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How Are We Doing So Far? g
Glenda M. Payne RN, MS, CNNESRD Technical AdvisorCMS, Dallas & Atlanta
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Objective: To Answer jThese Questions:
What can we do to be sure our What can we do to be sure our facility is in compliance with the new rules of the game?
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the new rules of the game?
What’s ExpectedWhat’s Expected…Subpart A: GeneralSubpart A: General1. Compliance with Federal State & local
laws and regulationslaws and regulations
Subpart B: Patient SafetySubpart B: Patient Safety2. Infection control3. Water and dialysate quality4. Reuse of hemodialyzers
35. Physical environment
Subpart C: Patient CareSubpart C: Patient Care6 P ti t ’ i ht6. Patients’ rights7. Patient assessment8. Patient plan of care9. Care at home9. Care at home10. QAPI11 Special purpose dialysis 11. Special purpose dialysis
facilities
412. Laboratory services
Subpart D: pAdministration
13. Personnel qualifications14. Responsibilities of
the medical director15. Medical records16. Governance16. Governance
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So How ARE We Doing? So, How ARE We Doing?
• From October 14, 2008 to February 12, 2009y ,
• 298 ESRD surveys done (or “uploaded”) nationallyuploaded ) nationally
• 53 Condition Level Findings• 31 Facilities (from 1 to 4 CfC each)• 31 Facilities (from 1 to 4 CfC each)
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Conditions Not MetConditions Not Met
• Infection Control (17)• Governance (10) • Medical Records
(2)• QAPI (6)• Responsibilities of the
Medical Director (5)
(2)• Laboratory (1)• Patient Medical Director (5)
• Water & Dialysate Quality (5)
• Patient Assessment (1)
• Personnel Quals (1)• Physical Environment
(3)• Reuse (1)• Plan of Care (1)
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Top Ten Citations: USTop Ten Citations: US
10. V143: IC: Aseptic technique for meds (22)
9 V504 A B/P & fl id t 9. V504: Assess B/P & fluid mgmt needs (22)
8 V403: PE: equipment maintenance; 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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Top Ten Citations: USTop Ten Citations: US
5. V115: IC: Wear Gowns/PPE (26)4. V116: IC: Items taken to station
D/D/D (26)D/D/D (26)3. V117: IC: Clean/dirty areas, med
prep area no common carts (27)prep area, no common carts (27)2. V113: IC: Wear gloves/ hand
hygiene (35)yg ( )1. V122: IC: Clean, disinfect surfaces,
equipment (38)
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Infection Control Citations
• All 29 tags have been cited• Most frequent cited Condition (17X)• SIX of the top 10 most frequently cited • 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 The most frequently cited QAPI indicator
cited is # 16: IC: trend/plan/act (20X)
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IC=Infection ControlIC=Infection Control
All about• HANDSHANDS• Supplies
M d• Meds• Saline• Heparin
• PPE11
PPE
“Hey Hey”“Hey-Hey”
• “Observe Care”• Pay attention to your practice and to
that of your co-workers colleagues that of your co-workers, colleagues, teammates, patient care techs, doctors, nurses, social workers, and dietitiansdietitians
• Call them on hand washing and glove use
• Pay attention to cleaning all surfaces: counters, tables, chairs, machines jugs etc
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machines, jugs, etc.
Top 10 Citations: TXp25 surveys
10. V515: PA: Eval current physical activity level & voc/phys. rehab (4X)
9 V545 POC Eff ti t iti l 9. V545: POC: Effective nutritional status (4X)
8 V511: PA: Dialysis access type & 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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Top 10 Citations: TXTop 10 Citations: TX
5. V502: PA: Assess current health status inc co-morbids (4X)
4 V507 PA A i (4X)4. V507: PA: Assess anemia (4X)3. V544: POC: Achieve adequate
clearance (4 X)clearance (4 X)2. V504: PA: Assess B/P & fluid
management needs (5X)g ( )1. V715: MD resp: ensure all adhere to
P&P (7X)
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So, No Infection Control ,Issues in Texas?
Not exactly…27 way “tie” for #3 actuallyy yAll 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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What About Other Areas?
• 62 of the 92 tags for Water & Dialysate
• V196: primary tag for problems in ch/chl monitoring & Dialysate
Quality have been cited
• V250: handheld checks of machine pH/conductivity
• #1 is this area = four way tie,
h ith 12
• V191: checking softener at end of the day V260 t t ff each with 12
citations:• V260: water staff
training/audits
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Problems in Ch/Chl Testing
• Policy = practice; • Policy matches test method in Policy matches test method in
use• Staff trained and competent• Staff trained and competent• Hey-Hey
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V196: Zero ≠ ZeroV196: Zero ≠ Zero
• Just because the label says “0” does not mean the strip will read to zero
• Strips only read to the lowest 0NUMBER on the range: 0.5 =
only reads to less than 0.5C /• Critical that strips/ reagents be sensitive “enough” to detect unsafe levels
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unsafe levels
ResidualResidual Chlorine Test StripsChlorine Test Strips
Test strips used to test for the
absence of BLEACH
NOT sensitive enoughto use to test for
19chloramine
V250: Verifying Machine y gFunction
For hand-held verification: • Maintain your equipmenty q p• Use in-date standards• Be sure staff know “why” they Be sure staff know why they
are doing the test and understand the allowable variation between the machine/ handheld results
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V191: Softener TestingV191: Softener Testing
• AAMI RD 52 states to do this testing “at the end of the gtreatment day”
• This means when the last This means when the last treatment is finished
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V260: Training for Water g& Dialysate
• Mandatory • Must cover quality testing, risks and
h d f i l d hazards of improperly prepared concentrate, bacterial issues
• Operators trained in use of equipment• Operators trained in use of equipment• Specific to functions performed• Periodic audits of operator’s Periodic audits of operator s
compliance • Ongoing training to maintain
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g g gknowledge and skills
Let’s Go Back to the Top 10: What is NOT IC? What is NOT IC?
