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 852569 (X3) Date Survey Completed 06/23/2023
Name of Provider or Supplier Dialysis Center Of Athens Street Address, City, State 210 Hawthorne Park, Athens, 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 Quarterly Update of the Fiscal Year 2023 Dialysis Facility Report (DFR: 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), a review of facility records, and staff interview, it was determined that the Quality Assessment and Performance Improvement (QAPI) Committee failed to track, trend, analyze, and develop plans of action to improve and sustain the facility's Dialysis Adequacy, Mineral Metabolism, Influenza Vaccination, and Transplant status for five of five months (available records at the time of this review - December 2022 to April 2023) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of 13 in-center hemodialysis (ICHD) patients, who were under the care of this facility. Findings include: A review of the Quarterly Update of the Fiscal Year 2023 DFR revealed the following facility report (specifically Quarter (Q)1, Q2 and Q3 of 2022): 1. Dialysis Adequacy - 0.0 but 100% missing or out of range 2. Mineral Metabolism (Phosphorus and Uncorrected Calcium) - 0.0 but 100% missing or out of range. 3. Influenza Vaccination - left blank -- US Threshold was 78.9% 3. Transplantation - 9.1% -- US Threshold was 17.7% The QDFR 2023 stated: "Missing values ('.') indicate there were too few patients to yield reliable results. A blank value indicates the measure was not calculated and therefore not reported for any facility". In comparison, a review of the facility's last five months available (that were available) of QAPI meeting minutes from December 2022 to April 2023, revealed the following outcomes that were greater than (>) the US threshold. ICHD patients: 1. Kt/V (a number used to quantify hemodialysis treatment adequacy) less than (<) 1.2 for ICHD ranged from 15% - 38%. Whereas, US threshold was 1.5%. 2. Mineral Metabolism: Phosphorus (PO4) greater than > 7.0 - ranged from 33.3% - 42.9%. Whereas, US threshold was 16%. Uncorrected Calcium greater than >10.2 - ranged from 5% - 26.4%. Whereas, US threshold was 1.2%. 3. Influenza Vaccination - 3 patients out of 13 were vaccinated (23%). Whereas, US threshold was 78.9% 4. Transplant - 7.69% (1 patient) on active waitlist. There were no new changes since December, 2022. The Registered Dietitian stated on 6/22/23 at approximately 1:30 p.m., that patients were educated about their PO4 and were prescribed Calcium Acetate, but most are noncompliant. During a discussion with the Facility Administrator on 6/23/23 at 3:30 p.m., she stated that the reported data in Crowne Web may have been entered incorrectly, but acknowledged the need to improve adequacy, mineral metabolism, influenza vaccination and transplantation as reflected in their monthly QAPI meeting minutes/report.