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 012502 (X3) Date Survey Completed 01/08/2020
Name of Provider or Supplier Tuscaloosa University Dialysis Street Address, City, State 220 15th Street, Tuscaloosa, 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)
V0111 IC-SANITARY ENVIRONMENT
CFR(s): 494.30

The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas.


This STANDARD is not met as evidenced by:
Based on observation, review of facility policy and procedure and interviews, it was determined the facility failed to ensure the staff: a) Maintained a safe and sanitary environment for all patients and staff. b) Followed the facility policy for the initiation of a dialysis treatment with an arteriovenous fistula (AVF). This affected 1 of 2 observations conducted, 1 of 4 patients interviewed, and did affect PI (Patient Identifier) # 2, PI # 11 and had the potential to negatively affect all patients served by the facility. Findings include: Title: AV Fistula or Graft Cannulation With Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of Heparin Loading Dose. Policy Number: 1-04-01E Revised Date: April 2019 Procedure: 8. Locate and palpate the needle cannulation sites prior to skin preparation... 10. While maintain aseptic technique, prep each planned needle site by applying a 70% alcohol prep pad to each site using a circular rubbing motion, center out... 13. Do not palpate insertion site once area has been prepped... Policy: Infection Control for Dialysis Facilities Policy Number: 1-05-01 Revision Date: October 2019 Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. ...Wall Box and Drain/Water Line Care and Maintenance ...61. ...The presence of flies (drain flies, sink flies, filter flies or sewer gnats which are small true flies with short, hairy bodies and wings...) will prompt a report to the Facility Administrator and Biomedical Services for advanced drain care options. 1. During observations of care on 1/8/2020 from 10:00 AM to 2:00 PM, the surveyor observed gnats flying at station # 1, # 6, # 10, and near the treatment exit door. An interview was conducted on 1/8/2020 at 1:00 PM during observation of care with PI # 2 at station # 10. The surveyor asked PI # 2 if she/he had observed gnats in the facility before today. She/he answered, "Yes." During an interview on 1/8/2020 at 2:30 PM with Employee Identifier (EI) # 1, Facility Administrator, the surveyor requested an invoice from the pest control company's last visit. EI # 1 stated there was none, but provided the surveyor a copy of the bill received for December 2019 services, and a copy of the pest control contract. 2. During observations of care on 1/6/2020 at 10:25 AM the surveyor observed EI # 2, Certified Clinical Hemodialysis Technician, prepping the sites with an antiseptic for cannulation of PI # 11 at station # 14. After the sites were prepped EI # 2 then palpated/touched both sites with his/her fingers without repeating skin antisepsis before cannulation, thus leading to potential contamination. An interview was conducted on 1/8/2020 with EI # 1 at 12:22 PM who verified staff failed to follow the facility policy for accessing of an AV Fistula. 3. During a flash tour of the Peritoneal Dialysis Room on 1/6/2020 at 1:15 PM the surveyor observed the 2 walls behind the dialysis chair with multiple stains, black marks and paint peeling. The rolling stool legs were completely covered with rust. An interview was conducted on 1/6/2020 at 1:23 PM with EI # 1 who verified the above findings, and stated, "We are aware of how it look's and we are told that we are due for an upgrade to the facility this year". 39098