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 08/09/2023
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)
V0633 QAPI-INDICATOR-VASCULAR ACCESS
CFR(s): 494.110(a)(2)(v)

The program must include, but not be limited to, the following: (v) Vascular access.


This STANDARD is not met as evidenced by:
Based on a review of the 2023 Dialysis Facility Report (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), facility records review, and staff interview, it was determined that the facility failed to track, measure, and analyze vascular access (access used for dialysis) for six of six months (February 2023 to July 2023) of Quality Improvement Program/Quality Assessment and Performance Improvement (QAPI) meeting minutes reviewed, to decrease the use of catheters. This deficient practice increased the risk for incidence of infection related to catheter use for 26% of patients, who used catheter as their only vascular access for dialysis. The facility census was 17. Findings were: A review of the 2023 Dialysis Facility Report revealed that the US average for Central Venous Catheters (CVC) only, that had been in place for 90 days or more, should not exceed 10.3%. - The facility had 27% of patients who had CVC only, as their dialysis access. A review of the QAPI meeting minutes from February 2023 - July 2023 revealed no documentary evidence that the QAPI team conducted a comprehensive review of the patients with vascular access to decrease the use of catheters. - The QAPI meeting minutes revealed a lack of documented evidence that aggregate data had appropriate action plans, root cause analysis, and follow-up evaluations to ensure improvement and decrease the use of catheters. During an interview with the Facility Administrator on 8/9/23 at approximately 1:30 p.m., she stated that the information was reviewed. However, root causes, action plans, and evaluations should have been completed for the reduction of catheters.