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)
V0501 PA-IDT MEMBERS/RESPONSIBILITIES
CFR(s): 494.80

The facility's interdisciplinary team consists of, at a minimum, the patient or the patient's designee (if the patient chooses), a registered nurse, a physician treating the patient for ESRD, a social worker, and a dietitian. The interdisciplinary team is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive assessment must be used to develop the patient's treatment plan and expectations for care.


This STANDARD is not met as evidenced by:
Based on facility record review and staff interviews, it was determined that the facility failed to ensure that four of four Peritoneal Dialysis (PD) patients (P#1 - P#4) sampled, and one of one Home Hemodialysis (HHD) patient (P#5) sampled, had a current comprehensive Interdisciplinary Team (IDT) assessment that was used to develop the patient's treatment plan and expectations for care. This deficient practice had the potential to negatively affect the health and safety of all five patients sampled. The facility census was 16 PD patients and one HHD patient. Findings include: A review of the medical records of P#1 - P#5, revealed the following: - P#1 was admitted to this facility on 3/23/22. There was no documentary evidence that a comprehensive IDT initial assessment was completed. There was an incomplete assessment by the Registered Nurse (RN BB), and Social Worker (SW), with no dates, and no signatures from both disciplines. There was no documentary evidence of the Registered Dietitian's assessment nor of the Nephrologist's assessment. - P#2 was admitted to this facility on 1/15/20. There was no documentary evidence of a comprehensive IDT assessment. It was unknown if or when the last time P#2 had a comprehensive IDT assessment. In addition, P#2 had Peritonitis on 3/21/22 - 3/25/22 and again on 5/30/22 - 6/2/22. There was no documentary evidence of a re-assessment due to a change in P#2's condition. - P#3 was admitted to this facility on 6/10/20. There was no documentary evidence of a comprehensive IDT assessment. It was unknown if or when the last time P#3 had a comprehensive IDT assessment. - P#4 was admitted to this facility on 4/1/20. There was no documentary evidence of a comprehensive IDT assessment. It was unknown if or when the last time P#4 had a comprehensive IDT assessment except for an assessment by the SW, with no date and no SW signature. - P#5 was admitted to this facility on 2/18/19. There was no documentary evidence of a comprehensive IDT assessment. It was unknown if or when the last time P#4 had a comprehensive IDT assessment. A review of facility records revealed that there was no facility Policy and Procedures (P & P) regarding comprehensive IDT Assessments, except for a checklist, with a header, "Medical Record Audit". ... RN Assessment... complete RN assessment completed within 30 days. Assessment updated if treatment modality changes/as needed. Psychosocial/SW assessment - within 30 days of admission. Annually. Assessment updated if treatment modality changes/as needed. Nutrition Assessment - within 30 days of admission. Annually. Assessment updated if treatment modality changes/as needed. There was no mention of an Unstable Assessment Criteria. Registered Nurse (RN AA), also the new Administrator in training and Charge Nurse, stated on 6/9/22 at approximately 4:00 p.m., that she could not find any documentary evidence of the above patients' comprehensive IDT assessments. During a telephonic interview with the Medical Director on 6/10/22 at 9:17 a.m., he stated that whatever needed to be corrected will be corrected.