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 012505 (X3) Date Survey Completed 07/26/2018
Name of Provider or Supplier Physicians Choice Dialysis-Montgomery Street Address, City, State 1001 Forest Avenue, Montgomery, 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)
V0130 IC-HBV-ISOLATION-MACHINES/EQUIP/SUPPLIES
CFR(s): 494.30(a)(1)(i)

Isolation of HBV+ Patients To isolate HBsAg positive patients, ... dedicate machines, equipment, instruments, supplies, and medications that will not be used by HBV susceptible patients.


This STANDARD is not met as evidenced by:
Based on observation, review of facility policy, and interviews, it was determined the facility failed to ensure all equipment used in the isolation room was designated and labeled for "isolation" only. This had the potential to affect all Hepatitis B susceptible patients and staff at the facility. Findings include: Title: Infection Control and Isolation Measures for known or Suspected Hepatitis B Surface Antigen Positive Patients Policy #: 1-05-09 Revision Date: April 2017 Purpose: To provide additional infection control measures for care of the suspected or confirmed hepatitis B surface antigen (HBsAg) positive patient. Note: Policy will be followed at all times. In addition, teammates caring for the hepatitis B surface antigen positive (HBsAg) patient will observe the following precautions... Confirmed Hepatitis B Surface Antigen Positive "...2. Patients who are confirmed hepatitis B surface antigen positive (HBsAg) are dialyzed on a dialysis delivery system dedicated for use by surface antigen positive...patients only... 3. A dialysis delivery system dedicated for use only by Hepatitis B surface antigen positive (HB sAg) patients will be used. Establishing an Isolation Area/Room... 17. Ancillary supplies such as blood pressure cuffs, clamps, tourniquets, stethoscope, blood glucose meter, bicarb/dialysate jugs, bleach buckets, sharps container, thermometer, pens, centrifuge, and non-disposable items are designated for use by ... (HBsAg) positive patients only. Such supplies will be labeled "isolation" and will remain in the isolation room/area and be disinfected after every patient use with a 1:100 (one to one hundred) bleach solution..." 1. On 7/25/18 at 9:30 AM, following observations of care with Employee Identifier # 3, Registered Nurse, the isolation station equipment was inspected. There was no isolation label on the following equipment/supplies: Dialysis machine # 18 Patient treatment chair IV (intravenous) medication pump Centrifuge Glucometer Stethoscope Computer Terminal Sharps and and biohazard container Plastic dialysis supply container Bleach containers 1 Chair and 1 stool An interview conducted on 7/26/18 at 12:00 PM. EI # 1, Facility Administrator confirmed the findings above.