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 852579 (X3) Date Survey Completed 08/01/2024
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)
V0143 IC-ASEPTIC TECHNIQUES FOR IV MEDS
CFR(s): 494.30(b)(2)

[The facility must-] (2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and


This STANDARD is not met as evidenced by:
Based on observation and staff interviews, it was determined that the facility failed to ensure that one of one Licensed Practical Nurse [(LPN) AA], who prepared a medication that was not given immediately, labeled the medication with the patient's name, the name of medication, the dosage, and the date and time it was prepared along with LPN AA's initials. This deficient practice had the potential to negatively affect the health and safety of 25 Peritoneal Dialysis (PD) patients and three Home Hemodialysis (HHD) patients who were seen during monthly clinic visits and received support from the staff. Findings were: During observation of the medication refrigerator on 7/30/24 at approximately 11:00 a.m., this surveyor found an unlabeled and undated 10 ml (milliliter) syringe filled with a dark brown colored liquid. During an interview on 7/30/24 at 11:03 a.m., LPN AA stated "I pulled up Venofer (iron medication given intravenously) this morning to give to a patient but he did not show up and I did not need it, so I put it in the refrigerator." During an exit interview with the Director of Operations and the Clinical Manager on 7/31/24 at approximately 2:00 p.m., both acknowledged the findings.