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 852578 (X3) Date Survey Completed 04/12/2023
Name of Provider or Supplier Dialysis Care Center Pleasant Hill, Llc Street Address, City, State 1425 Georgia Ave, Suite 101, Macon, 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)
V0628 QAPI-MEASURE/ANALYZE/TRACK QUAL INDICATORS
CFR(s): 494.110(a)(2)

The dialysis facility must measure, analyze, and track quality indicators or other aspects of performance that the facility adopts or develops that reflect processes of care and facility operations. These performance components must influence or relate to the desired outcomes or be the outcomes themselves.


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) and develop action plans and outcomes, to 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 (October 2022 - March 2023). This deficient practice had the potential to negatively affect the health and safety of the 42 patients who were receiving dialysis services at this facility. Findings were: A review of 2022 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 October 2022 - March 2023 revealed that the facility's average percentage for Hgb < 10 g/dL was 30.8 % for in-center dialysis patients. The Quality Improvement Meeting minutes revealed a lack of documented evidence that anemia management for 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 Clinic Manager on 4/12/23 at approximately 12:00 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.