Transcript Document

What is New at The Net?
The New Conditions For Coverage –
Changes For Clinical Staff
Lana Kacherova & Patrick Ciriello, ESRD Network 18
Clinical Issues in Nephrology
October 19, 2008
2
Number of Prevalent ESRD Patients in the US
400,000
357,795
350,000
300,000
273,333
1980
1990
2000
2007
250,000
185,984
200,000
150,000
100,000
59,165
50,000
0
US
3
30,000
Network 18 Patient Distribution by
Modality
26679
25,331
25,000
20,000
2006
15,000
2007
10,000
6,367
6330
5,000
2,181
2480
1,217
1173
0
In-center hemo
Home dialysis
Transplanted
Awaiting transplant
4
Network 18 Mission Statement
To provide leadership and assistance to
renal dialysis and transplant facilities
in a manner that supports continuous
improvement in patient care,
outcomes, safety and satisfaction.
5
New ESRD Regulations:
What are some of the major
changes?
6
Special Thanks
for the Content Contribution to the
CMS Transition Team
Glenda Payne, Judith Kari
Teri Spencer, Kelly Frank
Rosemary Miller, Bonnie Greenspan
Beth Witten
The ESRD Regulation
Timeline

1976: First ESRD regulations published

70’s-90’s: Technical updates

1994: Community Forum Meeting to begin
complete rewrite of ESRD regulations

2008: New ESRD regulations published
8
CMS Expectations for State
Oversight of ESRD Facilities


Conduct initial surveys as soon as scheduling
allows; Tier 3 workload
Conduct resurveys, FY 2009

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Tier 2: 10%; must be from top 20% of
outcomes list
Tier 3: 30%; 4 year interval maximum
Tier 4: 33%; 3 year interval average
Conduct complaint surveys


When warranted
Within specified timeframes
9
ESRD Survey Focus:
Protect Patient Safety & Improve Patient
Outcomes


Data is used to focus surveys
During survey, observations focus
on identification of safety hazards


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Water/dialysate
Reuse
Machine operation/maintenance
Direct care
IDT assessment, planning &
delivery of care
10
Condition 494.30: Infection Control
(V110-V148)




Must report problems to Medical Director and QAPI
From One tag to whole Condition
Infection Control regulations – apply to both chronic
in-center dialysis & home dialysis programs
Incorporated CDC documents:


RR-05: Recommendations for Preventing Transmission
of Infections Among Chronic HD patients
RR-10: Guidelines for the Prevention of Intravascular
Catheter-Related Infections
Must report problems to Medical Director and QAPI
11
Environment/IC Program

Sanitary environment in the dialysis facility
& between the unit & other areas (V111)

Components of an infection control
program (V112)
12
Gloves & Hand Hygiene
“Hand washing is the most important measure to
prevent contaminant transmission.”--CDC
V113 requires:
 Wear gloves – Whenever caring for a patient or
touching the patient’s equipment.

Remove/change gloves – Must perform hand
hygiene after removal of gloves between each
patient or station.
13
Gloves & Hand Hygiene

Hand hygiene



Use soap & water or alcohol-based antiseptic hand
rub
Visibly soiled vs. not visibly soiled
Intravascular catheters
-
Staff should wear clean or sterile gloves when
changing the dressing on IV catheters
Hand hygiene performed before & after palpating
catheter insertion sites, as well as before & after
accessing or dressing an IV catheter
14
Sinks with Warm Water & Soap
V114 Requires:

Sinks must be available & easily accessible to facilitate hand
washing



Includes in the patient treatment area, reuse room, medication area,
home training room, & isolation area/room
Sinks must be supplied with both hot & cold water
Uncontaminated supply of paper towels available
Expect:



Dedicated hand washing sinks
Designated utility sinks
Sink available for patients to wash hands & access sites
15
PPE: Must Wear Gowns
V115 requires:

A gown or lab coat must be worn when the
spurting or spattering of blood, body fluids,
potentially-contaminated substances or chemicals
might occur


