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)
V0715 MD RESP-ENSURE ALL ADHERE TO P&P
CFR(s): 494.150(c)(2)(i)

The medical director must- (2) Ensure that- (i) All policies and procedures relative to patient admissions, patient care, infection control, and safety are adhered to by all individuals who treat patients in the facility, including attending physicians and nonphysician providers;


This STANDARD is not met as evidenced by:
Based on a review of medical records, staff interview, and a review of policy, it was determined that the medical director failed to ensure that two of three patients (P) (P#2, P#5) sampled who experienced high blood pressure (BP) readings, received medical care and supervision appropriate to patients' dialysis needs. Persistently high BP could cause heart disease and stroke. This deficient practice had the potential to negatively affect the health and safety of P#2 and P#5. The facility census was 19. Findings include: A review of treatment records revealed the following: P#2: On 7/26/24: - The initiation of P#2's dialysis treatment began at 5:29 a.m. and BP was 187/122 mmHg (millimeters of mercury). BP reading was 199/126 mmHg at 6:00 a.m.; 212/112 mmHg at 6:30 a.m.; 190/116 mmHg at 7:00 a.m.; 179/95 mmHg at 7:30 a.m.; 197/117 mmHg at 8:00 a.m. P#2 complained of shortness of breath and oxygen (O2) was administered; BP was 210/112 mmHg at 8:30 a.m., and 189/105 mmHg at 9:00 a.m., at the end of treatment. - There was a lack of documented evidence that the registered nurse (RN) notified the physician about P#2's high BP readings before, during and after dialysis treatment on 7/26/24 or followed protocol or policy for BP outside parameters. On 8/12/24: - The initiation of P#2's dialysis treatment began at 5:36 a.m. with a BP reading of 190/117 mmHg. Notes showed BP was elevated, patient requested O2 due to pain and breathing struggles and the RN was aware.; BP reading at 6:00 a.m. was 199/126 mmHg. The flowsheet showed "gave Meds (medicines) for BP" however, did not show what medications were given for BP. P#2's BP reading was 212/112 mmHg at 6:30 a.m.; 190/119 mmHg at 7:00 a.m. and the flowsheet showed BP remained elevated.; 176/111 mmHg at 7:30 a.m.; 187/117 mmHg at 8:00 a.m. and UF (ultrafiltration - fluid removal) off due to cramping; 187/107 mmHg at 8:30 a.m., and 190/119 mmHg at 9:06 a.m., at the end of treatment. - There was a lack of documentary evidence that the nurse notified the physician of P#4's high BP readings. There was a lack of interventions done for the elevated BP readings during dialysis treatment after the patient's home dialysis medication was taken at 10:51 a.m. and BP continued to be elevated and exceeded parameters per standing order for hypertension (elevated BP). P#5: On 7/24/24: - The initiation of P#5's dialysis treatment began at 5:27 a.m. and BP was 215/108 mmHg. The flowsheet showed that P#5 did not take BP meds. BP reading was 204/111 mmHg at 6:00 a.m.; 202/110 mmHg at 6:30 a.m.; 193/108 mmHg at 7:00 a.m.; 188/105 mmHg at 7:30 a.m.; 159/96 mmHg at 8:00 a.m.; 137/106 mmHg at 8:30 a.m., and 139/101 mmHg at 9:01 a.m., at the end of treatment. - There was a lack of documentary evidence that the nurse notified the physician about P#5's high BP readings outside parameters from 5:27 a.m. to 7:30 a.m. - There was a lack of interventions done for the elevated BP readings during dialysis treatment. A review of undated policy titled, "Use of Clonidine in Chronic Hemodialysis Patients" showed the following: Hypertension: May administer Clonidine by mouth 0.1 mg (milligram) as directed by physician, may repeat x2 (maximum 3 dose). A review of undated policy titled, "Clinical Parameters for Physician Notification" showed the following: The Dialysis Nursing Staff will notify the physician of the following: B/P diastolic (bottom number) > (greater than) 110 or systolic (top number) >190 or < (lower than) 80. The patient will be assessed, and physician notified of changes. Across the continuum of care. The patient's condition, relevant information, and interventions will be documented in the progress notes. The nurse and physician will document follow-up assessment in the progress notes, to include resolution of symptoms or stabilization of patient. The Facility Administrator was informed of the above findings on 8/14/24 at 3:30 p.m.