Lessons At This Point C Megulations


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ESRD Network of Texas, Inc. Annual Educational Collaborative for ESRD professionals.

Presentations from the 2009 Annual Meeting

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Lessons At This Point C Megulations

  1. 1. How Are We Doing So Far? g Glenda M. Payne RN, MS, CNN ESRD Technical Advisor CMS, Dallas & Atlanta 1
  2. 2. Objective: To Answer j These Questions: What can we do to be sure our facility is in compliance with the new rules of the game? 2
  3. 3. What’s Expected Expected… Subpart A: General 1. Compliance with Federal State & local laws and regulations Subpart B: Patient Safety 2. Infection control 3. Water and dialysate quality 4. Reuse of hemodialyzers 5. Physical environment 3
  4. 4. Subpart C: Patient Care 6. P ti t ’ i ht 6 Patients’ rights 7. Patient assessment 8. Patient plan of care 9. Care at home 10. QAPI 11. 11 Special purpose dialysis facilities 12. Laboratory services 4
  5. 5. Subpart D: p Administration 13. Personnel qualifications 14. Responsibilities of the medical director 15. Medical records 16. Governance 5
  6. 6. So, So How ARE We Doing? • From October 14, 2008 to February 12, 2009 y , • 298 ESRD surveys done (or “uploaded”) nationally uploaded ) • 53 Condition Level Findings • 31 Facilities (from 1 to 4 CfC each) 6
  7. 7. Conditions Not Met • Infection Control (17) • Governance (10) • Medical Records • QAPI (6) (2) • Responsibilities of the • Laboratory (1) Medical Director (5) • Patient • Water & Dialysate Assessment (1) Quality (5) • Personnel Quals (1) • Physical Environment • Reuse (1) (3) • Plan of Care (1) 7
  8. 8. Top Ten Citations: US 10. V143: IC: Aseptic technique for meds (22) 9. V504 A 9 V504: Assess B/P & fl id mgmt fluid t needs (22) 8. 8 V403: PE: equipment maintenance; follow DFU (23) 7. V506: Immunization/ med hx (23) ( ) 6. V715: MD resp: all adhere to P&P (26) 8
  9. 9. Top Ten Citations: US 5. V115: IC: Wear Gowns/PPE (26) 4. V116: IC: Items taken to station D/D/D (26) 3. V117: IC: Clean/dirty areas, med prep area, no common carts (27) area 2. V113: IC: Wear gloves/ hand hygiene (35) yg ( ) 1. V122: IC: Clean, disinfect surfaces, equipment (38) 9
  10. 10. Infection Control Citations • All 29 tags have been cited • Most frequent cited Condition (17X) • SIX of the top 10 most frequently cited tags are “IC” # 11 and #12 are also IC: 11: Handling infectious waste (21X) 12: HBV-vaccinate patients and staff (21X) The most frequently cited QAPI indicator cited is # 16: IC: trend/plan/act (20X) 10
  11. 11. IC=Infection Control All about • HANDS • Supplies • M d Meds • Saline • Heparin • PPE 11
  12. 12. “Hey-Hey” “Hey Hey” • “Observe Care” • Pay attention to your practice and to that of your co-workers colleagues, co-workers, colleagues teammates, patient care techs, doctors, nurses, social workers, and dietitians • Call them on hand washing and glove use • Pay attention to cleaning all surfaces: counters, tables, chairs, machines, jugs, etc. machines jugs etc 12
  13. 13. Top 10 Citations: TX p 25 surveys 10. V515: PA: Eval current physical activity level & voc/phys. rehab (4X) 9. V545: POC: Effective nutritional 9 V545 POC Eff ti t iti l status (4X) 8. 8 V511: PA: Dialysis access type & maintenance (4X) 7. V508: PA: Access renal bone disease (4X) 6. V505: PA: Assess lab profile (4X) 13
  14. 14. Top 10 Citations: TX 5. V502: PA: Assess current health status inc co-morbids (4X) 4. V507: PA: Assess anemia (4X) 4 V507 PA A i 3. V544: POC: Achieve adequate clearance (4 X) 2. V504: PA: Assess B/P & fluid management needs ( ) g (5X) 1. V715: MD resp: ensure all adhere to P&P (7X) 14
  15. 15. So, No Infection Control , Issues in Texas? Not exactly… 27 way “tie” for #3 actually y y All 27 have been cited 4 X – 3 are IC: • V122: Clean & disinfect surfaces • V117: Clean/dirty areas, med prep area, no common med carts , • V120: Transducer protectors not wetted/changed 15
  16. 16. What About Other Areas? • 62 of the 92 • V196: primary tag for problems in tags for Water ch/chl monitoring & Dialysate • V250: handheld Quality have checks of machine been cited pH/conductivity • V191: checking • #1 is this area softener at end of = four way tie, the day each with 12 h ith • V260 water staff V260: t t ff citations: training/audits 16
  17. 17. Problems in Ch/Chl Testing • Policy = practice; • Policy matches test method in use • Staff trained and competent • Hey-Hey 17
  18. 18. V196: Zero ≠ Zero • Just because the label says “0” does not mean the strip will read to zero • Strips only read to the lowest NUMBER on the range: 0 = 0.5 only reads to less than 0.5 •CCritical that strips/ reagents be / sensitive “enough” to detect unsafe levels 18
  19. 19. Residual Chlorine Test Strips Test strips used to test for the absence of BLEACH NOT sensitive enough to use to test for chloramine 19
  20. 20. V250: Verifying Machine y g Function For hand-held verification: • Maintain your equipment y q p • Use in-date standards • Be sure staff know “why” they why are doing the test and understand the allowable variation between the machine/ handheld results 20
  21. 21. V191: Softener Testing • AAMI RD 52 states to do this testing “at the end of the g treatment day” • This means when the last treatment is finished 21
