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 852551 (X3) Date Survey Completed 01/15/2025
Name of Provider or Supplier Duluth Dialysis Street Address, City, State 3170 Peachtree Ind Blvd, Ste 100, Duluth, 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)
V0175 CFC-WATER & DIALYSATE QUALITY
CFR(s): 494.40



This CONDITION is not met as evidenced by:
Based on observation, staff interviews, a review of the manufacturer's directions for use (DFU) and a review of the facility's Policy and Procedures (P&P), it was determined that the facility failed to ensure that there was a safe environment for all patients as evidenced by failure of three of three Patient Care Technicians (PCT AA, PCT BB and PCT CC) observed, verified the hemodialysis machine's dialysate pH (acidity), according to the manufacturer's DFU and facility P&P. This failure had the potential to negatively affect the health and safety of 10 of 10 patients seated at Station (S) 1, S2, S3, S6, S7, S8, S9, S11, S12, and S15, who were undergoing hemodialysis treatment at the time of this observation. Complications as minor as nausea and fatigue or as severe as metabolic acidosis (decrease in pH that could cause rapid breathing, confusion, dizziness, shortness of breath, chest pain) could result if dialysate composition is incorrect. The facility in-center hemodialysis census was 32. Findings were: Cross Reference: V 250 - Failure of the facility to ensure that three of three Patient Care Technicians (PCT AA, PCT BB and PCT CC) observed, verified the machine's dialysate pH, according to the manufacturer's Directions For Use (DFU) and facility P&P.