Transcript Document

The New ESRD
Regulations From
the Surveyors
Perspective
Liza Ben Vaughn, RN
KDHE BCCHF
QI Coordinator
ESRD Survey Focus
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Protect Patient Safety and Improve
Patient Outcomes
Data is used to focus surveys
Standards are incorporated into
regulations (AAMI, CDC and
NFPA)
Multiple resources for Standards
Resources for Standards
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Regulations and Guidelines
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FDA, NKF, NQF, American
Nephrology Nurses’ Association,
Renal Physicians Association
Manufacturer’s Directions
State Practice Acts
MAT (Measures Assessment Tool)
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Focused Basic Survey Process
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Initials
Complaints
Relocations
Change in service
STAR
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Surveyor Technical Assistant for
Renal Disease
An automated survey guide
Uses a wireless tablet PC
Guides the surveyor through the
process
Roll out in some states. Kansas
and Iowa are using STAR.
Sixteen Survey Tasks
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Pre-survey
Introductions
Tour/Observations
Entrance conference
Patient sample selection
Water treatment-Dialysis preparation
Reprocessing-Reuse
Machine operation-maintenance
Home training department review
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Patient interviews
Medical record reviews
Personnel interviews
QAPI
Personnel record reviews
Decision Making
Exit conference
“FLASH SURVEY”
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Waiting room
Patient restrooms
Reuse room
Water-Dialysate areas
Home training area
Treatment area
Isolation
Observations and Tour
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Ongoing throughout the survey
Physical environment
Infection control
Patient – Staff interaction
Patient care delivery
Staffing
Medical record and logs in use
Patient Sample Selection
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Ten percent sample with a minimum of 5
and maximum of 15.
Sample from ALL treatment modalities
offered.
Selection made from information
provided by the facility and general
observations.
Cumulative lab reports, infection logs,
hospitalization logs, vascular access
information, pediatric patients, LTC
facility patients, unstable patients are all
used to select sampled patients.
Patient Interviews
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Minimum of 5 patients
Can be same as sampled or
different.
Done in treatment area, waiting
room, in private or by phone
STAR has a structured guide or
may use “custom” questions
Sample of Interview Questions
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How do you participate in your plan of
care? (V541, V 556)
How does your dialyzer look when your
treatment is finished? V547)
Do you have a problem with your blood
pressure?
Is your weight goal generally achieved?
Have you had any problems while on
dialysis such as itching, chills, fever?
What happened? How did staff respond?
Medical Record Review~
How Will Surveyors Know the POC
Is Implemented?
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Physician’s orders
Laboratory values
IDT progress notes
POC changes and updates
Dialysis flow sheets
Medical Record Review
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FORMAT-electronic, manual or combination
CONTENTConsents, Medical Exam, Histories, Progress
notes, Labs, Treatment orders, Dialysis
treatment records, Patient educations, Patient
Assessment, POC, Demographic Information,
Anemia management records, plus information
from other disciplines.
Treatment Orders
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Peritoneal dialysis treatment
orders contain the Number of
Exchanges and Dialysate
Concentration-Volume.
Hemodialysis treatment orders
contain- Treatment duration and
frequency, BFR (Blood Flow Rate),
Dialyzer, Dialysate Rx and flow
rate, Target weight, Heparin dosing
and other medications.
Dialysis Treatment Records
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PD- contain flowsheets can be
electronic or manual and are
reviewed at least every 2 months.
Hemodialysis-contain PreTreatment, During Treatment and
After treatment information
Hemodialysis Pre-treatment Record
Surveyors Look For:
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Water Treatment
Dialysis machine
Reprocessed dialyzer checks
Dialysis orders
Patient information-demographic
information
Machine Safety and
Reprocessed Dialyzer
Checks
Machine assessment-conductivity
machine____manual____
pH____machine ____manual
Alarm test
Air detector on
UF system
Positive Presence Test___
Negative Residual Test___
Dialyzer ID___ Machine ID_____
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Treatment Orders-examples
Dialyzer____DFR____BFR____Tx Time___
Dialysate______K_____Ca_____Bicarb____
Sodium Modeling_________ UF Profiling____
Dialysate temp______
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Pre-Treatment, Post-Treatment
Information
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Include B/P – sit____stand___
Weight_____ EDW___Wt gain__
Wt loss___Wt removed_____
Time on___time off____
Assessment of patients GI,
Cardiac, Edema, Mental, Mobility,
and Access
Hemodialysis Treatment Records
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Surveyors review orders, tx records and
observe treatments to ensure all orders are
followed pre-treatment, during treatment, and
post treatment. Review for intradialytic patient
and machine monitoring, medication and
treatments administered. Heparin or
anticoagulation are reviewed and compared
with orders, observations, and interview
information.
