ESRD Network of Texas, Inc. Annual Educational Collaborative for ESRD professionals. Presentations from the 2009 Annual Meeting

1. How Are We Doing So Far?
g
Glenda M. Payne RN, MS, CNN
ESRD Technical Advisor
CMS, Dallas & Atlanta
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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?
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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. 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
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5. Subpart D:
p
Administration
13. Personnel qualifications
14. Responsibilities of
the medical director
15. Medical records
16. Governance
5

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)
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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)
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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)
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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)
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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)
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11. IC=Infection Control
All about
• HANDS
• Supplies
• M d
Meds
• Saline
• Heparin
• PPE
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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
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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)
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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)
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15. So, No Infection Control
,
Issues in Texas?
Not exactly…
27 way “tie” for #3 actually
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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
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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. Problems in Ch/Chl
Testing
• Policy = practice;
• Policy matches test method in
use
• Staff trained and competent
• Hey-Hey
17

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
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19. Residual Chlorine Test Strips
Test strips used
to test for the
absence of
BLEACH
NOT sensitive enough
to use to test for
chloramine
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20. V250: Verifying Machine
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Function
For hand-held verification:
• Maintain your equipment
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• 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
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21. V191: Softener Testing
• AAMI RD 52 states to do this
testing “at the end of the
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treatment day”
• This means when the last
treatment is finished
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22. V260: Training for Water
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& 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
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knowledge and skills
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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. 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
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• 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
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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.
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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.
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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.
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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
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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
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by 10/14/2009
• STCP and LTCP are so yesterday!
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• PA and POC: the way for the
future
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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. 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)
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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. 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!
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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=
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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”
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36. Achieving Compliance
Learn about the new
regulations:
• Read the Federal Register
• Read the Interpretative Guidance
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• Attend meetings (like this one!)
• Discuss with your peers
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• Ask questions!
ESRDsurvey@cms.hhs.gov 36

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
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38. Q
Questions?
ESRDsurvey@cms.hhs.gov 38

39. 39