Aprons are not sufficient PPE during procedures that
may result in the spurting or spattering of blood
Clarifies when staff, patients, & visitors should
wear PPE & when the PPE should be changed
16
Items Taken Into the Dialysis
Station
V116 requires:

Items taken into the dialysis station


Dispose, dedicate, or clean & disinfect
Unused supplies or medications should not be
returned to a common area or used on other
patients
17
Clean/Dirty Areas & Medication
Preparation Areas
V117 requires:

Separate clean from contaminated areas

Prepare individual patient meds in a centralized area away
from the treatment area
 Designate area only for medication prep
 Deliver separately to each patient

Do not move the medication cart from patient station to
patient station to deliver medications

If trays are used, clean between patients
18
Single Use Vials = Single Use
V118 requires:

Single dose vials cannot be punctured more than once

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Must be used for only one patient
Not entered more than once
If entered, may not be stored for future use.
BRAND NEW: MMWR August 15, 2008 retracts the
2002 CDC communication allowing multiple use of
single use vials

Multi-use vials: residual medication from two or more
vials must not be pooled into a single vial
19
Supply Cart & Supplies
V119 requires:


If a common supply cart is used, do not
move the cart from patient station to patient
station to deliver supplies
Do not carry supplies, patient care items, or
medications in pockets
20
Transducer Protectors
V120 requires:

External venous & arterial pressure transducer
filters/protectors




Use for each patient treatment
Change between each patient
Change if it becomes “wet”
If the external transducer protector becomes wet

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Replace immediately & inspect
If fluid visible, qualified personnel must inspect inside of
the dialysis machine after that patient treatment
If contaminated occurred, machine must be taken out of
service & disinfected
21
Handling Infectious Waste
V121 requires:

Handling, storage, & disposal of potentially
infectious waste infectious waste

Be aware of your State & local laws
22
Cleaning & Disinfecting of Contaminated
Surfaces, Medical Devices, & Equipment
V122 requires:

Protocols for cleaning & disinfecting surfaces &
equipment



Manufacturer’s DFUs followed
CDC recommended disinfection procedures
Cleaning & disinfection of environmental surfaces
completed between patient uses

Chairs, beds, machines & containers associated with
prime waste, adjacent tables & work surfaces
23
Cleaning & Disinfecting of Contaminated
Surfaces, Medical Devices, & Equipment
V122 requires:
 Clean & disinfect medical devices &
equipment after each patient
Scissors, hemostats, clamps, stethoscopes, blood
pressure cuffs
Blood spills cleaned effectively & immediately
 “Intermediate-level” disinfectant


24
Hepatitis B Routine Testing, Vaccination,
Screening, & Seroconversion (V124-127)

Routine testing for HBV (V124)




HBV status of all patients known before admission to the
HD unit
Test all patients as required by the CDC schedule
Results of HBV testing promptly reviewed (V125)
Vaccination of susceptible patients & staff members
(V126)

All susceptible patients & staff are offered hepatitis B
vaccination
25
Hepatitis B Routine Testing, Vaccination,
Screening, & Seroconversion


Test for response to the Hepatitis B vaccine
(V127)
Seroconversion (V125)



Reported to the State or local health department
Isolation of the seroconverted patient
Review all patients’ lab test results for
seroconversion
26
HBV+ Isolation Room/Area
V128 & V129: Isolation of HBV+ Patients


Effective Feb 9, 2009, every new facility MUST
include an isolation room for treatment of HBV+
patients, unless the facility is granted a waiver of
this requirement
For existing units in which a separate room is not
possible, there must be a separate area for HBsAg
positive patients
27
Isolation of HBV+ Patients

Dedicated machines, equipment, supplies, &
medications (V130)


Used only for HBV+ patients until patient is discharged
from facility
Staff assigned to care for HBV+ patient (V131):


May only care for other HBV+ patients or
HBV immune patients
28
Staff Training & Education
V132
 Infection Control Training & Education

Required for both new & existing staff
members
V147
 Education & training for care of IV
catheters
29
Oversight for Infection Control Practices/
Program & Reporting Requirements




Biohazard & infection control policies & activities
(V142)
Compliance with current aseptic techniques in IV
medication dispensing & administration (V143)
Reporting of infection control issues to the medical
director & QAPI committee (V144)
Reporting communicable diseases (V145)
30
IV Catheter Care & Maintenance
V146-148
 Adopts RR-10 CDC recommendations
related to catheters as regulation (V146)
 Monitor catheter sites (V147)
 Conduct surveillance for catheter related
infections (V148)
31
Condition 494.80:
Patient Assessment
32
Major Change: No LTP
(Long-Term Plan)


No expectation for a long term program or
“signature” of transplant surgeon
Requirements for patients to be informed of all
modalities (transplant & therapies not offered at
their current clinic) are addressed under:



Patients’ Rights
Patient Assessment
Plan of Care
33
A New Day…




The new CfCs of Patient Assessment & Plan of
Care require defined Standards
The new CfCs use Standards developed by the
ESRD community
Surveyors have a fabulous tool for reference of
these Standards in the MAT (Measures
Assessment Tool)
If an individual patient does not meet a goal on
the MAT, expect to see revised plan for that
aspect
34
Interdisciplinary Care vs.
Multidisciplinary Care
Interdisciplinary
Multidisciplinary
Work collaboratively
Work sequentially
Communication by
regular discussions
about patient status &
the evolving plan of
care
Medical record is the
chief means of
communication
35
The Interdisciplinary Team (IDT)
Includes at a minimum:





The patient or their designee (if the patient
chooses)
A registered nurse
A physician treating the patient for ESRD
A social worker
A dietitian
36
Patient Assessment (V501) and
Patient Plan of Care (V541)
These 2 Conditions:


Are interrelated (“can’t have one without the other”)
Address patient assessment & care delivery
requirements in “care areas” associated
with complications of ESRD
37
§ 494.80 Patient Assessment



The IDT must provide each patient an
individualized comprehensive assessment
(V501)
14 assessment “criteria” (V502-515)
Reassessments at defined frequencies
(V516-520)
38
§ 494.90 Patient Plan of Care
(V541)

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The IDT must develop & implement a
written, individualized comprehensive
patient plan of care (POC)
POC based upon the comprehensive
assessment
Addresses each patient’s care needs
Outcome goals in accordance with clinical
practice standards
39
Correlation of PA & POC
PA
POC
Current health status (V502)
Appropriateness of dialysis
prescription (V503)
Lab profile (V505)
Medication/immunization history
(V506)
Incorporated into all POC tags,
including adequate clearance
(V544)
BP/fluid management needs (V504)
Manage volume status (V543)
Assess anemia (V507)
Manage anemia (V547)
Home pt ESA (V548)
ESA response (V549)
Assess renal bone disease (V508)
Manage mineral metabolism
(V546)
40
Correlation of PA & POC
PA
POC
Nutritional status (V509)
Effective nutritional status (V545)
Psychosocial needs (V510)
Evaluate family support (V514)
Psychosocial counseling/referrals/
assessment tool (V552)
Access type/maintenance (V511)
VA monitor/referral (V550)
Monitor/prevent failure (V551)
Evaluate for self/home care (V512)
Home dialysis plan (V553)
Transplantation referral (V513)
Transplantation status: plan or why
not (V554)
Evaluate current physical activity
level & voc/physical rehab (V515)
Rehab status addressed (V555)
41
Patient Assessment & Patient
Plan of Care


Consolidated into “care areas” for discussion
Each will include:




Patient assessment requirements
Plan of care: use of the MAT
How to survey
What to review in the medical record for
implementation
42
Patient Assessment:
Health Status and Co-morbid
Conditions
Health Status and Co-morbid
Conditions Assessment
What is expected: (V502)
 Use of medical & nursing histories and physical
exams
 APRN or PA may conduct medical areas of
assessment as allowed by states
 Must include etiology of kidney disease and
listing of co-morbid conditions
44
Dialysis Access: Assessment
What is expected: (V511)
IDT comprehensive assessment:



