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 852554 (X3) Date Survey Completed 02/28/2024
Name of Provider or Supplier Panola Dialysis Street Address, City, State 5360 Snapfinger Woods Dr, Ste 102, Stonecrest, 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)
V0000 An onsite survey to investigate complaint GA00242726 was initiated at Panola Dialysis on February 27, 2024 and concluded on February 28, 2024. The complaint investigation revealed that the allegation was substantiated and the facility was not in compliance with 42-CFR Part 494.150 - Responsibilities of the Medical Director and 42-CFR Part 494.180 - Governance, for End Stage Renal Disease Facilities. On 2/28/24, a determination was made that a situation in which the facility's noncompliance with 42-CFR Part 494.150 - Responsibilities of the Medical Director, resulted in an Immediate Jeopardy with potential harm to one of one Patient (P) #1, who experienced chest pain while at this facility. The Facility Administrator was informed of the Immediate Jeopardy finding on 2/28/24 at 9:00 a.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/6/23 at 9:30 a.m. The Immediate Jeopardy was abated on 2/28/24 at 4:00 p.m. upon completion of the following: An in-service was conducted on 2/28/24 by the Facility Administrator and the Director of Clinical Services on Policy and Procedure: 1-10-01 titled, "Medical Emergency" and Policy: 1-03-08 titled, "Pre, Intra, Post Treatment Data Collection, Monitoring and Nursing Assessment", with 100% of clinical staff in attendance. A Governing Body Meeting was held on 2/28/24. However, the Conditions remained out of compliance. The following standard level deficiency was also cited which resulted from the facility's noncompliance related to the survey: