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 012513 (X3) Date Survey Completed 07/14/2021
Name of Provider or Supplier Bma Langdale Street Address, City, State 8 Medical Park North, Valley, 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)
V0250 DIALYS PROPORT-MONITOR PH/CONDUCTIVITY
CFR(s): 494.40(a)

5.6 Dialysate proportioning: monitor pH/conductivity It is necessary for the operator to follow the manufacturer's instructions regarding dialysate conductivity and to measure approximate pH with an independent method before starting the treatment of the next patient.


This STANDARD is not met as evidenced by:
Based on observations, review of policy and procedure and interview it was determined the staff failed to rinse the pHoenix meter after each use per facility policy. This affected 4 of 4 observations and had the potential to negatively affect all patients who dialyze at this facility. Findings include: Facility Policy: Checking Conductivity and pH of Final Dialysate Published: 8/03/2020 Version: 7 Purpose: The purpose of this policy is to provide guidelines to verify final dialysate conductivity and pH prior to initiating hemodialysis treatments... Testing with pHoenix Meter Step 6 The pHoenix meter's internal cell must be rinsed between tests with RO (reverse osmosis) water. Attach the meter to the RO water bottle and rinse the cell two times. pHoenix Meter, pHoenix XL, and Tri-Station Care and Maintenance Published: 6/14/17 Version: 1 ...Maintenance Schedule Procedure Rinse Meter with RO after each use 1.On 7/12/21 at 11:05 AM CST (Central Standard Time) at the Tri-Station, Employee Identifier (EI) # 9, Certified Clinical Hemodialysis Technician (CCHT) tested dialysate solution from station 13 for pH and conductivity using the pHoenix meter. After results were obtained, EI # 9 expelled the solution into the dirty sink then placed the pHoenix meter on the rack. EI # 9 failed to rinse the pHoenix meter with RO water after use according to facility policy. 2. On 7/12/21 at 11:20 AM CST at the Tri-Station, EI # 4, PCT tested dialysate solution from station 6 for pH and conductivity using the pHoenix meter. After results were obtained, EI # 4 expelled the solution into the dirty sink then placed the pHoenix meter on the rack. EI # 4 failed to rinse the pHoenix meter with RO water after use according to facility policy. 3. On 7/12/21 at 11:35 AM CST at the Tri-Station, EI # 5, Patient Care Technician (PCT), ) tested dialysate solution from station 4 for pH and conductivity using the pHoenix meter. After results were obtained, EI # 5 expelled the solution into the dirty sink then placed the pHoenix meter on the rack. EI # 5 failed to rinse the pHoenix meter with RO water after use according to facility policy. 30952 4. On 7/12/21 at 12:25 PM CST at the Tri-Station, EI # 7, Certified Clinical Hemodialysis Technician tested dialysate solution from station 11 for pH and conductivity using the pHoenix meter. After results were obtained, EI # 7 expelled the solution into the dirty sink then placed the pHoenix meter on the rack. EI # 7 failed to rinse the pHoenix meter with RO water after use. In interview on 7/14/21 at 11:25 AM CST, EI # 1, Director of Operations, confirmed staff had failed to follow the facility procedure and rinse the pHoenix meter with RO water after each use.