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 852575 (X3) Date Survey Completed 05/25/2022
Name of Provider or Supplier Cc&D Services Street Address, City, State 5040 Snapfinger Woods Dr, Ste 108, Decatur, 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)
V0122 IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL
CFR(s): 494.30(a)(4)(ii)

[The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment.


This STANDARD is not met as evidenced by:
Based on observations, staff interview, and a review of Centers for Disease Control and Prevention (CDC) guidelines, it was determined that the facility failed to ensure that three of three Patient Care Technicians (PCT AA, PCT BB and PCT CC), and one of one Registered Nurse (RN AA), who were present during these observations, immediately and thoroughly cleaned and disinfected blood-contaminated surfaces between patient use. This failure could lead to the transmission of dangerous pathogens through cross contamination. This deficient practice had the potential to negatively affect the health and safety of 15 of 15 Patients (P#1 - P#15), who were undergoing hemodialysis (HD) treatment at the time of this observation. The facility had a total census of 34 in-center hemodialysis patients. Findings include: During observation in the patients' treatment room on 5/25/22 between 12:05 p.m. and 1:40 p.m., the following was revealed: - There were five dried blood stains (thin and light pinkish-red colored) measuring approximately 2 cm in diameter on the floor between Stations (S) 6 and 7. - There were also five dried blood stains (thin and light pinkish-red colored), that appeared splattered (different shapes and sizes) measuring approximately 1 cm - 2 cm in diameter on the floor next to S5. According to CDC guidelines, failure in environmental cleaning and disinfection have led to transmission of bloodborne pathogens (e.g., Hepatitis B virus) and other infections from one patient to another in hemodialysis units. Correct cleaning and disinfection of environmental surfaces (including floors, patient chair or bed surfaces, dialysis equipment surfaces, adjacent tables and work surfaces, etc., especially with blood splatters) must be performed between patient uses to prevent transmission of dangerous pathogens. The Facility Administrator (in training) was present during this observation and acknowledged the presence of these blood stains. The Outgoing Facility Administrator was notified of these observations on 5/25/22 at 4:17 p.m. and she stated that the blood stains should be cleaned immediately. A review of facility personnel education and audit records pertaining to Bloodborne Pathogens and Infection Control was dated 1/7/19.