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)
V0710 CFC-RESPONSIBILITIES OF THE MEDICAL DIRECTOR
CFR(s): 494.150



This CONDITION is not met as evidenced by:
Based on a review of facility records and staff interviews, it was determined that the Medical Director (MD) failed to demonstrate responsibility for the operations of the facility. This failure had the potential to negatively impact the health and safety of all 16 Peritoneal Dialysis patients and one Home Hemodialysis patient who were under the care of this facility. Findings include: Cross Reference the following cited deficiencies: V 501 - Failure of the facility to ensure that the entire Interdisciplinary Team (IDT) completed patients' comprehensive assessments. V 516 - Failure of the facility to ensure that the IDT completed a comprehensive interdisciplinary assessment that was conducted by the entire interdisciplinary team (IDT) within 30 calendar days of admission or after 13 dialysis treatments for one of one sampled new patient (P#1), who was admitted to the facility on 3/23/22. V 542 - Failure of the facility to ensure that the entire IDT completed patients' Plan of Care (POC). V 637 - Failure of the facility 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). V 714 - Failure of the Medical Director to develop, review and approve facility Policies and Procedures for comprehensive IDT assessments and care plans. 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.