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 852556 (X3) Date Survey Completed 07/11/2019
Name of Provider or Supplier Thomas County Home Training Street Address, City, State 708 South Broad Street, Thomasville, 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)
V0628 QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS
CFR(s): 494.110(a)(2)

The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves.


This STANDARD is not met as evidenced by:
Based on a review of facility records, review of the fiscal year (FY) 2019 Dialysis Facility Report [DFR: A report prepared for this facility per Centers for Medicare and Medicaid Services (CMS)], and staff interview, it was determined that the facility failed to analyze the causes of hospitalizations and infections of all patients, and develop action plans in six of six months (January 2019 - June 2019) of Quality Assurance Performance Improvement (QAPI) meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of all 77 home peritoneal dialysis patients and 17 home hemodialysis patients who were receiving home services at this facility. Findings include: A review of the hospitalization and infection records on 7/10/19 between 10:50 a.m. and 11:04 a.m. revealed 39 total hospitalizations and 18 total infections, from January 2019 to June 2019. A review of the facility's DFR for FY 2019 showed hospitalization with septicemia was 16.2%. The U.S. average was 11.2%. A review of the QAPI meeting minutes from January 2019 to June 2019 revealed that the facility had no documentation that hospitalizations and infection episodes were discussed, reviewed, evaluated, and analyzed to ensure that clinical outcomes were met. The Group Facility Administrator, Facility Administrator and Clinical Service Specialist were informed of the above findings on 7/11/19 at 1:30 p.m. The Facility Administrator stated on 7/11/19 at 1:30 p.m., that hospitalizations and infections data were not analyzed in their QAPI meetings.