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)
V0681 PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY
CFR(s): 494.140

All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility's staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility's staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions.


This STANDARD is not met as evidenced by:
Based on a review of facility records, a review of personnel file, and patient and staff interviews, it was determined that the facility failed to ensure that one of one Patient Care Technician (PCT AA) sampled, who was specifically mentioned in the complaint investigation, and one of one Facility Administrator (FA), were certified and licensed and able to demonstrate and sustain the skills necessary to perform the duties that were assigned to them or refrain from performing nursing skills without being duly licensed. Findings include: A review of all PCTs and licensed personnel records at the facility revealed the following: - PCT AA was hired by this facility on 11/20/20. There were no records of PCT AA's certification status, no records of CPR training(CPR - Cardiopulmonary Resuscitation, is a lifesaving technique that's useful in many emergencies, such a a heart attack or near drowning, in which someone's breathing or heartbeat has stopped), there were no records of PCT AA's skills competency checks both for initial and annual competencies and check offs, no records of Emergency Preparedness Plan training and testing, Infection Control, Water and Dialysate, and Machine Training, nor any health records since she was hired at this facility on 11/20/20. -A review of PCT AA's Time Card or schedule of hours worked from June 3, 2022 through July 11, 2022 revealed that PCT AA continued to work at this facility on 6/3/22, 6/6/22, 6/8/22, and on 6/10/22, with an average of 11.93 hours per work day. The complainant (C#1), on 7/6/22 at approximately 11:40 a.m., stated that PCT AA told her and several other patients on 5/25/22 (when a State Surveyor came to investigate a complaint), that if the surveyor ask for PCT AA's name, she was to be called another PCT's name (PCT VV), who had left employment in September of 2021. According to the Chief Executive Officer (CEO/Owner) on 7/6/22 at approximately 1:30 pm., he could not find any of PCT AA's personnel records on file. He stated that both FA and PCT AA left employment at about the same time. A review of personnel records revealed that FA's personnel file was missing. The CEO stated on 7/6/22 at approximately 3:00 p.m., that he could not find FA's personnel file and FA was a Certified Clinical Hemodialysis Technician but went back to attend nursing school and graduated last year but he was told by FA that she was only given a temporary license as a Registered Nurse last year due to the pandemic (COVID 19). This surveyor looked up FA's licensure status in the Georgia State's Licensure website but FA's name was not listed. This was confirmed by the CEO on 7/7/22 at approximately 2:30 p.m. that FA was not a licensed nurse. - A review of the FA's Time Card or schedule of hours worked from June 3, 2022 through July 11, 2022, revealed that FA worked at this facility every Monday, Wednesday, and Friday through 6/17/22; and was hired as the Facility Administrator on 9/22/19. - A review of patients' (P#1, P#5, P#6, P#7, and P#8) Flowsheets revealed the following: - P#1's hemodialysis treatment on 5/27/22 using a central venous catheter (CVC) was initiated and terminated by FA, including pre and post assessment. Only licensed nurses in this state are allowed to initiate and terminate hemodialysis treatment on a patient with a CVC. - P#5 was given on 5/25/22 the following medications by FA: Heparin (anticoagulant) bolus of 1500 units via intravenous push (IVP) and maintenance dose of 1000 units every hour for 3 hours; Epogen 8000 units (Erythropoietin Stimulating Agent for anemia) via IVP; and Promethazine 25 mg (for the treatment of allergy or allergic reactions) via IVP. FA also performed the pre- and post-assessment of P#5 (which included lung sounds), to be performed by a licensed nurse. - P#5 was again given by FA, the same doses of Heparin and Epogen via IVP on 6/1/22; and in addition, Doxercalciferol (used to treat secondary hyperparathyroidism) 2 mcg via IVP; as well as performing pre and post assessments on P#5. - P#6's pre and post assessments were conducted by FA on 5/25/22. IVP of Heparin Bolus 1500 units, Heparin maintenance dose of 1000 units per hour for three hours; Epogen 8000 units; and Doxercalciferol 2 mcg were also administered IVP by FA. The same medications were also administered by FA via IVP on 5/27/22, 6/1/22, 6/3/22, and 6/29/22, as well as pre and post assessments. - P#7 was given Heparin Bolus of 2000 units IVP by FA on 6/29/22, as well as Benadryl (antihistamine) 25 mg IVP. FA also performed pre-assessment. - P#8's pre and post assessments were conducted by FA and medications such as Heparin Bolus 3000 units and maintenance dose of 1500 units per hour for three hours; Epogen 4000 units; and Doxercalciferol 2 mcg were administered via IVP by FA on 5/25/22, 5/27/22, 6/1/22 and 6/3/22. In addition, FA also gave P#8 Parsabiv (additional dose?), also for the treatment of hyperparathyroidism via IVP on 5/27/22. The CEO could not find doctor's order changes or records at the time of this investigation and he stated on 7/7/22 at approximately 1:00 p.m. that he had tried to contact FA several times via phone calls or text messages but FA did not return calls nor text messages. During patient interviews on 7/6/22 between 11:45 a.m. and 12:15 p.m., the following was revealed: - P#2 stated that FA had given him medications before while on the machine. - P#6 stated that FA had initiated her hemodialysis treatment before. P#6 had an arterio-venous fistula (AVF). - P#9 at Station (S9) stated that he could not remember if FA had given him medications before but remembered that FA had initiated his treatment in the past, but unsure of date. P#9 had a CVC.