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)
V0196 CARBON ADSORP-MONITOR, TEST FREQUENCY
CFR(s): 494.40(a)

6.2.5 Carbon adsorption: monitoring, testing freq Testing for free chlorine, chloramine, or total chlorine should be performed at the beginning of each treatment day prior to patients initiating treatment and again prior to the beginning of each patient shift. If there are no set patient shifts, testing should be performed approximately every 4 hours. Results of monitoring of free chlorine, chloramine, or total chlorine should be recorded in a log sheet. Testing for free chlorine, chloramine, or total chlorine can be accomplished using the N.N-diethyl-p-phenylene-diamine (DPD) based test kits or dip-and-read test strips. On-line monitors can be used to measure chloramine concentrations. Whichever test system is used, it must have sufficient sensitivity and specificity to resolve the maximum levels described in [AAMI] 4.1.1 (Table 1) [which is a maximum level of 0.1 mg/L]. Samples should be drawn when the system has been operating for at least 15 minutes. The analysis should be performed on-site, since chloramine levels will decrease if the sample is not assayed promptly.


This STANDARD is not met as evidenced by:
Based on observation, review of procedure, and interview, it was determined the facility failed to ensure the CCHT (Certified Clinical Hemodialysis Technician) performed the Total Chlorine Test per policy. This had the potential to affect all patients dialyzing at the facility. Findings include: Procedure: Serim Hisense Ultra 0.1 Test for Total Chlorine in Feed or Rinse Water Procedure Number: 2-05-02G Revision Date: March 2015 Procedure: ...4. Remove test strip from the test water and shake to remove excess sample. Immediately compare reacted test strip to the color chart on Serim Hisense Ultra 0.1 test bottle. Rationale: Delaying comparison of the reacted test strip with the color chart may cause test results to be reported inaccurately. On 1/6/2020 at 12:00 PM the surveyor observed Employee Identifier (EI) # 2, CCHT (Certified Clinical Hemodialysis Technician), perform a total chlorine water test. The CCHT performed a chlorine test using the Serim Hisense Ultra test strip, and then discarded the strip and water sample. EI # 2 then stated she/he was going to do the test again to take to the treatment floor for the nurse to confirm results. EI # 2 obtained another sample and another test strip. After removing the test strip from the sample, EI # 2 proceeded to the treatment floor. Once inside door, EI # 2 took the strip and bottle to EI #9, RN (Registered Nurse) for verification of results, which was 45 seconds after the test was completed. An interview was conducted on 1/8/2020 at 1:45 PM with EI # 2, who confirmed she had verified the results.