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)
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 policies / procedures and interviews, it was determined the facility failed to ensure: 1. Staff followed the facility procedure for monitoring dialysate conductivity prior to treatment initiation 2. Staff rinsed the Myron L meter with dialysis quality water post testing. 3. The hemodialysis machine conductivity was within acceptable range +/- 0.4 mS (millisiemens) of the manual conductivity testing. This affected 2 of 6 in-center hemodialysis records reviewed, including Patient Identifier (PI) # 6 and PI # 7 and had the potential to negatively affect all patients who dialyze at this facility. Findings include: Facility Procedure: Title: Testing Dialysate Conductivity with Dual Range Myron L Meter (D-2) Procedure: 2-08-01E ... Procedure: ... 3. Obtain proportioned dialysate sample per manufacture's recommendations. 4. Rinse meter by filling cell cup with sample above top electrode and dropping plunger into sample to be tested 3 or 4 times and discard. Perform this step at least three (3) times. Rationale: 4. Verifies that any prior sample solution has been rinsed free from the cell. Procedure: 5. Fill cell cup with sample so upper electrode is immersed. Insert plunger. Press Read/Check battery button and read conductivity on appropriate scale. Rationale: 5. If electrode is not immersed, results may be affected. Procedure: 6. Repeat step % 3 twice and record the last reading... 9. When test is complete, rinse cell cup and plunger with dialysis quality water... Facility Policy Title: Testing pH and Conductivity if Proportioned Dialysate and verification of Temperature of Proportioned Dialysate Policy: 1-03-02 Purpose: To provide guidance for testing and documenting pH, conductivity and temperature of proportioned dialysate. Policy: ... 4. The acceptable range for machine displayed and final dialysate conductivity is 12-15.5 mS. (See step 5 below.) If the physician orders dialysate sodium of 136 or less in specific circumstances, then the acceptable range for final dialysate conductivity is 12.8 - 15.5 mS. If the machine displayed and final dialysate conductivity is not within this range, do not initiate treatment and investigate the reason the values are outside the acceptable range. 5. The final dialysate conductivity should be checked with approved independent meter. Independent meter reading should be +/- 0.4 mS of the machine displayed conductivity based on your facility's machine type: Fresenius Machine - TCD... (Note: This facility utilizes Fresenius 2008K machines) On 7/24/18 at 11:24 AM, the surveyor observed Employee Identifier (EI) # 4, Certified Clinical Hemodialysis Technician (CCHT) perform testing of dialysate. EI # 4 filled, rinsed and emptied the cup on the plunger three (3) times with dialysate sample. EI # 4 poured the next sample of the dialysate into the cell cup of the Myron L meter, then tested the sample. On 7/24/18 at 12:01 PM, the surveyor observed EI # 5, CCHT perform testing of dialysate. . EI # 5 filled, rinsed and emptied the cup on the plunger one (1) time with dialysate sample. EI # 5 poured the next sample of the dialysate into the cell cup of the Myron L meter, then tested the sample. Both EI # 4 and EI # 5 failed to rinse the cell cup of the Myron L with dialysate 3 or 4 times prior to testing the sample and failed to rinse the Myron L with dialysate quality water after testing was completed. 1. PI # 6 was admitted to this facility on 7/7/14 with End Stage Renal Disease (ESRD) and was receiving in-center hemodialysis three times a week. Review of the Post Treatment Flowsheet dated 6/11/18 revealed the manual conductivity was 14.1 and the machine conductivity was 13.6, which was 0.5 mS greater than the machine conductivity. An interview was conducted on 7/26/18 at 11:35 AM with EI # 1, Facility Administrator, who verified the above findings. 2. PI # 7 was admitted to this facility on 12/21/16 with ESRD and was receiving in-center hemodialysis three times a week. Review of the Post Treatment Flowsheet dated 7/12/18 revealed the manual conductivity was 14.4 and the machine conductivity was 13.6, which was 0.8 mS greater than the machine conductivity. Review of the Post Treatment Flowsheet dated 7/17/18 revealed the manual conductivity was 14.1 and the machine conductivity was 13.6, which was 0.5 mS greater than the machine conductivity. An interview was conducted on 7/26/18 at 11:53 AM with EI # 1, who verified the above findings.