A. BUILDING(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:STATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X3) DATE SURVEYCOMPLETED
PRINTED: 06/05/2008FORM APPROVED
(X2) MULTIPLE CONSTRUCTIONB. WING _____________________________
______________________
DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-0391
452639
05/13/2008
C
LUFKIN, TX 75904
STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER
LUFKIN DIALYSIS CENTER
700 S JOHN REDDITT
PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)
(X5)COMPLETIONDATE
IDPREFIXTAG(X4) IDPREFIXTAGSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)
V 000INITIAL COMMENTSV 000An entrance conference was conducted at thisend stage renal disease (ESRD) facility on April28, 2008, 2008 at 12:50 p.m. with the facility'sRegional Director and the Medical Director. Thepurpose of the survey and the survey processwas explained. An opportunity was provided for questions and answers.An onsite unannounced complaint investigationfor TX#00093935, TX#00094614 andTX00093224 was conducted per Section 2278,2700-2764, and Appendix H of the StateOperations Manual (CMS Pub. 100-7) todetermine the ESRD facility's compliance with therequirements at 42 CFR 405, SubpartU-Conditions for Coverage of suppliers of ESRDservices using the applicable survey report form.Complaint #00094614 and TX#00093935 werefound to be substantiated with related deficienciescited and an immediate jeopardy was identified.The facility voluntarily closed on a temporarybasis effective the last shift on 4/28/08, removingthe threat to the patient safety. The facilitysuccessfully transferred all patients on 4/29/08.This finding was considered an immediate jeopardy on 4/28/08 and the immediate jeopardywas removed with the voluntary closure of thefacility on 4/28/08 after the last patient shift.Recommend 90 day termination. The followingConditions for Coverage were not met. GoverningBody, (405.2136); Medical Records(405.2139);Physician Director of an ESRD Facility(405.2161); and Staff of a renal dialysis facility(405.2162).Complaint # TX 00093224 was found to be
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURETITLE
(X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined thatother safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 daysfollowing the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continuedprogram participation.
FORM CMS-2567(02-99) Previous Versions ObsoleteINPH11
Event ID:
Facility ID:820110
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