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 852584 (X3) Date Survey Completed 12/18/2020
Name of Provider or Supplier Mountainside Dialysis Street Address, City, State 700 N Main Street, Jasper, 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)
V0000 An initial certification survey in conjunction with COVID-19 Focused Infection Control Survey were conducted at Mountainside Dialysis on December 18, 2020. The surveys revealed that the facility was not in compliance with 42 CFR Part 494.40 - Water and Dialysate Quality and 42 CFR 494.180 - Governance for End Stage Renal Dialysis Facilities. On December 18, 2020, a determination was made that a situation in which the facility's noncompliance with 494.40 - Water and Dialysate Quality, resulted in an Immediate Jeopardy (IJ) with potential harm to the health and safety of three of three patients who were undergoing hemodialysis treatment at the time of this observation. The facility in-center hemodialysis census was 4. The Facility Administrator and the Manager of Clinical Services were notified of the IJ finding on 12/18/20 at 10:30 a.m. The noncompliance related to the IJ was identified to have existed on 12/18/20 at 10:30 a.m. The IJ was abated during the survey on 12/18/20 at 1:30 p.m. when the facility implemented a Credible Allegation of Compliance related to the IJ. However, the Condition remained out of compliance. Also, the following standard level deficiency was cited: