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The Survey Scoop: panel discussion on CMS regulations and survey readiness.

Debbie Cote, Administrator, Dialysis Program, University of Virginia Health System

Kim Deaver, MSN RN CNN FNKF; Nurse Manager, University of Virginia

Bridget Pfaff, MS; Administrative Director, Gundersen Health

Julie Williams, BS, Administrator, Branson Dialysis and Heartland Kidney Programs

Objectives• Summarize recent changes in

CMS regulations that affect dialysis facilities Identify 3 elements that are must haves in The facility emergency plan.

• List 2 things to change to prepare for your next CMS survey.

• Define 2 key strategies to help prepare staff for survey.

• Describe the components of a plan of action to correct deficiencies.

No Conflicts

• Images may be of products/supplies, reference tools, but no financial interest in those identified through discussion.

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https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCletter09-01.pdf

Purpose

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/ESRD-Core-Survey-Field-Manual.pdf

Core Survey –what and how? • Industry (NRAA) raised concerns• CMS addressed –results = Core Survey.

– Individual dialysis facility– Staff who routinely deliver care

• audits

– Record review– Facility level QAPI

• Narrative instructions in the training manual.• Focuses on facility practices that impact:

– Patient safety– Clinical outcomes

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HOT TOPICS…..WHAT’S

NEW.

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So what’s new? Released August ‘18

• Well: Quality, Safety & Oversight Group for one.• Pulled the “FAQ’s” to update them, they were in

opposition to the changes made in 2017 regarding vacating the station as well as some other things.

• Released an update on regulations August 10, 2018– Guidance on ESRD activities relates to relocations, addition of

stations, expanded services and temporary closures.– Guidance for dialysis services provided in a nursing home.– Infection control considerations.– Medical Director waivers.

• Sufficient space between stations.

• Home training support must have a plan/arrangement for patients when there is an interruption in the patient's routine home dialysis service.

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Dialysis in the Skilled Nursing Facility. • Medicare reimbursement is available for certified ESRD facilities for

nursing home residents.• Nursing homes are not required to accommodate dialysis services on

site. (State regulations).• Nursing home residents may receive chronic dialysis

– In-Center by transporting them to an offsite location or transporting the resident to and from a separately certified ESRD facility that is located in or adjacent to the nursing home.

– Home dialysis in the nursing home administered and supervised by personnel who meet the Vtag 494.1 and you must have a written agreement between the two parties.

– No additional approval is required from CMS for an ESRD facility to enter into an agreement with the nursing home.

– However, you must notify your State Agency (CMS form 3427)

CMS Requirements • Must have policies, procedures and or protocols that are

equivalent to the standards in the ESRD facility . • Must be reviewed an updated as necessary to be current. • Must follow CfC related to infection control practices, patient

assessment, plan of care, and care of the patient at home (Vtags494.30 and 494.8-494.100).

• Onsite supervision by an RN who has completed ESRD facility training.– An LPN/LVN can do PD. – Documentation of training and ongoing competency assessment must

be kept in both the ESRD facility and the LTC facility.

• Must be present in the room and maintain direct visual contact.

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Points that make you go hmmm…• If the nursing home is unable to provide dialysis for staffing reasons

the ESRD facility must provide to avoid delay or cancellation. • Whether PD or HHD, the RN, LPN/LVN must initiate and discontinue

the treatment.• A trained nursing home staff member such as a nurse’s aide or trained

care giver may monitor the patient.• Initiation or discontinuation must only be performed by the

supervising nurse. What about technician’s????

• ESRD facility must provide LTC facility with equipment troubleshooting and contacts for equipment failures.

Final points• Coordination of care - 24/7 communication with an on

call schedule (MD’s and RN’s).• IDT collaboration between the two facilities. • Emergency plans responsibility of ESRD facility. • The doctors orders must state what emergency

medications to have on hand for patients. • Should have adequate inventory and keep at least an

extra 5 days for emergencies.• ESRD facility must provide LTC facility with medications. • Surveyors are required to do an onsite survey.

Emergency Management

• Elements of performance to go into effect November 2017

• Hurricane Harvey August 2017.

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https://www.today.com/news/hurricane-harvey-floods-texas-nursing-home-residents-saved-t115666

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• Hazard vulnerability assessment (HVA).• Complete your plan.• Connect in your community.• Create a communication plan.• Complete 2 drills annually.• Complete community-wide table-top annually.• Conduct one additional drill or document on a real event.• Complete After Action Reports.• Adjust your plan and track changes.

Key steps

• https://www.nraa.org/services/emergency-preparedness• https://www.dhs.wisconsin.gov/publications/p01948i.pdf• https://www.calhospitalprepare.org/hazard-vulnerability-analysis

Where Can You Find Resources?

