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 08/14/2024
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 facility's Fiscal Year 2024 Quarterly Dialysis Facility Report (FY2024 QDFR), (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 interview, it was determined that the Quality Assessment and Performance Improvement (QAPI) Committee failed to track, trend, analyze, and develop plans of action to improve and sustain the facility's Anemia Management, Nutrition, Mineral Metabolism and Bone Disorder, Fluid Management, and Vascular Access Management, for six of six months (February 2024 - July 2024) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of all 19 in-center hemodialysis (ICHD) patients who were receiving dialysis services at this facility. Findings include: A review of the FY2024 QDFR, (third quarter 2023), revealed that the facility was above the United States (US) threshold in: 1. Nutrition [Albumin < (less than) 4.0] - this facility was 74.0 %, whereas, US was 50.5% 2. Mineral Metabolism and Bone Disorder - [Phosphorus greater than (>) 7.0] - this facility was 29.5 %, whereas, US was 15.6 %. 3. Anemia - (Hemoglobin <10.0) - facility was 41.2 %, whereas, US was 23.4 %. 4. Vascular Access - (Long-Term Catheter Rate) - facility was 18.9 %, whereas, US was 17.2 %. In Comparison, a review of the facility's last six months of QAPI meeting minutes from December patients using a Central Venous Catheter (CVC) =/> 90 days ranged between 25 % (lowest in May) and 42.86 % (highest in July). 5. Fluid Management - UFR (ultrafiltration rate - fluid removal) >13 mL/kg/hr was 11.6%, whereas, US was 7.7%. Additionally, the facility's QAPI meeting minutes from (December 2023 - June 2024) revealed no documentary evidence that the interdisciplinary team (IDT) conducted a comprehensive review of the above outcomes with appropriate action plans, root cause analysis, and follow-up evaluations to ensure and sustain improvement. The Facility Administrator (FA) stated on 8/14/24 at approximately 12:15 p.m., that the IDT will work toward improvement of these outcomes. The FA revealed that for anemia, the lab was monitoring Hgb 9-11 rather than Hgb <10 for QAPI; for bone/mineral management, the laboratory was monitoring phosphorus (PO4) of 3.5-5.5 rather than PO4 > 4; and the IDT was not currently monitoring UFR for QAPI.