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 10/31/2024
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)
V0638 QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE
CFR(s): 494.110(b)

The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time.


This STANDARD is not met as evidenced by:
Based on a review of the Fiscal Year 2025 Dialysis Facility Report (QDFR: A report prepared by the Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients), Quality Assessment and Performance Improvement (QAPI) minutes, and staff interview, it was determined that the QAPI Committee failed to track, trend, analyze and develop plans of action to improve and sustain the facility's anemia management and mineral metabolism/bone disorder, for six of six months (April 2024 - September 2024) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of 65 patients who were receiving dialysis services at this facility. Findings include: A review of the FY 2025 Pre-Survey DFR (third quarter 2023), revealed that the facility was above the United States (US) threshold in: 1. Mineral Metabolism and Bone Disorder - (Phosphorus greater than (>) 7.0) - facility was 22 %, whereas US was 12.6 %. The % of patients with Phosphorus >7.0 was 24.6 % in April 2024, 17.5 % in May 2024, 23 % in June 2024, 20.3 % in July 2024, 17.7 % in August 2024, and 25 % in September 2024. 2. Anemia - Hemoglobin (Hgb) (a protein containing iron that facilitates the transport of oxygen in red blood cells)<10.0 facility was 22 %, whereas, US was 16.8 %. The facility was not monitoring the percentage of patients with Hgb less than (<)10.0; the facility was monitoring the percentage of patients with a Hgb of < 9. A review of the facility's QAPI meeting minutes from April 2024 - September 2024 revealed documentary evidence that the interdisciplinary team (IDT) conducted a review of anemia and mineral/bone. However, no changes were made to the action plans to achieve and sustain improvements in anemia.