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 852560 (X3) Date Survey Completed 02/22/2024
Name of Provider or Supplier Poplar Dialysis Street Address, City, State 2301 Newnan Crossing Blvd, Ste 180, Newnan, 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 Dialysis Facility Report (DFR) for Fiscal Year (FY) 2024, review of facility records, and staff interview, it was determined that the facility failed to track, measure, and analyze quality indicators that reflected processes of care and operations to improve patient care, on six of six months (July - December 2023) Continuous Quality Improvement (CQI) meeting minutes reviewed. Fimdings were: A review of Facility Health Meetings (FMH - CQI) for July through December 2023 revealed the following: The DFR (a report prepared for by the University of Michigan Kidney Epidemiology and Cost - contracted by Centers for Medicare and Medicaid Services, to provide a comparative summary of treatment patterns and patient outcomes for End Stage Renal Disease patients) were not analyzed. At this facility, the Standard Mortality Ratio (SMR) was 1.24, which was 24% more deaths than expected. Among U.S. facitilties, 84% of facilities had a four-year SMR lower than 1.24. The 2019 - 2022 SMR was 1.06 and 1.03 for the state of Georgia and Network respectively. The mortality rate on the facility dashboard was 1.68%. There was no documentation that the facility reviewed, evaluated, and analyzed trends in the causes of patient's deaths; and the relationship to the care received at the facility. There was no documentation in the FHM minutes that the causes of deaths were reviewed and analyzed to ensure that clinical standards were met . During an interview on 2/21/24 at approximately 2:00 p.m., the Facility Administrator (FA) stated that mortality was discussed during the meetings. However, the cause of mortality related to dialysis treatment was not discussed. A review of Policy: 1-14-06 titled, "Continuous Quality Improvement Program" dated April 2021 showed: 7. The facility will measure, analyze, and tract quality indicators or other aspects of performance. The program must include, but not be limited to, the following: ... - Mortality - review of deaths 8. Continuous monitoring of the above indicators will be reflected in the meeting minutes.