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)
V0550 POC-VASCULAR ACCESS-MONITOR/REFERRALS
CFR(s): 494.90(a)(5)

The interdisciplinary team must provide vascular access monitoring and appropriate, timely referrals to achieve and sustain vascular access. The hemodialysis patient must be evaluated for the appropriate vascular access type, taking into consideration co-morbid conditions, other risk factors, and whether the patient is a potential candidate for arteriovenous fistula placement.


This STANDARD is not met as evidenced by:
Based on the review of the facility policy and procedure, medical records, and interviews, it was determined the staff failed to follow the policy and procedure for AV (arteriovenous) fistula (AVF) access site cleaning/antisepsis and document the type of disinfectant used prior to access site cannulation. This affected three of three in-center records with AVF/Grafts which included PI (Patient Identifier) # 2, PI # 3, PI # 4 and had the potential to negatively affect all in-center patients who dialyze at the facility. Findings include: Facility Policy: 1-04-01 Title: AV (arteriovenous) Fistula and Arteriovenous Graft (AVG) Vascular Access Care Revision Date: April 2022 Policy: 4. Patients are encouraged to wash access extremity with soap and water upon arrival...If unable to wash access site, patient care teammate will clean access extremity with skin cleanings agent... 7. Acceptable skin antiseptics may include: Povidone iodine (PVP) ExSept Plus only for skin Isopropyl 70 % alcohol NOTE: Use Isopropyl 70 % alcohol as the single skin antiseptic ONLY when the patient has documented allergies to other skin antiseptics... Facility Procedure: 1-04-01E Title: AV (arteriovenous) Fistula (AVF) or Graft Cannulation with Nipro or Medisystems Safety Fistula Needles (SFN) and Administration of heparin Loading Dose Revision Date: April 2022 ...Materials required: Liquid soap or other skin cleanings agent 70% alcohol preps ...Skin antiseptic ... Notes: Check for patient sensitivity to preferred skin antiseptic/skin disinfectant listed in table below. Use Isopropyl as the single skin antiseptic ONLY when the patient has documented allergies to other skin antiseptics. Skin Antiseptic Povidone Iodine... Hypochlorite (ExSept Plus)... Isopropyl Alcohol 70 %... Procedure 1. Have patient wash access site with...antibacterial soap...If unable...teammate will clean with...skin cleansing agent... 10. While maintain aseptic technique, prep (prepare) each planned needle site by applying a 70 % alcohol prep pad to each site... 12. For patients who have...allergy to povidone iodine or ExSept Plus, necessitating alcohol alone, apply alcohol... 1. PI # 2 was admitted to the facility on 5/24/19 with diagnoses including End Stage Renal Disease (ESRD). Review of the Patient Summary Report revealed orders dated 6/8/22 for dialysis treatment three times a week via an AVF. Review of the Treatment Details Reports dated 7/5/22, 7/7/22, 7/9/22, 7/12/22, 7/14/22, 7/16/22 revealed no documentation of AVF cleaning and antisepsis with an acceptable antiseptic agent appropriate for the patient. In an interview on 7/21/22 at 11:54 AM, EI (Employee Identifier) # 1, Facility Administrator confirmed staff failed to document access antisepsis. 2. PI # 3 was admitted to the facility on 3/19/21 with diagnoses including ESRD. Review of the Patient Summary Report revealed orders dated 6/28/22 for dialysis treatment three times a week via an AVF. Review of the Treatment Details Report dated 7/5/22, 7/7/22, 7/9/22, 7/12/22, 7/14/22, 7/16/22 revealed no documentation of AVF cleaning and antisepsis with an acceptable antiseptic agent appropriate for the patient. In an interview was conducted on 7/21/22 at 12:04 PM, EI # 1 confirmed the staff failed to document AVF antisepsis. 39098 3. PI # 4 was admitted to the facility on 5/16/22 with diagnoses including ESRD. Review of the Patient Summary Report revealed orders dated 7/7/22 for dialysis treatments three times a week with access type: AV Graft. Review of 5 Treatment Details Reports dated 7/5/22, 7/9/22, 7/12/22, 7/14/22, and 7/16/22 revealed no documentation of AVG cleaning and antisepsis with an acceptable antiseptic agent appropriate for the patient. An interview was conducted on 7/21/22 at 10:48 AM with EI # 1, who confirmed staff failed to document access antisepsis.