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)
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 facility records and staff interview, it was determined that the facility failed to conduct regular fire drills at least every six months for 12 of 12 months of fire drill records reviewed (4/1/22 - 4/1/23). Failure to conduct periodic fire drills for each shift of patients, had the potential to negatively affect the health and safety of the 42 patients who were dialyzing at this facility. Findings were: A review of the facility fire drill records from 4/1/22 to 4/1/23, showed a lack of documented fire and evacuation drills for each shift of patients for the last twelve months. The last documented fire drill was completed on 12/1/22 for second shift patients only. A review of the policy titled, "Fire Emergency" dated 7/16/18 stated fire drills shall be performed quarterly for each shift of patients and staff. During an interview with the Clinic Manager on 4/11/23 at approximately 2:30 p.m., she stated that the fire drills should have been conducted quarterly.