safety of all 10 patients who were under the care of this facility. Findings include: - P#1 was admitted to this facility on 3/18/20. There was no documented evidence that the patient had an initial comprehensive interdisciplinary (IDT) assessment, 90-day IDT reassessment, and an annual IDT reassessment and Plan of Care (POC). The Administrative Assistant stated on 6/9/21 at approximately 11:30 a.m., that P#1 was very non-compliant and had frequent absences such as "no shows" and hospitalizations although the IDT had repeatedly encouraged P#1 to come for his dialysis treatments. There was no documented evidence that the IDT evaluated and developed an unstable comprehensive assessment/reassessment and POC. - P#3 was admitted to this facility on 6/11/18. The last annual comprehensive IDT reassessment and POC was dated 2/21/20. - P#4 was admitted to this facility on 8/9/19. The last annual comprehensive IDT reassessment and POC was dated 2/21/20. - P#5 was admitted to this facility on 5/2/18. The only available IDT assessment and POC was from a previous facility where P#5 transferred from, dated 3/29/18. The Kidney Disease Quality of Life (KDQOL) was completed by the Social Worker on 7/27/20. There was no documentary evidence of an annual comprehensive reassessment and POC that was done by the IDT. The Assistant Administrator was notified of the above findings on 6/10/21 at 4:30 p.m. and did not provide evidence of comprehensive reassessments that were used for the revision of the above listed patients' plans of care. The Director of Nursing was not available for interview.