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 07/23/2025
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)
V0556 POC-COMPLETED/SIGNED BY IDT & PT
CFR(s): 494.90(b)(1)

The patient's plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient's designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided.


This STANDARD is not met as evidenced by:
Based on medical record review, including a review of facility Policy and Procedures (P&P), and staff interview, it was determined that the facility failed to ensure that three of five in-center hemodialysis (ICHD) patients (P) (P#1, P#2, and P#3) sampled, had a patient Plan of Care (POC) that reflected timely, collaborative participation of all members of the Interdisciplinary Team (IDT), including the patient or patient's representative. Failure to facilitate discussion and coordination among IDT members about the information gathered from the patient's comprehensive interdisciplinary assessment in a timely manner could result in delayed development/implementation of the patient's POC and delayed achievement of the desired goals. This deficient practice had the potential to negatively affect the health and safety of P#1, P#2, and P#3 and the other seven ICHD patients who were under the care of this facility. Findings Include: During a review of P#1's, P#2's and P#3's medical records, the following was revealed: - P#1 was admitted on 12/21/24. The Annual Care Plan was dated 3/21/25. The Social Worker's (SW's) signature was dated 3/21/25. The Registered Nurse's (RN's) signature was dated 4/14/25. The Registered Dietician's (RD's) signature was dated 7/21/25. The nephrologist's signature was on 7/21/25. P#1's or his representative's signature was missing. - P#2 was admitted on 4/1/21. The Annual Care Plan was dated 3/3/25. The SW's signature was dated 3/3/25. The RN's signature was dated 4/14/25. The RD's signature was dated 7/21/25. The nephrologist's signature was dated 7/21/25. P#2's or her representative's signature was missing. - P#3 was admitted on 4/1/21. The Annual Care Plan was dated 2/28/25. The SW's signature was dated 2/28/25. The RN's signature was dated 4/7/25. The RD's signature was dated 7/21/25. The nephrologist's signature was dated 7/21/25. P#3's or his representative's signature was missing. - P#1, P#2, and P#3 were diagnosed with End Stage Renal Disease (ESRD) and were receiving hemodialysis treatment three times per week. There was no documentary evidence that all three patients or their representatives were included in the development nor discussion of their Annual Care Plan, as required. Though the IDT provided signatures, their uncoordinated timing could have led to missed interventions due to gaps in communication for issues like poor nutrition status, fluid overload, psychosocial concerns, medication management affecting treatment outcomes and patient adherence. A review of facility Policy: (no number), titled, "Monthly/ Long term Careplans", (no effective/revision dates), stated: 3. The careplans will be reviewed with the patient and the patient will sign the careplan after review. A review of facility Policy: (no number), titled, "Plan of Care", (no effective/revision dates), stated: 2. Team Involvement: The interdisciplinary team may include the patient's nephrologist, nurse, dietician, social worker, and the patient or their representative. 3. Updates may be documented separately by discipline to allow for: 1. Clinical accuracy 2. Real- time documentation 3. IDT scheduling flexibility Final review and acknowledgement must occur within 30 days of the earliest entry triggering the update. -During the exit interview on 7/23/25 at 9:00 a.m., the Director of Operations acknowledged these findings.