Expect assessment for most appropriate access
for the patient: AVF, graft, CVC, PD catheter
Consider co-morbid conditions/risk factors,
patient preference
The efficacy of HD & PD patient’s access
correlates to adequacy of dialysis treatments
45
Dialysis Access: Assessment
What is expected: (V511)
IDT evaluation may include:

Evaluation for/of HD access:
–
–

Communication with radiologist, interventionist,
vascular surgeon
Venous mapping, vascular access surveillance, new
access placement
Evaluation of PD access
–
–
Absence of infection (exit site/tunnel, peritonitis)
Patency & function
46
Dialysis Access: POC
What is expected: (V550)
IDT comprehensive plan shows evidence of:
 Patient evaluation as candidate for AVF



If CVC >90 days, action plan for a more
permanent vascular access
Location of patient access to preserve
future sites, for long term patient survival
Monitoring to ensure capacity to achieve &
sustain adequate dialysis treatments
47
Dialysis Access: POC
What is expected: (V551)
IDT comprehensive plan shows evidence of:
 Vascular access surveillance
 Early detection of failure
 Timely referrals for interventions
 Medical record documentation of the action
taken
48
Adequacy: Assessment
What is expected: (V518)
IDT comprehensive assessment includes:
 HD patient- initially & monthly Kt/V (or
equivalent measure, URR)
 PD patient- initially & at least every 4
months Kt/V (or equivalent measure, none
currently)
49
Adequacy: POC
What is expected: V544
POC Demonstrates:

Achievement of target: Kt/V of at least 1.2 (3
x/week HD) or 1.7 (PD)

Alternative equivalent (URR), currently none for
PD,
OR
50
Adequacy: POC (V544)

Modification of the dialysis prescription



HD: change dialyzer size, time on dialysis, BFR, DFR,
type of access
PD: change number of exchanges, volume (ml), dialysate
dextrose content (%), dwell time; consider membrane
integrity, infections (peritonitis)
Efficacy of the vascular access can also affect adequacy
OR

Rationale for not achieving the expected target
51
Access & Adequacy: Medical
Record Documentation



If expected outcomes for dialysis access or
adequacy are not achieved, there should be
evidence of reassessment for that aspect of
care
If patient is not achieving the expected
targets, expect to see documentation of the
reason WHY & a change in plan
Adjust the plan/implement the changes
52
Access & Adequacy: Medical
Record Documentation
Where to look:



IDT Assessment
Plan of care
Implementation of care plan



Flowsheets
Progress notes
Physician orders, etc.
53
Blood Pressure and Fluid
Management Assessment
What is expected: (V504)
IDT assessment should include:
 Patients BP on and off dialysis
 Interdialytic weight gains
 Target weight and intradialytic symptoms
54
Blood Pressure and Fluid
Management: POC


IDT develops and implements POC to achieve established
targets in fluid management (V622)
Fluid management and blood pressure are closely linked:
–
–
–



BP medications affect ability to reach target without symptoms
Insufficient fluid removal exacerbates hypertension
Symptomatic Drops in BP during treatment require plan
revision
Outcome oriented plan
If expected interdialytic or intradialytic goals for fluid
management are not achieved, reassess this aspect
Adjust the plan/implement the changes
55
Immunization Assessment
What is expected: (V506)
 IDT to evaluate the patient’s immunization
history/status for hepatitis , influenza,
pneumococcus
 Evaluate for tuberculosis screening what is
expected: (V127)
 Evaluate Anti-HBs on all vaccinees
56
Immunization: POC
What is Expected (V506)
CDC Recommendations for Dialysis Patients
 Be tested for at least once for baseline tuberculin
skin test results, retest if exposure is suspected
 Be offered influenza and pneumococcal vaccines
 (V126) Vaccinate all susceptible patients for
Hepatitis B
57
Immunization Medical Record
Documentation
What to expect (V506,V126, V127)
 Record of testing and immunizations
 Documentation of immunity or acknowledgement of
absence of immunity
 Documentation of further action planned if required
58
Anemia Management:
Assessment
What is expected: (V507)
 IDT to evaluate the patient’s laboratory values
(Hct, Hgb, serum ferritin, transferrin saturation,
iron stores)
 Evaluate co-morbid conditions
 Evaluate for ESA &/or iron therapy
59
Anemia Management: POC






