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 07/13/2022
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 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 Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed (December 2021 - June 2022 ). This deficient practice had the potential to negatively affect the health and safety of seven 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 Hgb <10 g/dL should not exceed 22.3 % for hemodialysis patients. The facility's average Hgb <10 g/dL for fiscal year 2021, was 32 %. A review of the facility's QAPI meeting minutes from December 2021 - May 2022, revealed the following percentage of patients with Hemoglobin <10 g/dL: December 2021 - 82% January 2022 - 62% February 2022 - 62% March 2022 - 71% April 2022 - 56% May 2022- 71% 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. The action plans were not revised and implemented to maximize the number of patients who achieve the goals for anemia. During a discussion with the Charge Nurse on 7/11/22 at approximately 12:30 p.m., she stated that the Medical Director does the Mircera adjustments and keeps the Mircera in his office refrigerator, and only gives the Mircera to staff, to give to patients when he comes to the facility. During a discussion with the Administrative Assistant on 7/13/22 at approximately 12:00 p.m., the Administrative Assistant stated that the Medical Director did the adjustments for Mircera (medication given for low Hgb) which he kept himself and brought them to the facility when it's time to give patients their injections.