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 852586 (X3) Date Survey Completed 07/09/2025
Name of Provider or Supplier Dialysis Care Center Gwinnett, Llc Street Address, City, State 558 Old Norcross Road, Suite 104, Lawrenceville, 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)
V0556 POC-COMPLETED/SIGNED BY IDT & PT
CFR(s): 494.90(b)(1)

The patient's plan of care must- (i) Be completed by the interdisciplinary team, including the patient if the patient desires; and (ii) Be signed by the team members, including the patient or the patient's designee; or, if the patient chooses not to sign the plan of care, this choice must be documented on the plan of care, along with the reason the signature was not provided.


This STANDARD is not met as evidenced by:
Based on medical record review, staff interviews, and a review of facility Policy and Procedures (P&P), it was determined that the facility failed to ensure that five of seven sampled patients (P#1, P#3, P#4, P#6 and P#7), had a Patient Care Plan that reflected participation of all members of the Interdisciplinary Team (IDT), including the patient or patient representative. This lack of IDT collaboration and participation had the potential failure to identify new patients' concerns and outcomes that were not achieved. The facility census was 71. Findings include: During a review of patients' medical records, the following was revealed: - P#1 was admitted on 2/20/23. The Annual Care Plan was dated 6/11/25. - P#3 was admitted on 4/10/25. The 90-day Care Plan was dated 5/1/25. - P#4 was admitted on 5/20/25. The 90-day Care Plan was dated 6/16/25. - P#6 was admitted on 4/11/23. The Annual Care Plan was dated 8/13/24. - P#7 was admitted on 5/31/25. The 90-day Care Plan was dated 6/16/25. - There were no IDT signatures, nor any signatures from the patients or their representatives, as required per facility P&P in the development or discussion of the 90-Day and Annual Care Plans for P#1, P#3, P#4, P#6, and P#7. - A review of Policy DCC-IC-AD-100-007 titled, "Comprehensive Assessment & Plan of Care", with latest revision date of December 16, 2019, showed the following: II. Performed By: Interdisciplinary Team (Attending physician or physician extender [where permitted by State law], Registered Nurse [RN], Registered Dietician [RD], and Social Worker [SW], patient and/or care giver). Plan of Care Requirements The Plan of Care must be signed by the IDT members including the patient or designated care partner/caregiver. If the patient is unable or chooses not to sign the Plan of Care, this must be documented in the Plan of Care along with the reason the signature was not provided. During the exit interview on 7/9/25 at 12:30 p.m., the above findings were acknowledged by the Clinical Manager, and the Area Manager.