| 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) |
| V0630 | QAPI-INDICATOR-NUTRITIONAL STATUS CFR(s): 494.110(a)(2)(ii) The program must include, but not be limited to, the following: (ii) Nutritional status. This STANDARD is not met as evidenced by: Based on a review of Fiscal Year 2025 Quarterly Dialysis Facility Report (QDFR: A report prepared by Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients of this facility, as compared to other facilities in the U.S.), facility records, and staff interviews, it was determined that the facility failed to effectively manage patients' nutritional status by identifying root causes and commonalities among patients who did not reach the minimum expected target of albumin (a protein in blood plasma) equal or greater than (>) 4.0 g/dL (grams per deciliter) per "CMS Measures Assessment Tool", in six of six months of Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed (June 2024 - November 2024). The facility also failed to take remedial action or adjust portions of the plan that are not successful, to maximize the number of patients who achieve the goal. Low albumin levels are highly predictive of mortality risk amongst dialysis patients. This facility had 32 in-center hemodialysis (ICHD) patients and 19 Peritoneal Dialysis (PD) patients. Findings include: A review of the facility's QAPI meeting minutes from June 2024 - November 2024, revealed no documentary evidence that the QAPI team conducted analysis of the underlying reasons for the facility's low albumin levels for both ICHD and PD patients. A review of Fiscal Year 2025 QDFR revealed that 61.0% of ICHD patients and 87.0% of PD patients at this facility had albumin levels of < 4 g/dL. The U.S. average was 51.8%. This facility's average albumin of <4 g/dL for the past six months (June 2024 - November 2024) was 68% for ICHD and 88% for PD. A review of this facility's ICHD Albumin report for the last six months, showed the following: - In June 2024, 61% of patients had Albumin levels of <4.0 g/dL. - In July 2024, 60% of patients had Albumin levels of <4.0 g/dL. - In August 2024, 46% of patients had Albumin levels of <4.0 g/dL. - In September 2024, 60% of patients had Albumin levels of <4.0 g/dL. - In October 2024, 64% of patients had Albumin levels of <4.0 g/dL; and - In November 2024, 68% of patients had Albumin levels of <4.0 g/dL. A review of this facility's PD Albumin report from June 2024 - November 2024 revealed the following: - In June 2024, 87% of patients had Albumin levels of <4.0 g/dL. - In July 2024, 88% of patients had Albumin levels of <4.0 g/dL. - In August 2024, 88% of patients had Albumin levels of <4.0 g/dL. - In September 2024, 76% of patients had Albumin levels of <4.0 g/dL. - In October 2024, 76% of patients had Albumin levels of <4.0 g/dL; and - In November 2024, 88% of patients had Albumin levels of <4.0 g/dL. Although the facility data was collected monthly, there was no documented evidence that a root cause analysis was conducted. The plan for the last six months was to educate patients on foods rich in protein. There was a lack of documented evidence that the interdisciplinary team modified or adjust part of the plan nor actively intervene on actionable factors. At 11:24 a.m. on 1/15/25, the Facility Administrator stated that a more thorough investigation will be implemented to identify the underlying cause for both modalities. The Medical Director (MD) acknowledged the above findings on 1/15/25 at 3:30 p.m. |