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 012501 (X3) Date Survey Completed 06/30/2021
Name of Provider or Supplier Gadsden Dialysis Street Address, City, State 409 South First Street, Gadsden, 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)
V0250 DIALYS PROPORT-MONITOR PH/CONDUCTIVITY
CFR(s): 494.40(a)

5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer's instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient.


This STANDARD is not met as evidenced by:
Based on observations, review of facility procedure and interview with facility staff, it was determined the staff failed to follow the facility procedure for testing dialysate conductivity prior to treatment initiation. This affected 1 of 2 observations, including Patient Identifier (PI) # 7 and had the potential to negatively affect all patients who dialyze at this facility. Findings include: Title: Operation of Portable Myron L Conductivity Meter (D-1) Procedure: 2-08-01 B Revision Date: April 2019 Material required: Myron L dialysate meter ...Dialysis quality water obtained fresh daily Procedure 10. When you are finished...RINSE thoroughly with dialysis quality water... 1. An observation was conducted on 6/28/21 at 8:15AM to observe Employee Identifier (EI) # 6, Certified Clinical Hemodialysis Technician, perform conductivity testing at station 6 prior to arrival of PI # 7. After conductivity testing was complete EI # 6 failed to rinse the meter thoroughly with dialysis quality water after use as directed per the facility policy. An interview was conducted on 6/30/21 at 11:50 AM with EI # 1, Facility Administrator, who verified the staff failed to follow the facility procedure for testing dialysate conductivity prior to treatment initiation.