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)
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: Facility Policy: Hepatitis B Surveillance, Vaccination, Infection Control Measures and Isolation Guidance Policy number: 1-05-02 Revision Date: October 2021 Purpose: To prevent the spread of Hepatitis B infections in the dialysis setting. Policy: ...Dialyzing Confirmed Positive or Suspected/ Unknown Status ...15. Confirmed positive patients are dialyzed in an isolation room... Infection Control Measures for Confirmed Positive or Suspected/ Unknown Status ...19. Equipment/ Supplies a. Dedicated ancillary supplies such as ...bleach buckets, sharps' container... centrifuge, and non-disposable items will be used. b. Such supplies will be labeled "isolation" and will remain in the isolation room/ area or station and be disinfected after every patient use... 1. On 7/19/22 from 3:45 PM to 4:15 PM observations were made with EI (Employee Identifier) # 1, Facility Administrator in the isolation room during inspection of the equipment/supplies housed in the isolation unit. There was no isolation label on the following equipment/supplies: Patient treatment chair Centrifuge Scale Sharps container Plastic dialysis supply container IV (Intravenous) pole Three plastic bleach containers with lids Patient privacy screen Mop In an interview conducted on 7/19/22 at 4:10 PM during the inspection, EI # 1 confirmed all equipment and supplies in the isolation room were not labeled and designated for isolation only use.