  22. 22. V260: Training for Water g & Dialysate • Mandatory • Must cover quality testing, risks and hazards of i h d f improperly prepared l d concentrate, bacterial issues • Operators trained in use of equipment • Specific to functions performed • Periodic audits of operator’s operator s compliance • Ongoing training to maintain g g g knowledge and skills 22
  23. 23. Let’s Go Back to the Top 10: What is NOT IC? 10. V143: IC: Aseptic technique for meds (22) 9. V504 A 9 V504: Assess B/P & fl id mgmt fluid t needs (22) 8. 8 V403: PE: equipment maintenance; follow DFU (23) 7. V506: Immunization/ med hx (23) ( ) 6. V715: MD resp: all adhere to P&P (26) 23
  24. 24. Patient Assessment: #9: V504: Assess B/P and fluid management needs (22 X) Why would this be cited? • Review of flow sheets = no evidence B/P is being monitored g • Post weight does not = goal and no comment is made • Fluid removed and weights do not match and no comment is made Note: Surveyors are being taught to look at flow sheets for the implementation of the assessment-based plan of care p 24
  25. 25. # 7. V506: Immunization/ Medication Hx (23 X) • “Immunization history should Immunization history” include whether the patient has received standard immunizations (pneumococcal, hepatitis, and influenza), and has been screened for tuberculosis. f t b l i • The immunization record is expected include at least the patient’s immunization history as of the effective date of this regulation. 25
  26. 26. # 7. V506: Immunization/ Medication Hx (23) CDC recommends all dialysis patients: • Be tested at least once for baseline tuberculin skin test results (TST) and re-screened if TB exposure is detected. Chest x-rays may be used y y as an option. • Be offered influenza and pneumococcal vaccine and th t th i l i d that their immunization history be tracked. 26
  27. 27. Medication history • Should include a review of the patient’s allergies and of all medications including over the over-the- counter medications and supplements that the patient is pp p taking. • The assessment should demonstrate that ll th t all current medications were t di ti reviewed for possible adverse effects/interactions and continued need. 27
  28. 28. Another Word about PA/POC* Here is our REAL opportunity to CHANGE the way care is delivered! Here is our REAL opportunity to INCREASE patient involvement and INDEPENDENCE = improved satisfaction & better working conditions for everyone! *Remember, th T *R b the Top 10 in TX! i 28
  29. 29. Time for Change! • Expectation that all facilities are in the process of converting all patients to the new system of planning and evaluating care—all p patients converted to this system y by 10/14/2009 • STCP and LTCP are so yesterday! y y • PA and POC: the way for the future 29
  30. 30. Correlation of PA & POC PA POC Current health status Incorporated into all p (V502) POC tags Lab profile (V505) Medication/immunization history (V506) Appropriateness of dialysis Provide adequate prescription (V503) clearance (V544) BP/fluid management Manage volume status needs (V504) (V543) Assess anemia (V507) Manage anemia (V547) Home pt ESA (V548) ESA response (V549) Assess renal bone disease Manage mineral 30 (V508) metabolism (V546)
  31. 31. PA POC Nutritional status (V509) N t iti l t t Effective nutritional status Eff ti t iti l t t (V545) Psychosocial needs (V510) y ( ) Psychosocial y Evaluate family support counseling/referrals/ (V514) assessment tool (V552) Access type/maintenance VA monitor/referral (V550) (V511) Monitor/prevent failure (V551) Evaluate for E l t f self/home care lf/h Home dialysis plan (V553) H di l i l (V512) Transplantation referral p Transplantation status: plan p p (V513) or why not (V554) Evaluate current physical Rehab status addressed activity level & voc/physical (V555) rehab (V515) 31
  32. 32. How Is This Supposed to Work? pp • PA: identifies intradialytic weight gains (IDWG) of greater than 12 pounds/treatment • POC: • IDT members (all) to work with patient on risks of excessive fluid gains and (RD) on ways to handle thirst • Agree to a goal for IDWG to be reduced by 10% each week until goal of no greater than 5 pounds is reached • Monitor IDWG each treatment. Praise positive actions (RN, PCT) • If IDWG remains at same levels at end of one month, review and revise POC 32
  33. 33. PA/POC Everyone has one year to comply with these two Conditions About ½ of your patients should now be on the new system “Monitor, recognize and address” Make thi M k this work worthwhile—it i k th hil it is not about paper or the form! 33
  34. 34. #8: V403: PE: equipment maintenance; follow DFU (23 X) Equipment R E i t Repair & M i t i Maintenance *DFU= Directions for use DFU= 34
  35. 35. #6: V715: MD resp: all adhere to P&P (26 X) Admission policies • Orders • Baseline H&P •NNursing assessment prior t 1st i t i to treatment • “Adhere to P&P” 35
  36. 36. Achieving Compliance Learn about the new regulations: • Read the Federal Register • Read the Interpretative Guidance p • Attend meetings (like this one!) • Discuss with your peers y p • Ask questions! ESRDsurvey@cms.hhs.gov 36
  37. 37. Achieving Compliance Then: • Evaluate current practice and compare to new requirements • Implement policy changes as needed • Educate staff to new policy and new regulation • Audit practice for compliance •RRepeat, repeat, repeat… t t t 37
  38. 38. Q Questions? ESRDsurvey@cms.hhs.gov 38
  39. 39. 39