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 06/09/2022
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)
V0000 A Recertification survey was conducted at Dublin Kidney Institute from June 7, 2022 through June 9, 2022. The survey revealed that the facility was not in compliance with 42-CFR Part 494.80 - Patient Assessment, 42-CFR Part 494.90 - Patient Plan of Care, 42 CFR Part 494.150 - Responsibilities of the Medical Director, and 42 CFR Part 494.180 - Governance, for End Stage Renal Disease Facilities. The following standard level deficiencies were also cited which resulted from the facility's noncompliance related to the survey: