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)
V0754 GOV-ADM RESP FOR FISCAL OPERATIONS
CFR(s): 494.180(a)(2)

The governing body or designated person responsible must appoint an individual who serves as the dialysis facility's chief executive officer or administrator who exercises responsibility for the management of the facility and the provision of all dialysis services, including, but not limited to- (2) Fiscal operations;


This STANDARD is not met as evidenced by:
Based on patient and staff interviews and facility record review, it was determined that the facility failed to ensure that patients did not miss their prescribed hemodialysis treatments when the facility had to close due to power outages and water leakage. This failure had the potential to negatively affect the health and safety of 34 of 34 patients (P#1 - P#34) who dialyzed at this facility. Findings include: During patient interviews while patients were undergoing hemodialysis in the treatment room between 12:05 p.m. and 1:40 p.m., the following was revealed: P#2 at Station (S) 5 stated that the facility had closed three times. Once in October 2021 and twice this year. The most recent closure was two weeks ago. She was notified by the Transport personnel (not the facility staff) on the Sunday before her Monday scheduled dialysis treatment about the closure, and was advised by the Transport personnel to go to the hospital if she had health issues. P#4 at S11 stated that the facility had closed a few times due to power outage and water leakage. P#5 at the Isolation Room (not currently used for Hepatitis B+ patients), stated that she was admitted to this facility last January 2022, and had experienced closure of the facility once on a Monday, since she had been here. She was re-scheduled for treatment the following day (Tuesday), but she had to work so she waited to come for her regular dialysis treatment the following Wednesday. P#6 at S26 stated that the facility closed twice and she was notified via phone call regarding the closure on the day of the incident, but it was too late, she had already arrived at the facility. She also stated that she tried to go to the hospital but was told at the hospital that she did not need an emergency treatment. She further stated that the facility staff re-scheduled her to come for treatment the following day (Tuesday). P#7 at S13 stated that he had been a patient at this facility for two years. The clinic had closed twice. He was not notified ahead of time but was re-scheduled the following day, however, he was late the following day due to transportation issues. He further stated that he had to "fix" his own transport because it was not his regular scheduled transportation day and when he arrived at the facility, he was late and was not dialyzed because the last patient ahead of him was almost done with his treatment. A review of facility records revealed that out of 28 scheduled patient treatments on 3/23/22 (Wednesday), only 18 patients dialyzed the following day, 3/24/22 (Thursday). The Facility Administrator stated on 5/25/22 at 2:30 p.m., that there was a water leak in the building (not at the facility), but the whole water system was turned off. When they re-scheduled the patients for treatment the following day, some patients refused to come back for treatment. The Facility Administrator also stated on 5/25/22 at 2:30 p.m., that on 5/2/22, there was a County Power Outage so they couldn't open the facility for patient treatment. The facility re-scheduled patient treatments the following day, 5/3/22. Out of 29 scheduled treatments, only 18 patients dialyzed at the facility. Six patients were "No Shows", two patients were in the hospital, one patient was on vacation, and one patient (P#7), did not have treatment because he came in late. The Facility Administrator further stated on 5/25/22 at 2:30 p.m., that the facility was also closed on 5/16/22 (Monday), due to Power Outage in the building. Patient treatments were re-scheduled the following day, 5/17/22 (Tuesday). Facility record review revealed only 18 patients were dialyzed, two were in the hospital, four patients did not answer the facility's phone call, one missed treatment, one patient was working and one patient refused. The Facility Administrator further stated when asked by this surveyor, that the facility's back up dialysis facility had their own patients to dialyze that day and they re-scheduled their own patients' treatments the following day. A review of the Governing Body (GB) Meeting minutes, with latest date (5/6/22), did not show any documentation about the facility closures and Plans of Action to avoid future closures or improve patients' re-scheduled treatments in an emergency or contingency plan. During an interview with Patient Care Technician (PCT AA) on 5/25/22 at 3:45 p.m., she stated that she has been working at this facility for one year. She confirmed that there was a power outage in the whole building which happened toward the end of the first shift patients. Two of the patients she called did not have an updated phone number so she couldn't reach them. Failure to update patients' contact numbers will result in the facility's inability to communicate with their patients in a timely manner.