IDT develops & implements POC to achieve
established targets in anemia management (V547)
Goals based on current clinical practice standards
MAT specifies targets for Hgb, Hct, & iron
Outcome oriented plan
If expected outcomes for anemia management are
not achieved, IDT to reassess this aspect
Must adjust the plan/implement the changes
60
Anemia Management: POC



Laboratory results reviewed monthly
Medication adjustment (may use algorithms/ESA
protocols)
Home patients: evaluate ESA administration &
storage
61
Anemia Management: Medical
Record



IDT assessment
Plan of care with measurable goals & timelines
Implementation of care plan:
 Flowsheets,
 Progress notes,
 Medication administration,
 Physician orders, etc
62
Nutrition: Assessment
What is expected:
 RD participates with the IDT in evaluation of
patients in all clinical assessment areas
 RD required to conduct an individualized
comprehensive review of the patient’s nutritional
status to include diet, hydration status,
metabolic/catabolic & cardiovascular status (V509)
63
Nutrition: POC






IDT develops & implements POC to achieve
established targets in nutritional management
(V545)
Goals based on community-based standards
MAT specifies targets for albumin, body weight
Outcome oriented plan
If expected outcomes for nutrition management
are not achieved, reassess this aspect
Adjust the plan/implement the changes
64
Nutrition: POC



Laboratory results reviewed monthly
Medication adjustment as needed
RD and IDT work with patient on dietary
adjustments
65
Nutrition: Medical Record
Documentation



IDT assessment
Plan of care with measurable goals & timelines
Implementation of care plan
– Flowsheets,
– Progress notes,
– Medication administration,
– Physician orders, etc.
66
Renal Bone Disease:
Assessment
What is expected (V508):
 IDT to evaluate the patient’s laboratory values
(calcium, phosphorous, PTH)
 Evaluate medications for management of bone
disease (phosphate binders, vitamin D analogs,
calcimimetic agents)
 Evaluate relevant dietary factors
67
Mineral Metabolism: POC



IDT develops & implements individualized POC
to achieve established targets in renal bone
disease management (V546)
Goals based on community based standards
MAT specifies targets for calcium, phosphorous
& intact PTH
68
Mineral Metabolism: POC





Outcome oriented plan
Laboratory results reviewed monthly
Medication adjustment as indicated
If expected outcomes for bone management are
not achieved, reassess this aspect
Adjust the plan/implement the changes
69
Mineral Metabolism: Medical
Record Documentation



IDT Assessment
Plan of care with measurable goals & timelines
Implementation of care plan; look at:




Flowsheets
Progress notes
Medication administration
Physician orders, etc.
70
Psychosocial Assessment
V tag Psychosocial Elements in Assessment
V512
Patient’s abilities, interests, preferences & goals for
participation in care, modality & setting
V513
Psychosocial factors related to interest in &
candidacy for transplantation
V514
Family & other support systems
V515
Physical activity & vocational rehab status & need
for referral for physical & voc rehab services
V520
Other psychosocial factors that may influence
instability
V767
Reassessment related to involuntary discharge
71
Psychosocial: POC
V Tag
Psychosocial Elements in Plan of Care
V552
Use a standardized survey to assess pt’s physical &
mental functioning
V555
Help patient to achieve & sustain desired level of
rehabilitation, including education for pediatric pts
V562
Educate pt about quality of life, rehab, psychosocial
risks/benefits related to access type, following the
treatment plan & modality selection
V543555
Address other elements as needed to assure pts
achieve & sustain appropriate psychosocial status
V767
Plan for involuntarily discharged pt
72
Psychosocial: Medical Record



IDT assessment
POC with goals and timelines
Implementation
 Flowsheets
 Progress notes
 Results of psychosocial surveys
 Plan of care
73
Timelines: Starting 10/14/08
Initial Assessments for New Patients:
• PA=30 days/13 treatments whichever is later
• POC implemented within this same timeline
Reassessment for New Patients:
• 3 months after initial assessment completed
• POC updated and implemented within 15 days of
reassessment
74
Then what?

