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 852542 (X3) Date Survey Completed 05/18/2021
Name of Provider or Supplier Red Hills Dialysis Street Address, City, State 201 Old Albany Road, Thomasville, 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)
V0403 PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU
CFR(s): 494.60(b)

The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer's recommendations.


This STANDARD is not met as evidenced by:
Based on observation, interview, and policy review, the facility failed to ensure strips used to detect residual disinfectant were not expired for one of two survey days. The failure to discard expired strips had the potential for staff to used strips that may not yield accurate results and could affect 85 in-center patients. Findings include: Observation on 05/17/21 at 1:45 PM revealed one bottle of "Minncare" HD Testing Strips, (used in testing residual Minncare HD (Disinfectant) levels in water was stored in a drawer across from Station 10 with an expiration date of 04/24/21. Observation on 05/17/21 at 1:55 PM revealed two bottles of "Minncare" HD Testing Strips was stored in a drawer at the medication preparation area that were expired 12/11/20 and 09/19/20. During an interview on 05/17/21 at 1:55 PM, the Clinic Coordinator Registered Nurse stated staff should be checking the expiration dates and throw out expired strips. He/she acknowledged if they were expired they could give false results. Review of the facility's policy titled, "Residual Minncare HD Testing Using Residual Minncare HD Acid Test Strips," revised April 2021, revealed the following, "Verify that strips are not expired. The expiration date is printed on the side of the vial."