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 012515 (X3) Date Survey Completed 04/20/2023
Name of Provider or Supplier Fresenius Medical Care Opelika Street Address, City, State 2609 Village Professional Drive, Suite 2, Opelika, 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)
E0038 ESRD EP Training Program

ยง494.62(d)(1): Condition for Coverage: (d)(1) Training program. The dialysis facility must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. Staff training must: (iii) Demonstrate staff knowledge of emergency procedures, including informing patients of- (A) What to do; (B) Where to go, including instructions for occasions when the geographic area of the dialysis facility must be evacuated; (C) Whom to contact if an emergency occurs while the patient is not in the dialysis facility. This contact information must include an alternate emergency phone number for the facility for instances when the dialysis facility is unable to receive phone calls due to an emergency situation (unless the facility has the ability to forward calls to a working phone number under such emergency conditions); and (D) How to disconnect themselves from the dialysis machine if an emergency occurs. (iv) Demonstrate that, at a minimum, its patient care staff maintains current CPR certification; and (v) Properly train its nursing staff in the use of emergency equipment and emergency drugs. (vi) Maintain documentation of the training. (vii) If the emergency preparedness policies and procedures are significantly updated, the dialysis facility must conduct training on the updated policies and procedures.


This STANDARD is not met as evidenced by:
Based on a review of the End Stage Renal Disease Core Survey Facility Worksheet: Personnel File, facility personnel file, and interview, it was determined the facility failed to ensure EI (Employee Identifier) # 3, RN (Registered Nurse), in one of three RN files reviewed, completed training for the facility emergency preparedness policies and procedures and demonstrated knowledge of facility emergency procedures. This had the potential to negatively affect all patients who dialyze at the facility. Findings Include: Review of the Core Survey Facility Worksheet: Personnel File documentation dated 4/19/23 revealed EI # 3's date of hire was 5/1/22. There was no documentation EI # 3 completed initial emergency preparedness training. Review of EI # 3's Education Transcript dated 4/18/2020 to 4/18/23 revealed no documentation that initial/annual training on the facility emergency preparedness policies and no documentation emergency procedures were demonstrated. In an interview on 4/20/23 at 10:50 AM, EI # 1, Director of Operations confirmed there was no emergency preparedness training documentation for EI # 3.