| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852592 | (X3) Date Survey Completed 07/16/2025 |
| Name of Provider or Supplier Kidneyspa East Atlanta Dialysis, Llc | Street Address, City, State 2375 Metropolitan Pkwy Sw, Atlanta, 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) |
| V0684 | PQ-NURSE MANAGER-12 MO RN+6 MO DIALYSIS CFR(s): 494.140(b)(1) (1) Nurse manager. The facility must have a nurse manager responsible for nursing services in the facility who must- (i) Be a full time employee of the facility; (ii) Be a registered nurse; and (iii) Have at least 12 months of experience in clinical nursing, and an additional 6 months of experience in providing nursing care to patients on maintenance dialysis. This STANDARD is not met as evidenced by: Based on a review of facility records and staff interviews, it was determined that the Governing Body failed to ensure that this facility had a full-time Registered Nurse (RN), who was in charge of nursing services, to supervise the provision of patient care by fifteen of fifteen Direct Patient Care (DPC) Staff (three full-time Registered Nurses (RN BB , RN CC, AND RN DD), one part-time RN - RN AA, four full-time Patient Care Technicians (PCTs) - PCT AA, PCT BB, PCT CC, PCT DD, two part-time PCTs (PCT EE and PCT FF) and five PRN (as needed) PCTs, (PCT GG, PCT HH, PCT II, PCT JJ, and PCT KK), who were employed by this facility. This failure had the potential to negatively affect the health and safety of all 61 in-center hemodialysis patients who were receiving hemodiaysis services at this facility. Finding include : A review of the Governing Body Meeting Minutes revealed that on 4/25/25, RN AA (part-time nurse) was designated as Nurse in Charge of Nursing Services/Clinical Coordinator. The duties included: Overseeing clinical care delivery, support nursing staff, and ensure compliance with quality standards and patient care protocol. Assisting the Facility Administrator with a variety of team member and clinic program support functions. During an interview with the Facility Administrator on 7/16/25 at 09:44 a.m., the Facility Administrator explained that she was a Registered Dietitian (RD) by profession and currently served in a dual role as both Facility Administrator and RD at the facility. She stated that the Clinical Coordinator was responsible for assessing patients for medical dialysis-related issues. During an interview on 7/16/25 at 1:00 p.m., with RN AA (adopted as the Nurse in Charge of Nursing Services), the following was revealed: RN AA stated that she was not the clinical coordinator nor nurse in charge of nursing services at this facility. She explained that she worked part-time only, on Mondays, Wednesdays, and Fridays (MWF) schedule. RN AA also stated that she was never asked to take on the Clinical Coordinator role, never applied for the position, and was not being compensated for performing any responsibilities associated with it. She further stated that she recently saw her name listed on a form at the facility indicating she had been designated as the Clinical Coordinator. According to RN AA, this occurred after the previous Facility Administrator (who was a RN) resigned, and the position (Facility Administrator), was filled by a RD. She emphasized that someone assigned her the Clinical Coordinator role without her knowledge or consent and she made it clear that she was not accepting the position. - A copy of the job description for Clinical Coordinator/Nurse In-Charge of Nursing Services, was presented to this surveyor by the Facility Administrator, but was not signed and dated by RN AA. - There was no other RN designated as Clinical Coordinator/Nurse in charge of Nursing Services in the Governing Body Meeting Minutes, except RN AA. |