| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852575 | (X3) Date Survey Completed 07/12/2022 |
| 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) |
| V0625 | CFC-QAPI CFR(s): 494.110 This CONDITION is not met as evidenced by: Based on a review of the Quarterly Update of the Fiscal Year 2022 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 interviews, it was determined that the Quality Assessment and Performance Improvement (QAPI) Committee failed to track, trend, analyze, and develop plans of action for the facility's Mortality, Hospitalization, Infection/Dialysis Access, Fluid Management, Anemia, Dialysis Adequacy, Nutrition and Influenza Vaccination and Transplant status for six of six months (January 2022 to June 2022) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of 32 in-center hemodialysis (ICHD) patients who were under the care of this facility. Findings include: Cross Reference: V 638 - Failure of the QAPI Team to consistently monitor, track and trend facility's performances and develop action plans to improve and sustain patient outcomes. |