Fmc - Newnan Dialysis Services

“PE-BUILDING-CONSTRUCT/MAINTAIN FOR SAFETY CFR(s): 494.60(a) The building in which dialysis services are furnished must be constructed and maintained to ensure the safety of the patients, the staff and the public. This Standard is not met as evidenced by: 03383 Based on observation and staff interview, it was determined that the facility failed to maintain a clean, orderly, and safe environment. This environmental concern was observed in one of one treatment area. This deficient practice could negatively affect the health and safety of all staff and 53 in center hemodialysis (ICHD) patients who were receiving dialysis. Findings were: During a tour of the facility on 11/19/24 at 10:42 a.m. with the Facility Administrator, a 12-to-15-inch round elevated bubbled up tiles was observed on the floor in the treatment area and presents as a trip hazard for patients and staff. The Facility Administrator acknowledged concern with this area and stated that it looks like where a sink was removed.”

“QAPI-MONITOR/ACT/TRACK/SUSTAIN IMPROVE CFR(s): 494.110(b) The dialysis facility must continuously monitor its performance, take actions that result in performance improvements, and track performance to ensure that improvements are sustained over time. This Standard is not met as evidenced by: 03383 Based on a review of the facility’s Fiscal Year 2025 Dialysis Facility Report (DFR: A report prepared by the Centers for Medicare and Medicaid Services to provide a comparative summary of treatment patterns and patient outcomes for dialysis patients), a review of facility records, and staff interview, it was determined that the Quality Assessment and Performance Improvement (QAPI) Committee failed to track, trend, analyze, and develop plans of action to improve and sustain the facility’s Mineral Metabolism and Bone Disorder and Vascular Access Management, for six of six months (April 2024 - September 2024) of QAPI meeting minutes reviewed. This deficient practice had the potential to negatively affect the health and safety of 53 in-center hemodialysis (ICHD) patients who were receiving dialysis services at this facility, and 4 PD patients receiving dialysis at home. Findings were: A review of the FY2025 QDFR, (first quarter 2024), revealed that the facility was above the United States (US) threshold for in-center dialysis in: 1. Adequacy: (Kt/v < 1.2) - facility was 5.1 %, whereas US was 2.1 % 2. Fluid Management: (Avg UFR>13 ml/kg/hour) - facility was 10.6 %, whereas US was 9.4 % 3. Vascular Access - (Long-Term Catheter Rate) - facility was 19 %, whereas US was 10.7 % A review of the FY2025 QDFR, (first quarter 2024), revealed that the facility was above the United States (US) threshold for PD 4. Adequacy: (Kt/V < 1.7) - facility was 30.6 %, whereas US was 5.2 % In Comparison, a review of the facility’s last six months of QAPI meeting minutes from April 2024 - September 2024, revealed the following outcomes that were greater than (>) the US threshold. Specifically, for ICHD patients: 1. Adequacy: The % of patients with Kt/V < 1.2 was 16.6 % in April 2024, 6.8 % in July 2024, 6.8 % in August 2024, and 9.3 % in September 2024. 2. Vascular Access - (Long-Term Catheter Rate). The % of patients with CVC only >90 days was 29.8 % in April 2024, 21.7 % in May 2024, 30.2 % in June 2024, 31.7 % in July 2024, 31.7 % in August 2024, and 30.9 % in September 2024. 3. Fluid Management for ICHD patients and Adequacy for PD patients was below US threshold April 2024 to September 2024. Additionally, the facility’s QAPI meeting minutes from (April 2024 - September 2024) revealed documentary evidence that the interdisciplinary team (IDT) conducted a comprehensive review of mineral/bone and vascular access with no changes made to the action plans to ensure and sustain improvement in mineral/bone and vascular access. The Facility Administrator and Nursing Supervisor (NS) were present during review on 11/21/24 at 7:58 a.m.; the Facility Administrator and NS were aware and agreed that they needed to do more to improve numbers for adequacy and catheter use. The NS stated the interdisciplinary team will work toward improvement of these outcomes. They confirmed that no changes were made to the plan for mineral/bone (PO4) in May, June, July, August, or September 2024.”