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 012306 (X3) Date Survey Completed 06/24/2021
Name of Provider or Supplier Childrens Hospital Of Alabama Esrd Street Address, City, State 1600 7th Avenue South, Birmingham, AL
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)
V0637 QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT
CFR(s): 494.110(a)(2)(ix)

The program must include, but not be limited to, the following: (ix) Infection control; with respect to this component the facility must- (A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence; (B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and (C) Take actions to reduce future incidents.


This STANDARD is not met as evidenced by:
Based on review of the Dialysis Facility Report for Fiscal Year (FY) 2021, facility hospitalization logs, February 2021 Exit Site/Peritonitis Apparent Cause Analysis Tools documentation, facility QAPI (quality improvement performance improvement) Meeting minutes and staff interviews, it was determined the IDT (interdisciplinary team) failed to ensure: 1) all exit site/peritonitis infection analysis included the potential contributing factors, lessons learned, and the action plan. 2) performance improvement actions were implemented and monitored when PD (peritoneal dialysis) infection rates trended upward. This affected PI (Patient Identifier) # 5 and had the potential to negatively affect all PD patients admitted to the facility. Findings include: Review of the Dialysis Facility Report for FY 2021 for Children's Hospital of Alabama ESRD (End Stage Renal Disease) 2019 rate of PD catheter-related infection was 4.2 per 100 PD patient-months, compared to 2.1 in Alabama, 2.7 in Network 8, and 2.1 nationally. Review of the facility January 2021 QAPI Meeting minutes for December 2020 Peritonitis and Tunnel Infections January 2020-December 2020 revealed the following: Total Patient month: January-218; February-228; March-236; April-247, May-260; June-274; July-290; August-304; September-319; October-335; November-348; December-363. Total Infection Episodes: January-15; February-16; March-18; April-19, May-19; June-21; July-23; August-23; September-23; October-23; November-23; December-24. Peritonitis Rate Total-January-14; February-14: March-13; April-13, May-13; June-13; July-13; August-13; September-14; October-14; November-15; December-15. In addition, the facility documented "PD Outcomes are Declining; Improvement Area, Yes; Action Plan Needed, Yes. If Yes, New Plan. The PD Infection Problems Statement was" Trend of increase tunnel infections. The Goal -Standardizing treatment of peritonitis, tunnel, and exit site infections. The Root Cause-Barriers documented were "Inconsistency of treatment for exit site infections." Review of the facility 2021 Hospitalization logs revealed in January 1 peritonitis hospitalization and 3 patients hospitalized for peritonitis in February 2021. Review of the facility QAPI Meeting Minutes documentation revealed in January 2021 there were 2 new Peritonitis infections and in February 2021 there were 3 new Peritonitis infections. There were no problem statements, goal, baseline data, root cause -Barriers documented. There was no action, start date, check point, end point documented and no responsible IDT members were identified. Review of facility documentation titled, Exit site/Peritonitis Apparent Cause Analysis Tool, included PI # 5 with the infection date 2/5/21, and an unsampled record with an infection date 2/11/21. There was no documentation the IDT identified potential contributing factors, lessons learned, and there was no action plan documented for 2 of 3 patients hospitalized February 2021 with exit site/peritonitis infections. Review of the QAPI Meeting Minutes documentation revealed 2 new Peritonitis infections in March 2021, in April 2021 2 new Peritonitis infections and in May 2021 there were 2 new Peritonitis infections and 1 tunnel infection reported. There were no problem statements, goals, baseline data root cause -barriers documented. There was no action, start date, check point, or end point documented, and no responsible IDT members were identified. In an interview on 6/24/21 at 1:55 PM, Employee Identifier # 1, Dialysis Coordinator the surveyor requested the facility action plan for improvement of PD infections. EI # 1 reported we review the numbers, discuss the cases each month and re-train the patient/caregiver. EI # 1 confirmed there was no documentation the facility implemented performance improvement actions and monitored the actions for effectiveness as identified during the January 2021 QAPI meeting.