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 012509 (X3) Date Survey Completed 03/30/2023
Name of Provider or Supplier North Alabama Nephrology Center Street Address, City, State 1311 North Memorial Parkway #200, Huntsville, 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)
V0119 IC-SUPPLY CART DISTANT/NO SUPPLIES IN POCKETS
CFR(s): 494.30(a)(1)(i)

If a common supply cart is used to store clean supplies in the patient treatment area, this cart should remain in a designated area at a sufficient distance from patient stations to avoid contamination with blood. Such carts should not be moved between stations to distribute supplies. Do not carry medication vials, syringes, alcohol swabs or supplies in pockets.


This STANDARD is not met as evidenced by:
Based on observation, review of facility policy and procedure, and interview, it was determined the facility failed to ensure staff disinfected the dialysis station before patient supplies were set up per facility policy. This had the potential to negatively affect all patients who dialyzed at the facility. Findings include: Facility Policy: Cleaning and Disinfection of the Dialysis Station Reference Number: 47806 Published: 11/07/2022 Version: 13 Purpose The purpose of this policy is to provide guidelines to prevent the spread of infectious disease in accordance with appropriate regulations, and to maintain a clean, safe, and aesthetically pleasant environment for patients, staff, and visitors. Responsibility All dialysis facility staff Background The Centers for Medicare and Medicaid Services (CMS) has regulations that in order to prevent contamination, a dialysis station must be cleaned and disinfected between dialysis patients. The chair and dialysis equipment are used by multiple patients during a treatment, and it is critical that these be thoroughly cleaned and disinfected between uses. Definition Dialysis Station: Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment... Equipment in the dialysis station may include... the following: Dialysis machine/cycler and attachments such as IV (Intravenous) pole, B/P (Blood Pressure) cuff... Chair/bed General Cleaning The dialysis station could become contaminated with blood and other body fluids during treatment. Work Surface Cleaning and Disinfection without Visible Blood using Bleach Solutions. All work surfaces shall be cleaned and disinfected with 1:100 bleach solution after completion of procedures. Make the surface glistening wet and let air dry unless otherwise specified by the manufacturer. Vacating the Machine To prevent cross-contamination between patients...the previous patient...vacate the station before staff begin cleaning and disinfection of the station and set up for the next patient. For patients dialyzing in a treatment area where multiple patients dialyze...vacate the dialysis station before the dialysis machine can be externally disinfected, allowed to dry and set up for the next treatment. Procedure Follow the steps below to disinfect the dialysis station after each dialysis treatment: Step: ...3. Use a cloth wetted with 1:100 bleach solution... to clean and disinfect the dialysis station (chair/bed, tables, machine, television, IV pole, B/P cuff... chaise wall behind chair... 4. Clean all surfaces... 1. On 3/29/23 at 9:22 AM, the surveyor observed EI (Employee Identifier) # 6, CCHT (Certified Clinical Hemodialysis Technician) clean/disinfect the dialysis machine at station 4. After EI # 6 disinfected the dialysis machine, EI # 6 cleaned the left chairside table top, exited the station and returned with patient supplies, a dialyzer, saline solution bag and dialysis lines and proceeded to set up the saline solution, prime the dialysis lines and dialyzer. EI # 6 failed to complete the dialysis station disinfection before patient supplies were brought to the station and treatment set up for the next patient had begun. In an interview conducted on 3/30/23 at 10:05 AM, EI # 1, Facility Administrator confirmed staff failed to follow the facility policy and disinfect the dialysis station before setting up the dialysis machine for the patient.