10. V143: IC: Aseptic technique for meds (22)
9 V504 A B/P & fl id t 9. V504: Assess B/P & fluid mgmt needs (22)
8 V403: PE: equipment maintenance; 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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Patient Assessment: #9: V504: Assess B/P and fluid 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 Fluid removed and weights do not match
and no comment is madeNote: Surveyors are being taught
to look at flow sheets for the to look at flow sheets for the implementation of the assessment-based plan of care
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p
# 7. V506: Immunization/ Medication Hx (23 X)Medication Hx (23 X)
• “Immunization history” should Immunization history should include whether the patient has received standard immunizations (pneumococcal, hepatitis, and influenza), and has been screened f t b l i for tuberculosis.
• The immunization record is expected include at least the patient’s include at least the patient’s immunization history as of the effective date of this regulation.
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effective date of this regulation.
# 7. V506: Immunization/ Medication Hx (23)Medication Hx (23)
CDC recommends all dialysis patients:• Be tested at least once for baseline
tuberculin skin test results (TST) and tuberculin skin test results (TST) and re-screened if TB exposure is detected. Chest x-rays may be used y yas an option.
• Be offered influenza and l i d th t th i pneumococcal vaccine and that their
immunization history be tracked.
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Medication historyMedication history
• Should include a review of the patient’s allergies and of all medications including over themedications including over-the-counter medications and supplements that the patient is pp ptaking.
• The assessment should demonstrate th t ll t di ti that all current medications were reviewed for possible adverse effects/interactions and continued
27need.
Another Word about PA/POC*Another Word about PA/POC*Here is our REAL opportunity to Here is our REAL opportunity to
CHANGE the way care is delivered!delivered!
Here is our REAL opportunity to INCREASE patient involvement INCREASE patient involvement and INDEPENDENCE = improved satisfaction & better working satisfaction & better working conditions for everyone!
*R b th T 10 i TX!28
*Remember, the Top 10 in TX!
Time for Change!Time for Change!• Expectation that all facilities are • Expectation that all facilities are
in the process of converting all patients to the new system of patients to the new system of planning and evaluating care—all patients converted to this system p yby 10/14/2009
• STCP and LTCP are so yesterday! y y• PA and POC: the way for the
future29
Correlation of PA & POCPA POC
Current health status Incorporated into all (V502)Lab profile (V505)Medication/immunization
pPOC tags
Medication/immunization history (V506)Appropriateness of dialysis prescription (V503)
Provide adequate clearance (V544)prescription (V503) clearance (V544)
BP/fluid management needs (V504)
Manage volume status (V543)
Assess anemia (V507) Manage anemia (V547)Home pt ESA (V548)ESA response (V549)
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ESA response (V549)Assess renal bone disease (V508)
Manage mineral metabolism (V546)
PA POCN t iti l t t (V509) Eff ti t iti l t t Nutritional status (V509) Effective nutritional status
(V545)Psychosocial needs (V510) Psychosocial y ( )Evaluate family support (V514)
ycounseling/referrals/ assessment tool (V552)
Access type/maintenance VA monitor/referral (V550) Access type/maintenance (V511)
VA monitor/referral (V550) Monitor/prevent failure (V551)
E l t f lf/h H di l i l (V553)Evaluate for self/home care (V512)
Home dialysis plan (V553)
Transplantation referral Transplantation status: plan p(V513)
p por why not (V554)
Evaluate current physical activity level & voc/physical
Rehab status addressed (V555)
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activity level & voc/physical rehab (V515)
(V555)
How Is This Supposed to Work? pp• PA: identifies intradialytic weight gains
(IDWG) of greater than 12 (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 thirstways 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 5 pounds is reached
• Monitor IDWG each treatment. Praise positive actions (RN, PCT)
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• If IDWG remains at same levels at end of one month, review and revise POC
PA/POCPA/POC
Everyone has one year to comply with these two Conditions
About ½ of your patients should now be on the new systemnow be on the new system
“Monitor, recognize and address”M k thi k th hil it i Make this work worthwhile—it is
not about paper or the form!
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#8: V403: PE: equipment maintenance; follow DFU (23 X)maintenance; follow DFU (23 X)
E i t R i & M i tEquipment Repair & Maintenance
*DFU= Directions for use34
DFU= Directions for use
#6: V715: MD resp: all adhere to P&P (26 X)adhere to P&P (26 X)
Admission policies• OrdersOrders• Baseline H&P
N i t i t 1st• Nursing assessment prior to 1st
treatment• “Adhere to P&P”
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Achieving ComplianceAchieving Compliance
Learn about the new regulations:
• Read the Federal Register• Read the Interpretative Guidancep• Attend meetings (like this one!)• Discuss with your peersy p• Ask questions!
Achieving ComplianceAchieving ComplianceThen:Then:• Evaluate current practice and
compare to new requirementscompare to new requirements• Implement policy changes as
neededneeded• Educate staff to new policy and
new regulationnew regulation• Audit practice for compliance
R t t t37
• Repeat, repeat, repeat…
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