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 852553 (X3) Date Survey Completed 06/13/2019
Name of Provider or Supplier Flint River Dialysis Street Address, City, State 700 Gordon Avenue, Bainbridge, 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)
V0750 CFC-GOVERNANCE
CFR(s): 494.180



This CONDITION is not met as evidenced by:
Based on observation, staff interviews, and a review of facility policy and procedure, it was determined that the Governing Body failed to ensure that the dialysate (fluid used on the other side of the membrane to remove impurities) used for dialysis was safe prior to the start of dialysis treatment. On 6/12/19, a determination was made that a situation in which the facility's noncompliance with 42 CFR Part 494.40(a) -Dialys Proport-Monitor pH/Conductivity, resulted in an Immediate Jeopardy with potential harm to the health and safety of one of 15 patients (P) (P#10), who were receiving dialysis treatment at the time of observation. The Facility Administrator and Clinical Service Specialist were informed of the immediate jeopardy finding on 6/12/19 at 10:55 a..m. The noncompliance related to the immediate jeopardy was identified to have existed on 6/12/19 at 10:55 a.m. The immediate jeopardy was removed on 6/12/19 at 3:15 p.m., when the facilty implemented a Credible Allegation of Compliance related to the immediate jeopardy. Findings include: Cross Reference: V 250 - Failure of the facility to test the pH (acidity) and conductivity (ability of the dialysate to conduct electricity) of dialysate prior to the start of dialysis treatment. .