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 08/18/2022
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)
E0038 ESRD EP Training Program

ยง494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures.


This STANDARD is not met as evidenced by:
Based on a review of facility records, a review of personnel file, and staff interviews, it was determined that the facility failed to ensure that one of three Registered Nurses (RN DD), one of two Patient Care Technicians (PCT CC), and one of two Certified Clinical Hemodialysis Technicians (CCHT ZZ), received training and testing of the facility's Emergency Preparedness Program Plan. This deficient practice had the potential to negatively affect the health and safety of 33 patients who were under the care of this facility. Findings include: A review of personnel file showed the following: - RN DD was hired on 6/1/22. There was no record of Emergency Preparedness Program Training and Testing in her file. - PCT CC was hired on 5/1/22. There was no record of Emergency Preparedness Program Training and Testing in her file. - CCHT ZZ was hired on 7/8/22. There was no record of Emergency Preparedness Program Training and Testing in her file. During an interview with the Facility Administrator on 8/17/22 at approximately 2:00 p.m., she stated that she was not able to complete the personnel file and staff training. During an interview with the Chief Executive Officer/Owner on 8/17/22 at approximately 2:30 p.m., he stated that the personnel file should have been completed since it was to be worked on from the date of exit of the last survey and was to be a priority.