Statement of Deficiencies

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)

V0681

PQ-STAFF LIC AS REQ/QUAL/DEMO COMPETENCY
CFR(s): 494.140

All dialysis facility staff must meet the applicable scope of practice board and licensure requirements in effect in the State in which they are employed. The dialysis facility's staff (employee or contractor) must meet the personnel qualifications and demonstrated competencies necessary to serve collectively the comprehensive needs of the patients. The dialysis facility's staff must have the ability to demonstrate and sustain the skills needed to perform the specific duties of their positions.

This STANDARD is not met as evidenced by:
Based on review of facility policies, facility personnel record, and interview, it was determined facility failed to ensure the Certified Clinical Hemodialysis Technician (CCHT) was competent to reinfuse the extracorporeal circuit for a patient who dialyzed via a Central Venous Catheter (CVC). This affected Patient Identifier (PI) # 6, one of two patients observed for discontinuation of dialysis with a CVC and had the potential to negatively affect all patients with a CVC served by this facility. Findings Include: Facility Policy Title: Knowledge, Skills and Competency Evaluation for Clinical Staff Published: 10/12/21 Version: 3 Purpose ...provides all clinical field employees with initial and ongoing development and evaluation of the knowledge and skills essential for a...well-trained workforce. Policy ...Employees are required to successfully complete all skills requirements, including an initial and annual skills validation... Employees without current documented competency...may be removed from performing independent direct patient care...until competency is demonstrated and documented... Facility Policy: Termination of Treatment Using a Central Venous Catheter and Optiflux Single Use Ebeam Dialyzer Published: 2/7/22 Reference Number: 45640 Version 7 Purpose: The purpose of this policy is to provide direction to reinfuse blood in the extracorporeal system to the patient at completion of the hemodialysis treatment using a Central Venous Catheter (CVC) and an Optiflux Single Use electron beam Dialyzer. Responsibility: ...Direct Patient Care Staff (based on job description, license, certification, Federal/State Regulation). Qualifications: Refer to Eligibility and Performance Requirements Policy for mandatory qualifications for a ...Patient Care Technician (PCT)....to provide hemodialysis catheter care and initiating and terminating treatments as permitted by State Regulation and or State Nursing Practice Acts and under the delegation of duties by the registered nurse... 1. On 3/29/23 at 11:00 AM, an observation of care was conducted at station 14 with EI (Employee Identifier) # 5, CCHT. EI # 5 paused the dialysis treatment, turned the blood flow to 200, squeezed (with his/her hands) the normal saline solution bag hanging from the IV (intravenous), then reinfused the extracorporeal circuit via a CVC. Review of EI # 5's personnel file documentation revealed the hire date was 7/25/22. EI # 5's personnel file included a Direct Patient Care Skills Validation Checklist dated 10/12/22 which revealed CVC Components for discontinuation of dialysis via a CVC was marked NA (not applicable). An interview was conducted on 3/30/23 at 10:02 AM with EI # 1, Facility Administrator, who verified staff should be competent to perform the task per facility policy. EI # 1 confirmed there was no documentation EI # 5 was competent to reinfuse the extracorporeal circuit with a CVC.