Stable patients = Annual reassessment

POC updated and implemented within 15 days

All patients: Continuous monitoring = any aspect
of care where the target is not met = revise that
aspect of POC

Unstable patients = monthly reassessment

POC updated and implemented within 15 days
75
Who Is “Unstable?”
Per V520, includes but is not limited to:
 Extended or frequent hospitalization (>8 days or
> 3 X a month)
 Marked deterioration in health status
 Significant change in psychosocial needs
 Concurrent poor nutritional status, unmanaged
anemia and inadequate dialysis
76
What About Current Patients?
As of October 12, 2008:
 Expect a plan to implement this new system
 Some assessments/POCs completed each month until
all are done
 All current patients to be included in the new system
within 12 months of 10/12/08
 Do not expect 3 month reassessment for current
patients
 Expect updates for any aspect of care that does not
meet targets
77
Transfer of Current Patients
After 10/14/08, when a patient is transferred, expect:
 Copy of most current IDT assessment and POC from
transferring facility in patient’s medical record
 Reassessment within 3 months of admission
 Revision and implementation of POC within 15 days
of completion of the reassessment
78
Also in POC: V 560

Dialysis facility must ensure that all patients be seen
by a physician, APNP or PA at least monthly, and
periodically, for in-center HD patients, while the
patient is on dialysis

If patients are seen in the physician’s office, facility
must have a system to ensure transfer of visit
information
79
Physical Environment
Life Safety Code (LSC) Requirements:
 Must meet provisions of NFPA 2000
 Grandfather clause for current facilities in nonsprinklered buildings if built prior to 1/1/2008
 State fire safety codes may be used in lieu of LSC
 Specific provisions of LSC may be waived in
some cases
80
Physical Environment

Every facility must have an AED or a defibrillator
(& ACLS qualified staff)

All equipment maintained & operated according to
manufacturer’s directions

Emergency preparedness for staff & patients,
including disaster prep—get to know your local
Emergency Ops Center
81
Care at Home




Separate Condition for home therapies
Care at home must be equal in quality to care
provided in-center
Training required for patient described in detail
Water treatment / dialysate separately addressed,
including newer technologies
82
Home Dialysis in Residential
Institutions

Interim: home dialysis in residential institutions
will be addressed in Survey & Certification Letter

Long-Term: future rules will address this area
83
Condition 494.110:
Quality Assessment and Performance
Improvement Project (QAPI)






Interdisciplinary team (IDT)
Must report problems to Medical Director and QAPI
Process continuous & on-going
Outcome focused: use community accepted standards as
targets
Include patient satisfaction, infection control, medical
injuries & medication errors
Plan/Do/Check/Act: Close the loop!
84
PDCA Style
ACT
PLAN
CHECK DO
85
V626 QAPI Condition Statement


The dialysis facility must develop, implement,
maintain and evaluate an effective, data driven,
quality assessment and performance improvement
program with participation by the professional
members of the interdisciplinary team...
…The dialysis facility must maintain and
demonstrate evidence of its quality
improvement and performance improvement
program for review by CMS
86
Interdisciplinary Team:
Show Me
The Progress
87
Performance Measures (See MAT)
(V629) Adequacy
Kt/V, URR
(V630) Nutrition
Albumin, body weight
(V631) Bone disease
PTH, Ca+, Phos
(V632) Anemia
Hgb, Ferritin
(V633)Vascular access
Fistula, catheter rate
(V634) Medical errors
Frequency of specific errors
V635) Reuse
Adverse outcomes
(V636) Pt satisfaction
Survey scores
(V637) Infection control
Infections, vaccination status
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Monitoring Performance
Improvement
(V638) The facility must:
 Continuously monitor its performance
 Take actions that result in performance
improvement
 Track to assure improvements are sustained over
time
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Prioritizing Improvement
Activities
(V639) Considerations in prioritization
 Prevalence of problem
 Severity of problem
 Impact on clinical outcomes
 Impact on patient safety
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Immediate Correction
Examples of serious health and safety threats:
 Unsafe water or dialysate
 Defective clinical equipment
 Unsafe reprocessing of dialyzers
 Epidemiological risks
 Insufficient number of competent staff to
perform scheduled treatments:



