Goals and Objectives

2. Goals and Objectives Provide guidance for “Survey Preparation” Discuss five (5) most common Conditions cited Life Safety Code Citations

3. Proactive Role

4. 494.30: Infection Control 29 Standards – Monitor Practice/Track QAI PPE/gloves/hand hygiene Cleaning/disinfection contaminated surfaces, medical devices and equipment Nondisposable items – cross contamination Medication preparation area Hepatitis B practices

5. Infection Control Hepatitis B: Hepatitis B screening Patient serological status Vaccination, patients/staff Isolation practices Infection control education Infection control reporting/tracking

6. 494.40: Water and Dialysate Quality 90 Standards – Monitor Practice/Track QAI Water purity i.e. bacteriology Water purification – chlorine/chloramine Alarms, diagrams & labels Water treatment system components

7. 494.60 Physical Environment- Life Safety Codes Building/furnishings/equipment - safe and functional All equipment – following manufacturer’s guidelines Emergency preparedness - equipment - practices

8. 494.80: Patient Assessment The Interdisciplinary Team (IDT) is responsible for providing each patient with an individualized and comprehensive assessment of his or her needs. The comprehensive plan must be used to develop the patients’ treatment plan and expectations for care i.e. Plan of Care. Remember to update it!

9. Patient Assessment Frequency: Initial comprehensive assessment must be conducted on all new patients within the latter of 30 calendar days or 13 outpatient hemodialysis sessions Follow up comprehensive reassessment must occur within 3 months after the completion of the initial assessment to provide information to adjust the patient plan of care

10. Patient Assessment Patient Reassessment: At least annually for stable patients At least monthly for unstable patients defined as follows: Extended or frequent hospitalizations Marked deterioration in health status Significant change in psychosocial needs Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis

11. 494.90 Patient Plan of Care The Patient’s Plan of Care must: Be completed, dated and signed by IDT members Begin within 30 days or 13 outpatient treatments Include monthly and/or annual updates of the plan performed within 15 days of the completion of the additional patient assessments Be adjusted, as frequently as monthly, if the expected Plan of Care outcome(s) are not being achieved

12. Patient Plan of Care Patient Plan of Care: The outcomes must be consistent with current evidence-based professionally-accepted clinical practice standards. Measures Assessment Tool (MAT) Include defined criteria Include, as appropriate, defined “Home Specific” criteria

13. 494.100:Care at Home Care at least equivalent to in-facility patients Patient’s training must be: Provided by a facility that is approved to provide home dialysis services Conducted by a registered nurse (qualified) Conducted for each home dialysis patient and address the specific needs of the patient

14. Care at Home Monitoring: Documentation of patient/caregiver completion and adequate comprehension of training Retrieval and timely review of self monitoring data from self-care patients or their designated caregiver(s) at least every 2 months Maintain information in the patient medical record

15. 494.110: Quality Assessment & Performance Improvement Program must: Achieve measurable improvement in health outcomes and reduction of medical errors Measure, analyze and track quality indicators

16. Quality Assessment & Performance Improvement Program must: Continuously monitor performance, take actions that result in improvement and track performance to ensure that improvements are sustained over time Prioritize by prevalence and severity of identified problems Immediately correct any identified problems that threaten patient health or safety

17. 494.140: Personnel Qualifications Medical Director Board-certified in internal medicine or pediatric by a professional board who has completed a board training program in nephrology and has at least 12-months experience in providing care to patients receiving dialysis

18. Personnel Qualifications Nursing Services * Nurse Manager: FT RN dedicated to one facility, 18 months experience 6 of which is in the care of dialysis patients. Self-care and home training nurse, RN with 12 months experience in providing nursing care with an additional 3 months of experience in the specific modality for which the nurse will provide self-care training. * Texas Licensure Regulations

19. Personnel Qualifications Nursing Services Charge Nurse: RN, LPN, or LVN with 12 months experience with 3 in the care of maintenance dialysis If such nurse is a LPN or LVN, work under the supervision of a RN in accordance with state nursing practice act provisions Staff Nurse RN or LVN meeting state practice requirements

20. Personnel Qualifications Dietitian Must be registered with the commission on dietetic registration AND Have a minimum of one year work experience in clinical nutrition as an RD.

21. Personnel Qualifications Social Worker Holds a master’s degree in Social work with specialization in clinical practice from an accredited school or Has served at least two years as a social worker one year of which was prior to 9/1/1976 and has a consultative relationship with a “qualified” social worker

22. Personnel Qualifications Patient Care Technicians Must meet all applicable State requirements Have a high school diploma or equivalency Completed a training program approved by the Medical Director and Governing Body Be certified under a State certification program or a national commercially available certification program Dialysis Assistants (Patient care/dialysis machine set up)

23. Personnel Qualifications Water Treatment System Technicians Technicians who perform monitoring and testing of the water treatment system must complete a training program that has been approved by the Medical Director and GB

24. 494.150: Responsibilities of the Medical Director Medical Director responsibilities include: Quality assessment and performance improvement program Staff education, training and performance Policies and procedures Participate in the development, periodic review and approval Ensure adherence of all individuals treating patients Interdisciplinary team adheres to discharge and transfer policies

25. 494.180: Governance Governance The Governing Body is responsible for: Designating a chief executive officer Staff appointments RN responsible nursing care – present at all times patients are in the facility Fiscal operations Maintaining adequate numbers of qualified and trained staff Furnishing services

26. Network 14: www.esrdnetwork.org CMS: www.cms.gov Glenda Payne email contact for questions: esrdsurvey@cms.hhs.gov NKF: www.kidney.org