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)
V0500 CFC-PATIENT ASSESSMENT
CFR(s): 494.80



This CONDITION is not met as evidenced by:
Based on a review of facility records and staff interviews, it was determined that the facility failed to ensure that comprehensive assessments and re-assessments were completed by the entire Interdisciplinary Team (IDT) for four of four Peritoneal Dialysis (PD) patients (P#1 - P#4) sampled, and one of one Home Hemodialysis (HHD) patient (P#5) sampled, . This deficient practice had the potential to negatively affect the health and safety of all 16 Home Peritoneal Dialysis (PD) patients (P#1-P#4, P#6-P#17) and one Home Hemodialysis (HHD) patient (P#5), who were under the care of this facility. Findings include: 1. Cross reference V 501 - Failure of the facility to ensure that initial comprehensive assessments of patients were completed by the entire IDT. 2. Cross reference V 516 - Failure of the facility to complete an initial comprehensive assessment within 30 days of patient's (P#1's) admission or/ after 13 dialysis treatments.