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 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)
V0638 QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE
CFR(s): 494.110(b)

The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time.


This STANDARD 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: - A review of the Quarterly Update of the Fiscal Year 2022 DFR for calendar year 2020, revealed that the facility was missing their Mortality, Hospitalization, Infection/Dialysis Access, Fluid Management, Anemia, Dialysis Adequacy, Nutrition and Influenza Vaccination and Transplant status, since Quarter (Q) 3 (July-September 2020) and Q4 (October - December 2020) reports. The only report recorded in the Quarterly Update of the Fiscal Year 2022 DFR for calendar year 2020 from this facility were: 1. Vascular Access: Central Venous Catheter (CVC) only greater than (>) 90 days/3 months was 81.8 %. The U.S. threshold was 61.7%. 2. Transplant Waitlist less than (<) 70 years old was 5.3%. The U.S. threshold was 17.4%. - A review of the facility's QAPI meeting minutes from January 2022 - June 2022 revealed the following: 1. Adequacy < 1.2 (not meeting acceptable range): U.S. threshold was 1.6% This facility: - January 2022 - 25% - February 2022 - 13.64% - March 2022 - 0% - April 2022 - 7.41% - May 2022 - 4.3% - June 2022 - 25% 2. Anemia - there was no documentation regarding anemia outcomes for the months of January - June 2022. 3. Phosphorus (P04) > 7.0 - the QAPI minutes only showed the % of patients whose PO4 were greater than 5.5. The Registered Dietitian was not available to provide percentage of patients who had PO4 greater than 7.0. Percentage of patients whose PO4 were > 5.5 (U.S. threshold for PO4 > 7.0 was 15.3%): January 2022 - 62.5% February 2022 - 44% March 2022 - 44.4% April 2022 - 34.5% May 2022 - 51.5% June 2022 - 46.4% 4. Albumin < 4.0. U.S. threshold was 56.3%. This facility: January 2022 - 75% February 2022 - 75% March 2022 - 80.8% April 2022 - 82.8 % May 2022 - 75.8% June 2022 - 75% There were no available records of the QAPI teams' tracking and trending of Bloodstream infections, CVCs, Hospitalizations and re-admissions, Fluid Management (UFR - Ultrafiltration Rate >13 mL/kg/hour), and Mortality Analysis. According to the Social Worker on 7/11/22 at approximately 1:00 p.m., there was one patient on the transplant list, and one patient who was referred for transplant evaluation in April of 2022. There was one who transplanted last year. The Chief Executive Officer (CEO)/Owner stated on 7/12/22 at approximately 11:30 a.m., that he couldn't find other QAPI records and the former Facility Administrator (FA) had left employment last June 17, 2022.