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)
V0714 MD RESP-DEVELOP, REVIEW & APPROVE P&P
CFR(s): 494.150(c)(1)

The medical director must- (1) Participate in the development, periodic review and approval of a "patient care policies and procedures manual" for the facility;


This STANDARD is not met as evidenced by:
Based on a review of the facility's policies and procedures (P&P), and staff interview, it was determined that the Medical Director (MD) failed to establish, adopt and annually review facility (P & P) in accordance with acceptable standards of practice to ensure the safety of all 16 Peritoneal Dialysis (PD) patients and one Home Hemodialysis (HHD) patients who were were under the care of this facility. Findings include: A review of the facility's P & P for Comprehensive Interdisciplinary Team (IDT) Assessments and Care Plans, revealed that there were no established and adopted P & P, and there were no documentary evidences of annual reviews of P & P, updates nor revisions. Cross References: 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).