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)
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 observations, review of facility policy, the Vaccinations and Surveillance Report, medical records, and interviews, it was determined the facility failed to ensure a teammate caring for a confirmed Hepatitis B surface antigen positive (HBsAg) patient, did not care for a surface antibody negative (susceptible/ non-immune) patient simultaneously. This affected one of two Hepatitis B surface antibody negative (susceptible) patients, including Patient Identifier (PI) # 22, who dialyzed at the same time as a HBsAg positive patient, PI # 20. This had the potential to negatively affect all susceptible (non-immune) 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: 1. HBV (Hepatitis B Virus) serological status... and Hepatitis B Surface Antibody... of all patients should be known before admission to the hemodialysis facility. ...4. All patients will be routinely tested... 5. Results will be reviewed promptly to verify patients are managed appropriately based on their testing results. 6. Documentation of the following will remain in the patient's current active medical record: a. HBV serology results... 20. Seating a. Hepatitis B surface antibody positive (immune as evidenced by HBsAb greater than or equal to ( > ) 10) or core positive patients are seated between the confirmed or suspect hepatitis B surface antigen (HBsAg) positive patient and the susceptible patient to serve as a geographic buffer. 21. Teammate Assignment a. Teammates caring for confirmed or suspect hepatitis B surface antigen positive (HBsAg) patients do not care for surface antibody negative (susceptible) patients simultaneously and will only be assigned to care for surface antibody positive (immune) patients. 1. PI # 22 was admitted to the facility on 6/11/19 with diagnoses including ESRD (End Stage Renal Disease). Review of the Vaccinations and Surveillance Report, printed on 7/19/22 at 10:30 AM revealed PI # 22's Hepatitis B surveillance status was "Immune." Further review of the report listed PI # 22's HBsAb results dated 3/23/22 as 6 (six), and 6/22/22 as 4 (four), which was less than 10, and therefore not immune. An interview was conducted on 7/19/22 at 3:00 PM with Employee Identifier (EI) # 10, Manager of Clinical Services, who reported the buffer zone stations were 1 (one), 2 (two), 3 (three), 11, 12, 13, and 14. Review of the facility seating chart dated 7/20/22 revealed PI # 22 was assigned to sit at station 14, and scheduled to dialyze from 4:45 AM to 8:00 AM. A hepatitis B positive patient was scheduled to dialyze in the isolation room from 4:45 AM to 8:15 AM. An observation of care on the treatment floor was conducted on 7/20/22 at 7:45 AM. PI # 22 was dialyzing at station 13, which was in the buffer zone. PI # 20, a Hepatitis B positive patient, was dialyzing in the isolation room. EI # 6, Registered Nurse, was observed in the isolation room wearing gown, face shield, and gloves. Review of PI # 22's Treatment Sheet dated 7/20/22 revealed EI # 6 administered Heparin infusion, start time 4:54 AM and ended at 7:39 AM, Epogen 800 units, intravenous push at 5:05 AM, and Calcitriol 0.25 micrograms, oral, at 5:11 AM. Review of PI # 20's Treatment Sheet dated 7/20/22 revealed EI # 6 provided all care for PI # 20 in the isolation room, including initiating dialysis, administering IV medications, collecting blood for lab tests, and monitoring during dialysis, which ended at 9:16 AM. EI # 6 provided care for a Hepatitis B positive patient, and a susceptible patient at the same time, thereby putting PI # 22 at an increased risk of Hepatitis B infection. An interview was conducted on 7/21/22 at 1:10 PM with EI # 1, Facility Administrator, who confirmed the buffer zone stations were 1 (one), 2 (two), 3 (three), 11, 12, 13, and 14. EI # 1 further confirmed EI # 6 simultaneously cared for PI # 20 and PI # 22, which was not per policy.