| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852579 | (X3) Date Survey Completed 06/07/2023 |
| Name of Provider or Supplier Home Dialysis Services Norcross, Llc | Street Address, City, State 3780 Holcomb Bridge Road, Suite E, Norcross, 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) |
| V0552 | POC-P/S COUNSELING/REFERRALS/HRQOL TOOL CFR(s): 494.90(a)(6) The interdisciplinary team must provide the necessary monitoring and social work interventions. These include counseling services and referrals for other social services, to assist the patient in achieving and sustaining an appropriate psychosocial status as measured by a standardized mental and physical assessment tool chosen by the social worker, at regular intervals, or more frequently on an as-needed basis. This STANDARD is not met as evidenced by: Based on a review of records and staff interview, it was determined that the interdisciplinary team failed to ensure that a Kidney Disease Quality of Life (KDQOL) assessment was completed annually for two of two patients (P) sampled for anemia (P#1 and P#5). Findings were: A review of the medical records for P#1 and P#5 revealed that the facility was not able to produce the last documented KDQOL respectively. There was no documentary evidence that an updated annual KDQOL assessments were completed on these patients. A review of policy titled, "Comprehensive Assessment and Plan of Care" dated 1/6/2016, stated the reassessment of the KDQOL will be conducted at least annually for stable patients. During an interview with the Facility Administrator on 6/6/23 at approximately 2:00 p.m., she stated that the KDQOL assessments should have been completed. |