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 03/25/2021
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)
V0681 PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY
CFR(s): 494.140

All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility's staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility's staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions.


This STANDARD is not met as evidenced by:
Based on a review of personnel records, facility's policies and procedures (P & P), and staff interviews, it was determined that the facility failed to ensure that one of one Home Hemodialysis (HHD) Registered Nurse (RN AA), completed training in Home Hemodialysis and a current skills checks to evaluate her ability to perform the duties that was assigned to her. Failure of RN AA to complete the HHD training, and to demonstrate competency had the likelihood to cause harm to one of one current HHD patient under the care of this facility, and all future HHD patients admitted to this facility. Findings include: During a review of personnel records, the following was revealed: NOTE: The facility solely used NxStage System One Cycler for their HHD patient (P#5). RN AA, who was also the Facility Administrator, was the only Home Therapy Nurse currently at this facility. RN AA's personnel file titled, "Orientation Skills Checklist HHD RN", dated 4/24/20, showed incomplete skills checked off. There were no initials by both the Learner (RN AA) and the Instructor (RN BB) regarding specific skills, and specific dates in the space provided for "Discussion, Demonstration, Observed, Demonstration with Assistance, and Unassisted" in the following topics, but not limited to: 1. Equipment Procedure 2. Machine Set-up RN AA's orientation training in NxStage titled, "System One Cycler, CAR - 170 / 172, and Ancillary Products Skills Sign Off" User Guide, dated 5/21/20, was incomplete. Specifically, "Skills Needed to Use NxStage Cycler with CAR 170 / 172, and Ancillary Products" was incomplete, and "Skills Needed to Use PureFlow SL", was incomplete. The Instructor's initials, signature, and dates were missing. Both records only showed the Learner's (RN AA's) initials, signature, and dates, and both records were incomplete. On 3/24/21 at 2:00 p.m., RN AA stated that the previous Home Therapy Nurse (RN BB) was training her during RN AA's orientation but was incomplete. RN BB had left the facility's employment, and had not signed RN AA's records. She also stated that she had been unsuccessfull in connecting with an instructor to complete her training, and competency skills check offs. During a telephonic interview with RN BB on 3/24/21 at 2:10 p.m., RN BB stated that she observed RN AA, but RN AA had not done HHD patient care and training on her own. During a telephonic interview with the Medical Director (MD), on 3/25/21 at 12:30 p.m., he stated that RN AA needed to complete her HHD training, and skills check offs as well as, PD competency skills check offs. A review of RN AA's peritoneal dialysis (PD) annual skills competency checks revealed that check off dates for PD competencies was 4/24/20, but was only dated and signed by RN AA. There were no initials, dates, and signature of the Preceptor or Instructor to validate the skills checklist. RN AA was hired on 10/19/19. RN AA stated on 3/23/21, at approximately 1:20 p.m., that she had PD Nurse experience for a year at another dialysis facility. The previous Home Therapy Nurse (RN BB), per documentation, checked her off as experienced PD RN on 10/19/19. RN AA was not able to provide current annual PD skills competency check offs with a Preceptor's or Instructor's initials, signature, nor date.