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 852550 (X3) Date Survey Completed 10/29/2019
Name of Provider or Supplier Dublin Kidney Institute Street Address, City, State 207 Industrial Blvd Ste 2, Dublin, 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)
V0110 CFC-INFECTION CONTROL
CFR(s): 494.30



This CONDITION is not met as evidenced by:
Based on observation and staff interview, it was determined that the facility failed to ensure that three of three Patient Care Staff (RN AA, RN BB, and LPN AA) observed, employed infection control techniques to prevent transmission of infectious pathogens in the home hemodialysis unit at a Skilled Nursing Facility (SNF). This deficient practice resulted in an immediate jeopardy (IJ) with harm to one patient (P#1) and a potential harm to the health and safety of the other two patients (P#2 and P#3), who were under the care of this facility and who dialyzed at the SNF. The Facility Administrator was informed of the IJ finding on 10/29/19 at 10:05 a.m. The immediate jeopardy was abated during the survey on 10/29/19 at 4:30 p.m., when the facility implemented a Credible Allegation of Compliance related to the Immediate Jeopardy. Findings were: Cross reference the following cited deficiencies: V 113 - Failure of the staff to perform hand hygiene when going from a "dirty" area or task; to a "clean" area or task and to wear and change gloves as appropriate. V 115 - Failure of the staff to wear personal protective equipment (PPE) when appropriate. V 117 - Failure of the staff to separate "clean" and "dirty" areas/items to prevent cross contamination. V 582 - Failure of the facility to provide sufficient training, supervision, and oversight to the staff who administered home hemodialyis treatments at the SNF.