| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 852595 | (X3) Date Survey Completed 02/09/2023 |
| Name of Provider or Supplier Fidelity Home Dialysis | Street Address, City, State 1230 Johnson Ferry Pl Suite H30, Marietta, 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) |
| V0597 | H-PROVIDE ORDERED SUPPLIES/EQUIPMENT CFR(s): 494.100(c)(1)(vi) Services include, but are not limited to, the following: (vi) Purchasing, leasing, renting, delivering, installing, repairing and maintaining medically necessary home dialysis supplies and equipment (including supportive equipment) prescribed by the attending physician. This STANDARD is not met as evidenced by: Based on a review of facility records and staff interview, it was determined that the facility failed to maintain records of preventive maintenance for the home hemodialysis (HHD) machines used for two of two HHD patients. This deficient practice had the potential to negatively affect the health and safety of the two patients who were receiving staff-assisted HHD at home. Findings include: A review of the facility's equipment maintenance logs revealed no documented evidence that routine quarterly and six month preventive maintenance (PM) of the HHD machines used for two of two home patients, were completed in accordance with the manufacturer's recommendations. During an interview with the Facility Administrator on 2/9/23 at 3:35 p.m., she stated that the new Biomed Technician organized the equipment PM records and placed them in one folder, but did not include the quarterly and six month PM records. The Facility Administrator could not provide the missing documents. |