Statement of Deficiencies

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)

V0131

IC-HBV-ISOLATION-STAFFING
CFR(s): 494.30(a)(1)(i)

Isolation of HBV+ Patients Staff members caring for HBsAg positive patients should not care for HBV susceptible patients at the same time, including during the period when dialysis is terminated on one patient and initiated on another.

This STANDARD is not met as evidenced by:
Based on review of facility policy, the Hepatitis B Report, team staffing schedule, Patient Call Back Schedule, medical records and interviews with facility staff, it was determined the facility failed to follow the facility policy and ensure teammates caring for confirmed or suspect hepatitis B surface antigen positive (HBsAg) positive patient (s) do not care for surface antibody negative (susceptible/ non-immune) patients simultaneously. This affected 5 of 5 Hepatitis surface antibody negative (susceptible) patients, which included Patient Identifiers' (PI) # 14, 15, 16, 17 and 18 who dialyzed at the same time as HBsAg positive patients. This had the potential to negatively affect all susceptible (non-immune) patients and staff. Findings include: POLICY: 1-05-09 Title: Infection Control and Isolation Measures for Known or Suspected Hepatitis B Surface Antigen Positive Patients 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. "...Patient Seating and Teammate Assignments 33. Surface antibody positive (immune) patients are seated between the confirmed hepatitis B surface antigen (HBsAg) positive patient and the susceptible patient to serve as a geographical buffer. 34. Teammates caring for confirmed or suspect hepatitis B surface antigen positive (HBsAg) positive patient(s) do not care for surface antibody negative (susceptible) patients simultaneously. 35. When preparing patient assignments, teammates who care for confirmed or suspected hepatitis B surface antigen (HBsAg) positive patient (s) will only be assigned to simultaneously care for surface positive (immune) patients. 39. It is recognized that some small facilities may only have one (1) nurse on duty per shift...In such cases...verify all other patients scheduled for treatment on the same shift as a HBsAG positive patient...are immune. Scheduling HBsAg positive patient at the end of the day...after ALL Susceptible patients have completed treatment AND exited the treatment area. 40. Facilities that are unable to meet there requirements above will make arrangements with another facility...to accept HBsAg + patients in accordance with CMS (Centers for Medicare and Medicaid Services)..." **** During the facility entrance conference on 7/24/18 at 8:15 AM, Employee Identifier (EI) # 2, Clinical Nurse Manager (CNM) reported the facility had an isolation unit with 1 HBsAg positive patient, Patient Identifier (PI) # 19 who dialyzed on Monday, Wednesday and Friday (M/W/F) on first shift and 1 HBsAg positive patient, PI # 20 who dialyzed on second shift. Observations of care on 7/24/18 from 8:30 AM to 12:40 PM revealed 1 Registered Nurse (RN), EI # 2, the CNM providing care for all facility patients. Review of the facility team staffing schedule for July submitted to the surveyor on 7/24/18 revealed 1 RN scheduled to work on Monday 7/2/18, on Wednesday 7/4/18, on Friday 7/14/18 and on Friday 7/27/18. Review of the Patient Call Back Schedule submitted to the surveyor on 7/24/18 revealed that on M/W/F, 1 HBsAg positive, PI # 19 scheduled for first shift and 2 HBV susceptible patients for first shift. On second shift, there was 1 HBsAg positive patient, PI # 20 and 3 HBV susceptible patients scheduled. In an interview conducted on 7/25/18 at 10:05 AM, EI # 2 reported there were not always 2 RN's to work on M/W/F, which was the days both HBV + patients dialyzed. EI # 2 verified one RN would care for both HBsAg positive and HBV susceptible patients at the same time. Review of the Hepatitis Report provided to the surveyor on 7/24/18 confirmed PI's # 14, # 15,# 16, # 17 and # 18 were HBsAg negative with hepatitis B antibodies less than 10, insufficient for protection against HBV. Review of facility post treatment report documentation on the following dates revealed EI # 3, RN and EI # 2, CNM provided care simultaneously to HBsAg positive and HBV susceptible: On 7/2/18 and 7/4/18 first shift, EI # 3 cared for HBsAg positive, PI # 19 and HBV susceptible patients, PI # 14 and PI # 15. On 7/2/18 and 7/4/18 second shift, EI # 3 cared for HBsAg positive PI # 20 and PI # 16 and # PI # 17, both susceptible. On 7/13/18 first shift, EI # 3 cared for PI # 19 HBsAg positive and PI # 14 and # 18, both HBV susceptible. On 7/13/18 second shift, EI # 3 and EI # 2 provided care to HBsAg positive patients and PI # 17, susceptible patient. EI # 3 also cared for and susceptible, PI # 16. On 7/16/18 first shift, EI # 3 cared for PI # 19 HBsAg positive and PI # 14 and # 18, both susceptible. On 7/16/18 second shift, EI # 2 provided care to HBsAg positive PI # 20, and HBV susceptible, PI # 17. On 7/18/18 first shift, EI # 3 provided care to HBsAg positive patient, PI # 19 and PI # 18, who was susceptible. In an interview on 7/26/18 at 12:00 PM, EI # 1, Facility Administrator reported all facilities were short staffed. EI # 2, CNM and EI # 1 both confirmed they knew 1 RN was scheduled to provide care for both HBsAg positive and surface antibody negative (susceptible) patients simultaneously.