2010 CMS Regulatory Update

1. 2010 CMS Regulatory Update Glenda M. Payne, RN, MS, CNN ESRD Technical Advisor CMS, Dallas & Atlanta Regions

2. We Can Do Better! We Can Do Better! “How To” Avoid Deficiency Citations “How to” Avoid Citations

3. Objectives • Describe common deficient practices identified in surveys. • Identify areas of continued confusion or misunderstanding in the CMS regulations. • Detail areas where pre-work may prevent deficient findings.

4. US: Frequently Cited Tags1276 Surveys of 5439 Providers

5. US: Frequently Cited Tags1276 Surveys of 5439 Providers

6. US: What About Water and Dialysate? From 1276 Surveys of 5439 Providers from Oct 2008 – April 2010

7. US: Condition Level Findings • CfC Infection Control is the most frequently cited Condition level finding (#29) • CfC Governance is the second most frequently cited Condition level finding (#40)

8. What About Texas?

9. US: What About Water and Dialysate? From 1276 Surveys of 5439 Providers from Oct 2008 – April 2010

10. TX: Frequently Cited Tags115 Surveys in 456 Providers

11. TX: Frequently Cited Tags115 Surveys in 456 Providers Note: NINE tags “tie” at having 11 citations: the two above plus: V502: PA assess current health status; V626: QAPI covers scope; V547: POC manages anemia; V711: Med Dir accountable to GB; V727: Med records completed promptly; V684: Pers Quals: Nurse Manager; and V401: PE safe, functional and comfortable.

12. TX: What About Water and Dialysate? From 115 surveys of 456 providers from Oct 2008 – April 2010

13. Note: • Half of the “Top Ten” nationally are infection control violations… • Four of the Texas “Top Ten” are infection control violations What Are Some of the Causes of These Findings?

14. Some Root Cause Analysis Your ideas: • .. • .. • .. • ..

15. Some Root Cause Analysis • Too little time between patients • Poor design, inefficient arrangement of the treatment area • Lack of knowledge • Of the regulations • Of facility policy & procedure • Of the reasons for the requirement

16. More Root Cause Analysis • Lack of training • Lack of understanding of the impact each person’s performance has on outcomes • Not enough staff • Changes from “historical” practices

17. We Can Do Better! In Meeting Infection Control Standards… We Can Do Better! “How To” Avoid Deficiency Citations

18. Consider Practice Audits • “Hey Hey” • Random practice audits: • Frequency • Spacing • Auditors • Everyone scoring 100% initially is a sign you either need a different tool or re-education of the auditors

19. Gloves and Hand Hygiene • Gloves: put them on • Use hand hygiene between gloves • Use clean gloves when approaching vascular access

20. Clean Surfaces • Tilt chairs back to clean • When cleaning up blood spills: 1st clean, then (with new supplies) disinfect • Treatment chairs: practice audits

21. Medication “Do’s” • Prepare all meds (including heparin & lidocaine) in a clean area away from the treatment area • Clean all stoppers with alcohol before puncturing (vials and lines) • Prepare meds close to time of use • Label meds not given immediately (with patient name, med name, dose, your initials)

22. Wet Transducers • Don’t work • Can be a source of contamination for the machine and thus other patients • Must be changed when wetted • The transducer must be inspected for breakthrough; if found, the machine must be taken out of service for maintenance.

23. We Can Do Better! We Can Do Better! “How To” Avoid Deficiency Citations In Patient Assessment and Plan of Care…

24. Community Based Standards: MAT • Use the current CMS Measures Assessment Tool (Vers. 1.6; on the NW 14 website…) • Use the listed Goals from the MAT for QAPI and PA/POC • Can some patients have lower goals?

25. IDT Members Participate in PA IDT includes: • Patient • RN • MSW • RD • Physician responsible for the patient Expected that all memberswould participate in each PA and POC; The relevant team member may update a portion of the POC, consulting other members as indicated.

26. Fluid Management #1 cause of death in kidney patients? • Heart Disease • Failure to manage fluid status increases the size of the left heart • How do we “measure” fluid management? Control of Weight and Blood Pressure

27. Fluid Management Management • Pay attention to blood pressure readings • Take action if readings or elevated or depressed • Pay attention to pre and post treatment weights • Take action if post treatment weight goal is not reached

28. We Can Do Better! We Can Do Better! “How To” Avoid Deficiency Citations With Compliance in the Technical Area…

29. Chair Side Measures of pH and Conductivity • Required before each treatment • Be sure staff members know the “why” • Be sure staff members know the allowed variability • Be sure staff do not falsify records

30. Did You Know? • Practice audits are required: • for water treatment • dialysate preparation • Don’t forget these when planning your audits

31. We Can Do Better! We Can Do Better! “How To” Avoid Deficiency Citations In All Regulatory Areas…

32. Be Prepared! “You can’t use knowledge you don’t have” Orientation and on-going education are CRITICAL

33. Help Each Staff Member Understand the “WHY”” • Understanding “why” promotes consistent practice • Understanding “why” decreases the likelihood of staff taking shortcuts or altering practice • Understanding “why” empowers staff to do the right thing

34. Questions? Thanks for the Work You Do! ESRDsurvey@cms.hhs.gov