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 07/21/2022
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)
V0116 IC-IF TO STATION=DISP/DEDICATE OR DISINFECT
CFR(s): 494.30(a)(1)(i)

Items taken into the dialysis station should either be disposed of, dedicated for use only on a single patient, or cleaned and disinfected before being taken to a common clean area or used on another patient. -- Nondisposable items that cannot be cleaned and disinfected (e.g., adhesive tape, cloth covered blood pressure cuffs) should be dedicated for use only on a single patient. -- Unused medications (including multiple dose vials containing diluents) or supplies (syringes, alcohol swabs, etc.) taken to the patient's station should be used only for that patient and should not be returned to a common clean area or used on other patients.


This STANDARD is not met as evidenced by:
Based on observations, review of facility policy and interview, it was determined the facility failed to ensure the staff cleaned and disinfected equipment before returning it to a common clean area or being used on another patient. This did affect one of three observations conducted for access of AV (arteriovenous fistula) or graft for initiation of dialysis including Patient Identifier (PI) # 18 and had the potential to negatively affect all patients served by the facility. Findings include: Facility Policy: Infection Control for Dialysis Facilities Policy Number: 1-05-01 Date Revised: October 2021 Purpose: To minimize the spread of infections or blood borne pathogens in the dialysis facility environment. ...Dialysis Station Management ...65. Items taken into the dialysis station will be... cleaned and disinfected before taken to a common clean area or used on another patient... 1. On 7/20/22 at 9:05 AM at station 13, during an observation of access of AV initiation for dialysis treatment for PI # 18, Employee Identifier (EI) # 5, CCHT (Certified Clinical Hemodialysis Technician) took PI # 18's temperature then placed the thermometer in the open drawer beneath the computer at station 13. EI # 5 did not clean/disinfect the thermometer after use and before storing the thermometer at the station. At 9:11 AM, EI # 9, CCHT entered station 13, retrieved the thermometer and exited station 13. EI # 9 then used the dirty thermometer on an unsampled patient at station 7. Staff failed to ensure all re-usable equipment was cleaned/disinfected between patients. An interview was conducted on 7/21/22 at 12:10 PM with EI # 1, Facility Administrator, who confirmed the staff failed to follow the policy, clean and disinfect the thermometer before use on another patient.