| 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) |
| V0765 | GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED CFR(s): 494.180(e) The facility's internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient's designated representative will be informed of steps taken to resolve the grievance. This STANDARD is not met as evidenced by: Based on a review of facility records and patient and staff interview, it was determined that the facility failed to ensure that Patient's(P#7's) complaint and grievance was followed through. This failure had the potential to negatively affect the health and safety of P#7 and the other 33 patients who dialyzed at this facility. Findings include: A review of the Complaint and Grievance logs revealed a lack of documentation of complaints and grievances. There was one grievance in 2/2020, one in 3/2020 and one in 12/1/21, not related to clinic closures. The only documented grievance for 2022, was dated on 5/3/22 by nursing staff and on 5/4/22, by the Social Worker, both regarding P#7 who was denied make up treatment on 5/3/22 because P#7 was late coming to the facility. According to the grievance records, P#7's scheduled treatment was at 10:00 a.m. and he arrived at approximately 1:55 p.m. P#7 requested the facility staff to call the ambulance for him to be transported to the hospital for dialysis treatment because the facility refused to provide him his make up dialysis treatment due to his late arrival. The staff refused to call the ambulance because according to the report, P#7 did not exhibit signs and symptoms of distress. However, P#7 became irate and hostile, so the Administrative Assistant called the police instead. P#7 called the ambulance himself and was transported to the hospital. According to the Social Worker's documentation, the Plan of Action was for the Social Worker to discuss the issue with all involved and the owners and get back with P#7 on findings, within one week, 5/11/22, but there were no further updates about any discussions with all involved including the owners mentioned. The Social Worker also added that P#7 had requested that his dialysis care be transferred to another facility. There were no other documentation on further updates since the initial Social Worker documentation dated 5/4/22. The Social Worker was not available for interview. During an interview with P#7 on 5/25/22 at approximately 1:00 p.m., he stated that he had to arrange for his own transport on the scheduled make up treatment because it was not his regular transport day and he was late getting to the facility. Although he may not have exhibited signs and symptoms of distress, he still felt sick that's why he wanted the facility to call the ambulance to take him to the hospital for dialysis treatment that day, 5/3/22, since he had not had dialysis treatment since Friday, 4/29/22. The Facility Administrator stated on 5/25/22 at approximately 2:45 p.m., that P#7 had a history of missing treatments and sometimes did not answer the facility's phone calls. |