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)
V0403 PE-EQUIPMENT MAINTENANCE-MANUFACTURER'S DFU
CFR(s): 494.60(b)

The dialysis facility must implement and maintain a program to ensure that all equipment (including emergency equipment, dialysis machines and equipment, and the water treatment system) are maintained and operated in accordance with the manufacturer's recommendations.


This STANDARD is not met as evidenced by:
Based on review of facility procedure, observations of care and staff interview, it was determined the facility failed to ensure staff had labeled open Tri-Station testing solution bottles. This had the ability to negatively affect all patients who dialyzed at the facility. Finding include: Procedure: Checking Conductivity and pH of Final Dialysate with the pHoenix Meter. Published date: 08/03/2020 Version: 7 Purpose This procedure provides instruction for measuring final dialysate conductivity and pH with a pHoenix meter. Supplies... Tri-Station with RO (Reverse Osmosis) water, 1% bleach, 14.0 mS (millisiemens, an electrical conversion unit) and 7.0 solutions. NEO-CARE Solution... Note: Tri-Station RO water and 1% bleach solutions are replaced daily. Label solutions with date, time, and initials... 1. A flash tour of the facility was conducted on 7/12/21 at 10:00 AM CST (Central Standard Time) and the surveyor observed Neo-Care, 14.0 mS, and 7.0 at the Tri-Station open and not labeled with the date opened. The 1% bleach bottle was not labeled with date, time, and initials. The RO water bottle was labeled with the date of 6/30/21. The surveyor asked EI (Employee Identifier) # 7, Certified Clinical Hemodialysis Technician, "Should solutions at the Tri-Station be labeled with date opened or replaced?" EI # 7 confirmed the solutions were not labeled when opened and RO water and bleach solution was not labeled when replaced daily. In an interview on 7/14/21 at 11:25 AM CST, EI # 1, Director of Operations confirmed staff had failed to label Tri-Station solutions when opened or replaced per policy.