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)
V0542 POC-IDT DEVELOPS PLAN OF CARE
CFR(s): 494.90(a)

The interdisciplinary team must develop a plan of care for each patient.


This STANDARD is not met as evidenced by:
Based on medical record review and staff interviews, it was determined that the facility failed to ensure that the Interdisciplinary Team (IDT) developed an effective, individualized Plan of Care (POC) 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 the five patients sampled and the other 12 PD patients who were under the care of this facility. 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 an individualized Plan of Care (POC) was developed and completed by the entire IDT. - P#2 was admitted to this facility on 1/15/20. There was no documentary evidence that an individualized Plan of Care (POC) was developed and completed by the entire IDT. 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 and revised POC 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 that an individualized Plan of Care (POC) was developed and completed by the entire IDT. - P#4 was admitted to this facility on 4/1/20. There was no documentary evidence that an individualized Plan of Care (POC) was developed and completed by the entire IDT. - P#5 was admitted to this facility on 2/18/19. There was no documentary evidence that an individualized Plan of Care (POC) was developed and completed by the entire IDT, except for a comment by the Social Worker, but there was no date when the information was entered or developed. A review of facility records revealed that there was no facility Policy and Procedures (P & P) regarding patients' individualized POC based on a comprehensive IDT Assessments, except for a checklist, with a header, "Medical Record Audit". PLAN OF CARE FORM (POC) -Present in medical record. Complete, i.e. signed /dated by: Physician, RN, SW, RD, Patient (Family member/Guardian)... Registered Nurse (RN AA), who was 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' individualized POC. 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.