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 012506 (X3) Date Survey Completed 04/13/2023
Name of Provider or Supplier Dothan Dialysis Street Address, City, State 216 Graceland Drive, Dothan, 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 an observation, facility policy, and interviews, it was determined the facility failed to ensure: 1. Non-disposable items were disinfected after each patient use, prior to the removal from the treatment area/station. 2. Unused supplies taken into the station were not returned to a common clean area. This affected one of five discontinuation of dialysis with an AVF/AVG (arteriovenous fistula/graft), including Patient Identifier (PI) # 10 and one of four preparation of the hemodialysis (HD) machine/extracorporeal circuit observation, including PI # 9 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 Revision date: April 2023 Purpose: To minimize the spread of infections or bloodborne pathogens in the dialysis facility environment. Supplies ...10. Unused supplies...taken into the station...should not be returned to a common clean area... Disinfection ...14. Non-disposable items are to be disinfected after each patient use, prior to removal from treatment area/station... 1. An observation was conducted on 4/11/23 at 12:05 PM at station 18 with Employee Identifier (EI) # 9, Patient Care Technician (PCT), to observe the discontinuation of dialysis and post dialysis AVF/AVG access care for PI # 10. Prior to the initiation of the procedure, EI # 9 obtained a clipboard from the nurses station and placed a form on the clipboard. EI # 9 proceeded to enter station 18 and hand the clipboard to PI # 10. PI # 10 held the clipboard to sign the paper on the clipboard then handed the clipboard back to EI # 9. EI # 9 then exited the station and laid the clipboard on the counter of the nurses station. EI # 9 failed to disinfect the clipboard after the patient use prior to the removal of the clipboard from the treatment station. An interview was conducted on 4/13/23 at 11:04 AM with EI # 1, Facility Administrator, who confirmed EI # 9 failed to disinfect the clipboard after the patient use prior to the removal of the clipboard from the treatment station per the facility policy. 2. An observation was conducted on 4/12/23 at 9:55 AM with EI # 9, to observe the preparation of the HD machine/extracorporeal circuit for PI # 9. During the observation, EI # 9 obtained an unused Solcart B (bicarbonate) Cartridge from station 11's counter and placed the cartridge with the common clean supplies. An interview was conducted on 4/13/23 at 11:04 AM with EI # 1 who confirmed EI # 9 failed to not return unused supplies taken into a dialysis station to a common clean area.