Preserve accesses
Monitor patients
Assure safe machine function
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Personnel


Defines individual qualifications:
 Medical Director
 Nurses: nurse manager, home training nurse,
charge nurse, staff nurse
 Dietitian
 Social Worker
Defines group qualifications:
 Patient care technicians
 Water treatment system technicians
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Personnel
Patient Care Technician
 High school diploma or equivalency or 4 years of
employment
 Complete a (defined) training course, approved by
Medical Director & Governing Body; under
direction of RN
 Be certified by a State or national program
 New employees: within 18 months of hire date
(starts after 10/4/08)
 Current employees: within 24 months of 4/4/08
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Medical Director

Accountable to the Governing Body

Responsible for patient care and outcomes

Responsible for effective QAPI and Infection
Control programs

Responsible to assure all staff, physicians & nonphysician providers “adhere” to all policies

Must be engaged in any involuntary patient transfer
or discharge
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Medical Records

Traditional rules on completeness & protection of
medical records

Transfer requested records to the receiving
facility within one day
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Staffing: Governance
Requirements

Adequate number of qualified & trained staff




Patient/staff ratio appropriate to the level of care &
meets the needs of the patients (V757)
RN, MSW, RD available to meet patient needs (V758)
RN present at all times in-center patients are being
treated (V759)
All staff have orientation to the facility & their
work responsibilities (V760) & continuing
education (V761)
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Condition: Governance
Separate Standards within this Condition:







Identifiable governing body/designated person
(CEO/Administrator) (V751-752)
Medical staff appointments (V762)
Internal grievance system in place (V765)
Involuntary discharge process (V766-767)
Emergency coverage (V768-770)
Electronic data submission (V771)
Relationship with the ESRD Network (V772)
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Emergency Preparedness:
Medical



Staff training/knowledge (V409 & V411)
Staff CPR certification (V410)
Patient orientation & training (V412)
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Emergency Coverage



Emergency preparedness – Implement
processes & procedures to manage
medical & non-medical emergencies
(V408)
Staff & patient training – Training &
orientation, including what to do,
where to go, & who to contact (V409)
Emergency plans – Evaluate/update
annually, make contact with local
Emergency Management (V416)
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KCER Tools & Resources


www.kcercoalition.com
Response Team Pages



Information & education
Drills & education
Helpful links


ESRD & disaster-related
information
www.kidney.org/help
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Emergency Coverage



V768: Written instructions to patients & staff for
obtaining emergency medical care
V769: Roster of physicians
V770: Agreement with a hospital that provides
inpatient dialysis (Separate certification for
“ESRD” for the hospital is NOT required)
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Network Relationship (V772)


Receive and acts upon recommendations from
their NW
Participate in NW activities and pursue NW goals




Improve the quality & safety of services
Improve independence, QOL, rehab for all pts.
Encourage activities to ensure achievement of these
goals
Improve the collection, reliability, timeliness and use
of data
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Condition: Laboratory Services



Laboratory services must be provided by a CLIA
certified laboratory
Facilities may choose to seek approval to perform
“CLIA-waivered” tests
Must have agreements with local laboratories for
time-sensitive testing
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Condition: Special Purpose
Dialysis Facility
Special certification: CMS/RO approval required


Vacation camps
Emergency circumstances




Natural or man-made disaster
Cases where dialysis services can not otherwise be
provided because of extreme physical/mental conditions
Certification limited to maximum of 8 months
May provide services only to those patients who would
otherwise be unable to obtain treatment in that geographic
locality
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Governance: Patient
Involuntary Discharge
Specific requirements