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CREATING A CULTURE OF READINESS

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Documents Required

What: ESRD Core Survey Facility Worksheet: Personnel File

Where: CMS.gov https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Dialysis.html

Documents Required

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Documents RequiredWhat: ESRD Core Survey Data Worksheet

Where: CMS.gov https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Dialysis.html

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CMS Preparedness BookContains all information monthly in sections for the ESRD Core Survey Data worksheet

Documents RequiredNotebook created with sections for each of the ESRD core Survey Data Worksheet.

The information is changed out the beginning or end of each month by the Administrative Assistant with help from the Assistant Nurse Manager/Facility Manager.

The ANM or FM can also use the information to help with monthly QAPI.

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Staff Competencies/Audits• Notebook with staff sections and all

CDC competency forms

• Engage the staff to assist in peer to peer competency observations

• Engage patients in assisting with audits such as handwashing, cleaning stations, cleaning access, etc.

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Documents Required

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Audit BookContains audit forms that any staff or patient can use for auditing.

Performing observations and

establishing consistent use of best practices

http://www.cdc.gov/dialysis/prevention-tools/index.htmlhttps://wwwn.cdc.gov/pubs/CDCInfoOnDemand.aspx?ProgramID=137

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Audit Tool Corresponds to Hemodialysis Catheter Connection and Disconnection Checklists

SURVEY EXPERIENCE PANEL.

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AFTER THE SURVEY.

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Plan of Correction

• What you say you will do about it.

– Deficiency

– Correction

– When

– Monitoring

– Responsibility

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Root Cause Analysis

• Pilot project. – https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/guidanceforrca.pdf

• Helps assure you are not jumping to solutions.

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Isolation of HBV+ Patients

Isolate HBsAg positive patients, designate a separate room for their treatment.

Interactions/Appeal

• Discussions during survey.

– Don’t argue

– Surveyor Variability

• Process is well defined.

• Focus on impacting policy/training.

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Closing Comments/Questions

Reference/Appendix

• The survey process outlined.

• Items to be covered during the panel discussion, included here for reference.

• Reference documents.

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Survey Process• Preparing for the survey

– Dialysis Facility Reports (DFR)– Review the facility complaint and survey history.– Contact the Network.

• Arrive on site– Introductions– Request for data

• Flash tour– Ask staff about a culture of safety– General treatment area, water treatment room, home training, reuse area.– Could go further: patient waiting area, patient bathrooms, supplies, RMW, lab

area.

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Survey details• Observations of direct patient care and infection control.

– Preparation for dialysis.– Initiation and discontinuation of dialysis with CVC and AVF/AVG

• Observations of testing of the water treatment system.• Medication preparation and administration.• Isolation practices.• Dialysis prescription delivery (orders vs. actual).• Home dialysis training and support review.• Review medical records.

Patient and Staff Survey• Personnel interviews (IDT members)• Review patient specific information.• Select 10% or a minimum of 4 patients.• Look for specific criteria:

– Unstable– Not meeting goals– New admission– Residents of LTC facilities– Observed patients

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Water treatment, Dialysate and Equipment Maintenance Review

• Review critical water treatment components.• Observe Chlorine testing and interview staff member. • Interview person who does the cultures and review the

culture reports.• Interview person responsible for mixing concentrate

and/or bicarbonate. • Review the practice audits on staff that routinely

perform these activities. • Preventative maintenance and repair review.

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And finally: QAPI • Monitoring care and facility operations:

– Clinical and operational indicators. – Oversight of technical operations and practice audits.

• Review activities and prioritization:– Mortality.– Infection prevention and control, including vaccines. – Medical error/adverse events/clinical variance tracking.

• Culture of Safety – Risk identification and reporting.– Staff engagement review– Staff and patient suggestion/complaint log

Survey Findings• Deficiencies can be at 3 levels:

– Standard level: • Non-compliance with any single requirement or several requirements within a

particular area. • Doesn’t substantially limit a facilities capacity to furnish adequate care or jeopardize

the patients health or safety.

– Condition level• Non-compliance with the requirements in a single standard, or several standards

within the condition. • Represents a critical health or safety breach.• 90 calendar day termination track.

– Immediate Jeopardy (i.e. IJ) • You are closed until it is fixed!• Non-compliance that has caused or is likely to cause serious injury , harm or even

death of a patient.• Harm does not actually have to occurred. • Correct immediately, you can stay open, but you still get the IJ and it will be listed as

abated.

Web Resources• NRAA Voices: https://voices.nraa.org/home• Core Survey Field Manual: https://www.cms.gov/Medicare/Provider-

Enrollment-and-Certification/GuidanceforLawsAndRegulations/Downloads/ESRD-Core-Survey-Field-Manual.pdf

• Medical Director Toolkit: http://esrdnetworks.org/resources/toolkits• Conditions for coverage: https://www.cms.gov/Medicare/Provider-

Enrollment-and-Certification/GuidanceforLawsAndRegulations/Dialysis.html

• ANNA Specialty Practice Networks: https://www.annanurse.org/about/committees-specialty-practice-networks/specialty-practice-networks-spn-central

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