Immunization Medical
Record Documentation
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V 506, V 126, and V 127
Record of testing and immunizations
Documentation of immunity or
acknowledgement of absence of immunity
Documentation of further action planned if
required.
Medical Record Documentation for
Access and Adequacy
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If expected outcomes for dialysis access or
adequacy are NOT achieved, there should be
evidence of reassessment for that aspect of
care.
If the patient is not achieving the expected
targets, there should be documentation of the
reason WHY and a change in plan
Adjust the plan and implement the changes.
Medical Record Documentation for
Access and Adequacy
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May be in IDT assessments
Plan of care
Implementation of the care plan may be on
flowsheets, progress notes, physician orders, etc.
Medical Record Documentation for
Anemia Management
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IDT assessments
Plan of care with measurable goals and timelines
Implementation of care plan:
flowsheets
progress notes
medication administration records
physician orders…etc
Medical Record Documentation for
Nutrition
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IDT assessment
Plan of care with measurable goals and
timelines
Implementation of care plan
flowsheets
progress notes
medication administration records
physician orders…etc
Medical Record Documentation for
Psychosocial
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V 730- Results of standardized survey of mental and
physical assessment (chosen by social worker)
Plan for psychosocial interventions (counseling and
referral) to achieve and sustain appropriate psychosocial
status
Plan for other elements of care that may be influenced by
psychosocial status
IDT assessment
POC with goals and timelines
Implementation documentation in flowsheets, progress
notes…etc….
Types of Medical Record Review
Comprehensive-all components
are reviewed
 Focused-review based on the
rationale for sampling.
Review areas of concern from
survey or other records
MAT will be used for reviews-see
example
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Patient Assessment and Patient
Plan of Care
CFR 494.80 Patient Assessment
The IDT must provide each patient an
individualized comprehensive
assessment- V501
There are 14 assessment criteria- V502515.
Reassessment frequency criteria is defined
at V515-520.
Kelly gave examples of the IDT POC and
its correlation with the PA.
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Staffing –COP V 750
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494.180 Governance-addresses the
overall management of the facility. The
GB must demonstrate:
Responsibility for the operation of the
facility:
Fiscal management
Staff Training and Coverage
Medical Staff appointments and
coverage
QAPI
Survey Process Staffing
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V 757and V 758 require the GB to
ensure adequate numbers of
qualified personnel are present for
the patient/staff ratio is appropriate
and meets the needs of patients.
The RN, social worker and dietitian
members of the IDT are available
to meet patient clinical needs.
Staffing
Surveyors consider patient acuity and care needs
of patients, staff experience and areas of
expertise. Staffing assignments and schedules
reviewed to determine if there is a pattern of
sufficient staff coverage to ensure safe patient
care.
Staffing review
continued:
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If the facility “shares”the social worker or dietitian
with multiple clinics or requires professional staff to
perform non-clinical tasks, it must NOT negatively
impact the time available to provide clinical
interventions require to achieve the goals identified
in the patient’s POC. The facility CEO or
administrator is RESPONSIBLE to assure
professional support staff members have sufficient
time available in the facility to meet the clinical
needs of in-center and home dialysis patients.
Surveyor Interviews With
Professional Staff
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Interview Professional staff to determine their
professional duties and number of nonclinical duties.
Determine if non-clinical duties or tacks
negatively impact the time available to
provide clinical interventions and
implementation of the plan of care.
Positive Patient Outcome
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The renal
community,
CMS, state
agency, and
Network all work
together to
improve patient
outcomes.
Questions???
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Liza Ben Vaughn, RN
Email- [email protected]
785-207-0203