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 012507 (X3) Date Survey Completed 03/14/2019
Name of Provider or Supplier Fresenius Kidney Care Mobile Street Address, City, State 2620 Old Shell Road, Mobile, 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)
V0111 IC-SANITARY ENVIRONMENT
CFR(s): 494.30

The dialysis facility must provide and monitor a sanitary environment to minimize the transmission of infectious agents within and between the unit and any adjacent hospital or other public areas.


This STANDARD is not met as evidenced by:
Based on observations, facility procedure and interview, it was determined the staff failed to follow their own policy for bleach preparation and storage. This had the potential to negatively affect all patients who dialyze at the facility. Findings include: Facility Procedure: Mixing Bleach FMS-CS-IC-II-155-110C5 Revision Date: 20-March-2013 ...Procedure: Follow the steps below for mixing bleach: 2...Measuring...1:100=1 part bleach + (plus) 100 parts water...1:10=1 part bleach +10 parts water... 4. Label opaque container with "Bleach Solution", strength of solution.. 6 Discard solution daily... Observations of care were conducted on 3/12/19 at 7:45 AM. There were 5 plastic containers which contained clear solutions on the supply carts on both sides of the patient treatment area and on the counter next to the dirty sink in the back of the treatment area. There was no documentation of what solution was in the containers. In an interview on 3/12/19 at 8:00 AM, the surveyor asked Employee Identifier (EI) # 4, Certified Clinical Hemodialysis Technician, what was in the containers? EI # 4 reported bleach. The plastic bleach containers were not labeled with the contents and the containers were not labeled with the strength of bleach solution. EI # 4 confirmed the above findings.