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 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)
V0765 GOV-INTERNAL GRIEVANCE SYS ID/IMPLEMENTED
CFR(s): 494.180(e)

The facility's internal grievance process must be implemented so that the patient may file an oral or written grievance with the facility without reprisal or denial of services. The grievance process must include- (1) A clearly explained procedure for the submission of grievances. (2) Timeframes for reviewing the grievance. (3) A description of how the patient or the patient's designated representative will be informed of steps taken to resolve the grievance.


This STANDARD is not met as evidenced by:
Based on patient and staff interviews, a review of facility records, and a review of the facility's Policies and Procedures (P&P), it was determined that the Facility Administrator failed to ensure that patient (P) #1, was treated with respect and dignity, and was provided with support and resolution regarding P#1's concerns and complaints/grievances. Additionally, it was determined that the Facility Administrator and the Medical Director failed to ensure appropriate assessment and follow-up was conducted regarding P#1's repeated reports of adverse medication reactions related to Mircera (a medication used to treat anemia caused by chronic kidney disease [CKD], by stimulating red blood cell [RBC] production). The Facility Administrator and the Registered Nurse (RN AA), identified as responsible for Clinical Coordination failed to follow the facility's established P & P regarding patient complaints and grievances. This lack of action deprived the patient of her right to be heard and to receive timely resolution of her concerns, which could negatively affect the health and safety of P#1 and the other 60 patients who were receiving hemodialysis services at this facility. Findings include: During a telephonic interview with P#1 on 7/15/25 at 5:00 p.m., P#1 stated that on 7/10/25, she was informed by the Facility Administrator that the facility would be discontinuing the use of Epogen (also a medication used to treat anemia caused by CKD, by stimulating RBC production) and will be using Mircera instead. P#1 expressed concern, stating that Mircera had caused blisters on both of her lower legs (while on Mircera), so she refused to resume treatment with Mircera. P#1 also added that since February 2025, she had spoken to the Medical Director (P#1's primary Nephrologist), regarding the blisters on her legs, but the Medical Director did not respond when she spoke to the Medical Director about it and did not examine/assess her legs. P#1 also stated that she told the Nurse Practitioner (NP AA) during weekly rounds about the blisters on her legs but NP AA did not examine her legs either. P#1 further stated that she requested the Facility Administrator to file a grievance on her behalf. P#1 further explained that when her medication was changed from Mircera to Epogen, the blisters on her legs dried up and improved. So when the Facility Administrator informed P#1 on 7/10/25 that Epogen will be discontinued and Mircera was to be resumed, P#1 was very concerned that the blisters on her lower legs will get worse again. - A review of P#1's medical records revealed the following: P#1 was admitted to this facility on 7/9/24. An order for Mircera 225 mcg (micrograms) was to be administered to P#1 via intravenous push during dialysis treatment every 14 days (on Tuesdays), and was initiated on August 20, 2024. Mircera was discontinued on February 27, 2025, when P#1 refused Mircera due to complaints of blisters on her lower legs. P#1's hemoglobin count on 5/16/25 was 6.8 g/dL (grams per deciLiter), while the hemoglobin's acceptable range was between 10-12 g/dL for adults with End Stage Renal Disease (ESRD). P#1 was then started on Epogen (also for the treatment of anemia) 5,000 units three times per week on 5/6/25 and was currently being used as P#1's anemia management medication. During a review of the Complaint and Grievance Logs between January 2025 and July 2025, there were no documented complaint/grievances regarding P#1 or in behalf of P#1's complaints of blisters, by the Facility Administrator. During an interview with the Facility Administrator on 7/16/25 at 9:44 a.m., the following information was disclosed: The Facility Administrator stated that on 7/3/25, she received a call from the corporate office informing her that the company would be discontinuing the use of Epogen. On 7/10/25, she communicated this decision to P#1 and informed her that she would need to resume treatment with Mircera. According to the Facility Administrator, the patient expressed concern, stating that Mircera had previously caused blistering on her legs and that her condition had improved since switching to Epogen. P#1 expressed her concern and wished to file a complaint because she believed that returning to Mircera would again cause the blistering on her lower legs. When asked whether the complaint had been officially documented, the Facility Administrator stated that instead of recording it in the designated Complaint and Grievance Log, she wrote it on a piece of paper and left it on her desk since the Social Worker (SW), who was responsible for managing patient complaints, had been off work for several days at the time. When asked if the Medical Director had been informed of the corporate's decision to discontinue Epogen, the Facility Administrator stated that she had not spoken to the Medical Director about it. Regarding P#1's prior complaints about Mircera and the development of blisters, the Facility Administrator recalled that in February 2025, P#1 had voluntarily discontinued some of her anemia-related medications, citing the development of blisters on the lower parts of both legs. When asked if she had personally examined the patient's legs to verify the blisters, 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 dialysis-related issues. When asked whether the Interdisciplinary Team (IDT) was aware of P#1's concerns, she responded that this question should be directed to the Clinical Coordinator (will be referred to as Registered Nurse (RN AA). During an interview with the Medical Director on 7/16/25 at 10:30 a.m., he stated that he was not aware corporate had made the decision to discontinue the purchase of Epogen. He added, however, that if necessary, he had the authority to override corporate decisions related to medications. When asked if he was aware that P#1 had complained about blistering on her legs, which she believed was caused by the use of Mircera, the Medical Director responded that P#1 was non-compliant, frequently refused dialysis treatments and medications, and had a history of signing out of the hospital against medical advice. When asked whether he (Medical Director), had assessed P#1's legs during his monthly rounds, whether P#1's concerns were discussed during Interdisciplinary Team (IDT) meetings following discontinuation of P#1's anemia medications in February 2025, and whether he had met with P#1 to address her concerns, the Medical Director stated that some patients prefer not to be awakened during rounds and he believed P#1 was one of them. He also added that a Nurse Practitioner made rounds at the facility three times a week to assist with patient care needs and assessments. - During an interview with RN AA on 7/16/25 at 11:30 a.m., she stated that she was not the Clinical Coordinator at this facility. She explained that she worked part-time only, on Mondays, Wednesdays, and Fridays (MWF), while P#1's scheduled dialysis treatments were on Tuesdays, Thursdays, and Saturdays (TTS). RN AA 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 was filled by the current Facility Administrator (who was 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 review of Policy # 04.113, titiled, "Internal Geievance Process", last revised 4/19/23, stated: Procedure for the Submission of Grievances: 1. Step 1: A grievant (person who wishes to file a grievance) should address thier question, complaint, or concern to the Facility Administror. If the grievant does not wish to provide the grievance to the Facility Administrator, they may enter into step 2 and contact the social worker. Timeframes for Reviewing Grievance: 1. The grievant shall recieve a response within 5 business days of the initial grievance being filed acknowledging the recept of the grievance. A review of "Patients Rights" stated: The following PATIENT RIGHTS will be observed by all person affecting care: 1. Quality Care You have the right to : a. Receive high quality healthcare that meets reconized professional goals. b. Be a part of a healthcare team, along with a social worker, nurse, physician, and dietitian 2. Information You have the right to: d. Be informed of any possible side effects of medications you are taking. 3. Individual Treatment You have the right to: a. Be treated with dignity, respect, and consideration. b. Suggest a change in the type of treatment you are receiving. c. Expect your kidney doctor and other members of your healthcare team to listen to you when you suggest changes in your dialysis treatment. 6. Treatment Options You have the right to: f. receive follow up care by dietary, social work, and nursing services.