Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 012515	(X3) Date Survey Completed 08/06/2025
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)

V0122

IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL
CFR(s): 494.30(a)(4)(ii)

[The facility must demonstrate that it follows standard infection control precautions by implementing- (4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-] (ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment.

This STANDARD is not met as evidenced by:
Based on observations, review of facility policy and procedure, and interviews, it was determined the facility failed to ensure: 1. Staff cleaned and disinfected dialysis stations which affected three of three observations for cleaning and disinfection of the dialysis station during the survey. 2. Staff removed tape and tape residue from dialysis treatment chairs, which affected fifteen of thirty dialysis incenter (IC) hemodialysis (HD) stations. Failure to clean and disinfect the dialysis station between patient treatments was cited during the recertification survey conducted on 4/20/23. This has the potential to negatively affect one hundred two IC HD patients who dialyze at the facility, staff, and visitors. Findings include: Facility Policy and Procedure: Cleaning and Disinfecting of the Dialysis Station Published: 09/05/2023 Version: 14 Purpose ...of this policy is to provide guidelines to prevent the spread of disease...maintain a clean...safe...environment for patients, staff, and visitors. Background ...The nature of dialysis treatments with frequent exposure to blood...close proximity...immunocompromised status of dialysis patients makes dialysis a high-risk area for spreading infectious disease... Definition Dialysis Station...including dialysis machine, chair...and other reusable equipment...utilized during dialysis treatment...not limited to the following: ...IV) intravenous pole), BP (blood pressure) cuff...television... Dialysis Wall Box...connect central distribution systems to a HD machine...located in the chase wall behind the machine. General Cleaning ...After use...supplies brought to the dialysis station... (ex [example] Stethoscope) must be disinfected... Cleaning of the Dialysis Wall Boxes...and the area around the wall box must be routinely cleaned at the end of each treatment day...All surfaces shall be disinfected with 1:100 (one part bleach, 100 parts water) bleach solution. Special attention should be given to removing build-up and/or cleaning splatter and spray of concentrate solution.... ...Procedure Follow the steps below to disinfect the dialysis station after each dialysis treatment: ...3. Use a cloth wetted with 1:100...bleach solution...to clean and disinfect the dialysis station...machine, IV pole, B/P cuff...chaise wall behind chair... 4. Clean all surfaces... 5...While wiping...wipe all surfaces of the machine... 7. Surface disinfect dialysis wall box and the area/wall around the wall box at the end of each treatment day... 1. An observation was conducted on 8/5/25 at 3:25 PM at station 4 to observe EI (Employee Identifier) # 5, Certified Clinical Hemodialysis Technician, perform cleaning and disinfection of the dialysis station at the end of the treatment day. EI # 5 failed to disinfect the top section of the IV (intravenous) pole including the four IV hooks, and stethoscope hanging on a hook. and failed to disinfect the blood pressure cuff and wire basket on the HD side. EI # 5 failed to clean the television, and arm, and the counters surrounding the dialysis station. EI # 5 failed to disinfect the chaise wall cabinet and dialysis wall box per policy. An interview was conducted on 8/6/25 at 1:30 PM with EI # 1, Clinical Manager, who confirmed the staff failed to follow the facility policy for cleaning and disinfection of the dialysis station. 2. An observation was conducted on 8/5/25 at 3:35 PM for cleaning and disinfection of station 21. EI # 6, Patient Care Technician (PCT), failed to disinfect the top section of the IV pole and the four IV hooks. EI # 6 failed to clean the television, the television arm, the surrounding counters, the wall box, and chaise wall cabinet after the last treatment of the day. An interview was conducted on 8/6/25 at 1:30 PM with EI # 1, who confirmed the staff failed to follow the facility policy for cleaning and disinfection of the dialysis station. 3. An observation was conducted on 8/5/25 at 3:55 PM for cleaning and disinfection of station 8. EI # 7, PCT, failed to disinfect the top section of the IV pole and the four IV hooks, the television, television arm, the surrounding counters, the chase wall cabinet, and wall box after the last treatment of the day. An interview was conducted on 8/6/25 at 1:30 PM with EI # 1, who confirmed the staff failed to follow the facility policy for cleaning and disinfection of the dialysis station. 4. Observations were conducted on the treatment floor on 8/5/25 from 4:35 PM to 5/20 PM with EI # 1, Clinical Manager. Fifteen of thirty dialysis stations had paper tape and tape residue on the patient treatment chairs, tabletops, and counters surrounding the dialysis stations. There was dust and dirt build up on the counters surrounding the dialysis stations, especially around the television arm connections. There was acid build up in the wall box at station 10. An interview was conducted on 8/5/25 at 5:20 PM with EI # 1 who confirmed staff had failed to ensure the dialysis stations were properly cleaned and disinfected between treatments. EI # 1 confirmed tape and tape residue not removed from the station could potentially lead to transmission of bloodborne pathogens, such as hepatitis B virus and other infections, from one patient to another in a HD unit.