Reassess the patient
Involve the Medical Director
Contact another facility and attempt to place
30 days notice unless threat to safety
Notify the Network and the State Agency
FYI: Network “DPC” program contains tools to
help prevent involuntary discharges
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Governance: Electronic Data
Submission
As of 2/1/09, every facility must electronically
submit data on all patients, including data on
clinical performance measures, to CMS.
CROWN Web
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Data Collection Today
Facilities
LDO
Batch
Networks
QualityNet
VISION
CMS
Third Party
Interfacing
UNOS
REMIS
SIMS
SIMS Local
Consolidated Renal Operations in a Web-Enabled Network
Data Collection Goal
Third Party Submitters
Batch
CMS
Third Party Interfacing
UNOS
REMIS
Networks/Facilities
Internet
Browser
CROWNWeb
Consolidated Renal Operations in a Web-Enabled Network
What is CROWNWeb?
•A web accessible system for collection and reporting
quality improvement measures
•Dialysis providers are the primary source of entry for
collected data
•Submit online CMS Form Data for:
•2728 (Patient SS Eligibility)
•2746 (Patient Death Notification)
•CPM-HD Form
•CPM-PD Form
What Else Can it Do?
•Online provider and patient search
•Online facility and personnel management
•Online submission of lab and treatment data
•Online batch submittal of data for LDOs
•Online comparative reporting
for submitted HD, PD, and
Fistula First data
Why CROWNWeb?
•Reduce duplicate instances of the same data
•Standardize measurements
•Provide timely comparative reporting
•Support ESRD Program administration
•Strengthen ESRD collaboration between
Networks and facilities
“Roles” in CROWNWeb

Assigned to a user based upon:


User’s need to access information
User’s responsibility to perform assigned
functions.
CROWNWeb is “role sensitive” - The
application displays content based on a
user’s role. Your role determines what
you can see!
112
“Scope” in CROWNWeb


Access to individual facilities for each unique
user.
Users with the same role may have different
scope.



One may work at only one facility.
One may work at multiple facilities and require
access to data for each facility.
Your Scope determines where you can see it!
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Role and Scope – A Visual
ROLES
-Facility Admin.
-Facility Editor
-Facility Viewer
SCOPE
CROWNWeb
ROLES
Facility
Administrator
•One user
•One role
•Supervises two
facilities
-Facility Admin.
-Facility Editor
-Facility Viewer
114
CAS
CROWNWeb Authentication System
Requires validation of credentials for every
administrative user.
• ESRD Networks
• Facilities / LDOs / Labs / Vendors
115
Role Assignment Hierarchy
→A System Administrator will set up a CMS
Administrator and other CMS users.
→A CMS Administrator will set up a Network
Facilitator, other Network users, and lower CMS
users.
→A Network Facilitator will set up a Facility
Administrator and other Facility users.
→A Facility Administrator will set up users in
their Facility.
116
What Roles are available ?

•
•
•
•
A total of 12 unique roles, grouped by:
System Administrator
CMS Roles
Network Roles
Facility Roles
117
Network Roles




Network Administrator
Network Facility Editor
Network Patient Editor
Network Viewer
118
Facility Roles




Facility Administrator
Facility Batch
Facility Editor
Facility Viewer
119
All About CRUD
CRUD is an acronym:
• Create (or add)
• Read
• Update (or edit)
• Delete
CRUD permissions are the core parameters that
define the functionality any user can access
in CROWNWeb!
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Helpful CMS Websites

ESRD Open Door Forum listserv
http://www.cms.hhs.govAboutWebs
ites/20EmailUpdates.asp

ESRD Center
http://www.cms.hhs.gov/center/e
srd.asp
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Svetlana (Lana) Kacherova
Quality Improvement Director
[email protected]
Patrick Ciriello
Director of IT Services
[email protected]
6255 Sunset Boulevard • Suite 2211 • Los Angeles • CA • 90028
(323) 962-2020 • (323) 962-2891/Fax • www.esrdnetwork18.org
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