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)
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 Dialysis Facility Report (DFR) and facility records and staff interview, it was determined that the facility failed to track and trend anemia rates (low red blood cell counts), develop action plans and evaluate the effectiveness of the facility's management of patients with a Hemoglobin (Hgb - protein in red blood cells that carries oxygen) of less than (<) 10 g/dL, for six of six months of Quality Improvement Meeting Minutes reviewed (February 2023 - July 2023). This deficient practice had the potential to negatively affect the health and safety of 17 patients who were receiving dialysis services at this facility. Findings were: A review of 2023 DFR (A report prepared by Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients of this facility, as compared to other facilities in the U.S.) revealed that the average Hgb < 10 g/dL should not exceed 16.8 % for in-center hemodialysis patients. A review of Quality Improvement Meeting reports for six of six months (February 2023 - July 2023) revealed that the facility's average percentage for Hgb < 10 g/dL was 28.9% % for in-center hemodialysis patients. The Quality Improvement Meeting minutes revealed a lack of documented evidence that anemia management for hemodialysis patients with a Hgb < 10 g/dL had appropriate action plans, root cause analysis, and follow-up evaluations to ensure improvement. During an interview with the Facility Administrator on 8/9/23 at approximately 1:30 p.m., she stated that the anemia management for patients with Hgb <10 were being reviewed. However, the action plans, root cause analysis and follow-up evaluation needed to be completed for hemodialysis patients with Hgb<10.