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)
V0632 QAPI-INDICATOR-ANEMIA MANAGEMENT
CFR(s): 494.110(a)(2)(iv)

The program must include, but not be limited to, the following: (iv) Anemia management.


This STANDARD is not met as evidenced by:
Based on a review of facility records and staff interviews, it was determined that the facility failed to develop and consistently implement plans of action to improve the effectiveness of the facility's management of patients with Hemoglobin (Hgb - Protein in red blood cells that carries oxygen throughout the body) less than (<) 10 g/dL, for six of six months of the facility's Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed (November 2020 - April 2021). This deficient practice had the potential to negatively affect the health and safety of all 10 patients who were under the care of this facility. Findings include: A review of the Dialysis Facility Report (DFR): A report prepared by the centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients, revealed that the average hemoglobin less than 10 g/dL should not exceed 22.3 % for hemodialysis patients. The facility's average DFR report for fiscal year (FY) 2021 was 32 %. The six months of QAPI monthly report of Hgb <10 g/dL percentages that was audited far exceeded the US average hemoglobin. A review of the facility's QAPI meeting minutes from November 2020 - April 2021, revealed the following percentage of patients with Hemoglobin <10 g/dL: November 2020 - 57% December 2020 - 57% January 2021 - 57% February 2021 - 75% March 2021 - 56% April 2021 - 56% There was documentation of the same root causes and action plans every month, however, there was no documentation that the effectiveness of the action plans were evaluated to ensure improvement in the patients' anemia status. During a discussion with the Administrative Assistant and the Director of Nursing on 6/8/21 at 2:00 p.m., the Administrative Assistant stated and confirmed by the Director of Nursing, that the Medical Director decided when to give Mircera Injections (medication to treat Anemia of patients with Kidney Failure), which he kept himself and brought them to the facility when it's time to give patients their injections.