| 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) |
| V0175 | CFC-WATER & DIALYSATE QUALITY CFR(s): 494.40 This CONDITION is not met as evidenced by: Based on observations, staff interviews, a review of the manufacturer's directions for use (DFU), and a review of the facility's Policy and Procedures (P&P), it was determined that the facility failed to ensure that the water used for dialysis was accurately monitored, to provide safe treatments for all patients. On 12/18/20 at 10:30 a.m., a determination was made that a situation in which the facility's noncompliance with 42 CFR 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 at the time of this observation. The facility in-center census was four. The Facility Administrator and the Manager of Clinical Services were informed 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 10:20 a.m. The IJ situation 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. Findings include: Cross Reference: V - 196 - Failure of the facility to ensure that staff accurately performed the Total Chlorine Test of water used for dialysis to ensure the water was safe for dialysis. |