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)
V0637 QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT
CFR(s): 494.110(a)(2)(ix)

The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents.


This STANDARD is not met as evidenced by:
Based on a review of the facility's quality assessment and performance improvement (QAPI) meeting minutes, and staff interview, it was determined that the Interdisciplinary Team (IDT) failed to identify and analyze trends, investigate all infections, develop recommendations, and take remedial actions to minimize the facility's infection rates, specifically Peritonitis (an inflammation of the abdominal membranes, most commonly due to bacterial infection), in seven of seven months (November 2021 - May 2022) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of all 16 Peritoneal Dialysis (PD) patients who were under the care of this facility. Findings include: A review of the facility's QAPI meeting minutes from November 2021 - May 2022 revealed that there was no documentary evidence that trends in Peritonitis infections were evaluated and investigated. - November 2021 - three patients out of 19 PD patients had Peritonitis. - December 2021 - one patient had Peritonitis. - March 2022 - one patient had Peritonitis. - May 2022 - two patients had Peritonitis. During a medical record review of patient (P#2), who was sampled for Peritonitis, it was revealed that P#2 had Peritonitis in March 21 to 25, 2022 and again on May 30 to June 2, 2022. There were no evidences of patient or caregiver re-training/re-education after the Peritonitis infection incidences and there were no home visits nor other evidences of analyzing root causes and interventions to avoid future infections. There was no documentary evidence of a comprehensive Interdisciplinary Team (IDT) assessments/re-assessments and care plans. P#2's initial PD training was completed on 3/6/20 and there were no documentary evidences of re-training nor evaluations. The last recorded home visit was on 11/11/21. Registered Nurse (RN AA) was unable to present any documentation of P#2's re-training, re-evaluation and follow up home visits after P#2's Peritonitis infections. RN AA stated on 6/9/22 at approximately 3:00 pm., that P#2 was transferred to in-center hemodialysis on 6/2/22 after his hospitalization.