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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. Number of Prevalent ESRD Patients in the US. Network 18 Patient Distribution by Modality.

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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

network 18 mission statement
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.

special thanks for the content contribution to the cms transition team

Special Thanks for the Content Contribution to the CMS Transition Team

Glenda Payne, Judith KariTeri Spencer, Kelly FrankRosemary Miller, Bonnie GreenspanBeth Witten

the esrd regulation timeline
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

cms expectations for state oversight of esrd facilities
CMS Expectations for State Oversight of ESRD Facilities
  • Conduct initial surveys as soon as scheduling allows; Tier 3 workload
  • Conduct resurveys, FY 2009
    • 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
esrd survey focus protect patient safety improve patient outcomes
ESRD Survey Focus: Protect Patient Safety & Improve Patient Outcomes
  • Data is used to focus surveys
  • During survey, observations focus on identification of safety hazards
    • Water/dialysate
    • Reuse
    • Machine operation/maintenance
    • Direct care
    • IDT assessment, planning &

delivery of care

condition 494 30 infection control v110 v148
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

environment ic program
Environment/IC Program

Sanitary environment in the dialysis facility & between the unit & other areas (V111)

Components of an infection control program (V112)

gloves hand hygiene
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.

gloves hand hygiene14
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

sinks with warm water soap
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


Dedicated hand washing sinks

Designated utility sinks

Sink available for patients to wash hands & access sites

ppe must wear gowns
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

items taken into the dialysis station
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

clean dirty areas medication preparation areas
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

single use vials single use
Single Use Vials = Single Use

V118 requires:

Single dose vials cannot be punctured more than once

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

supply cart supplies
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

transducer protectors
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

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

handling infectious waste
Handling Infectious Waste

V121 requires:

Handling, storage, & disposal of potentially infectious waste infectious waste

Be aware of your State & local laws

cleaning disinfecting of contaminated surfaces medical devices equipment
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

cleaning disinfecting of contaminated surfaces medical devices equipment24
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

hepatitis b routine testing vaccination screening seroconversion v124 127
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

hepatitis b routine testing vaccination screening seroconversion
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

hbv isolation room area
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

isolation of hbv patients
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

staff training education
Staff Training & Education


Infection Control Training & Education

Required for both new & existing staff members


Education & training for care of IV catheters

oversight for infection control practices program reporting requirements
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)

iv catheter care maintenance
IV Catheter Care & Maintenance


Adopts RR-10 CDC recommendations related to catheters as regulation (V146)

Monitor catheter sites (V147)

Conduct surveillance for catheter related infections (V148)

major change no ltp long term plan
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

a new day
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
  • Surveyorshave 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
the interdisciplinary team idt
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
patient assessment v501 and patient plan of care v541
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
494 80 patient assessment
§ 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)
494 90 patient plan of care v541
§ 494.90 Patient Plan of Care (V541)
  • 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
patient assessment patient plan of care
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
health status and co morbid conditions assessment
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
dialysis access assessment
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
dialysis access assessment46
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
dialysis access poc
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
dialysis access poc48
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
adequacy assessment
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)
adequacy poc
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,


adequacy poc v544
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


Rationale for not achieving the expected target

access adequacy medical record documentation
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
access adequacy medical record documentation53
Access & Adequacy: Medical Record Documentation

Where to look:

IDT Assessment

Plan of care

Implementation of care plan


Progress notes

Physician orders, etc.

blood pressure and fluid management assessment
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
blood pressure and fluid management poc
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
immunization assessment
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
immunization poc
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
immunization medical record documentation
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
anemia management assessment
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
anemia management poc
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
anemia management poc61
Anemia Management: POC
  • Laboratory results reviewed monthly
  • Medication adjustment (may use algorithms/ESA protocols)
  • Home patients: evaluate ESA administration & storage
anemia management medical record
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
nutrition assessment
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)

nutrition poc
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

nutrition poc65
Nutrition: POC

Laboratory results reviewed monthly

Medication adjustment as needed

RD and IDT work with patient on dietary adjustments

nutrition medical record documentation
Nutrition: Medical Record Documentation

IDT assessment

Plan of care with measurable goals & timelines

Implementation of care plan


Progress notes,

Medication administration,

Physician orders, etc.

renal bone disease assessment
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

mineral metabolism poc
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

mineral metabolism poc69
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

mineral metabolism medical record documentation
Mineral Metabolism: Medical Record Documentation

IDT Assessment

Plan of care with measurable goals & timelines

Implementation of care plan; look at:


Progress notes

Medication administration

Physician orders, etc.

psychosocial medical record
Psychosocial: Medical Record
  • IDT assessment
  • POC with goals and timelines
  • Implementation
    • Flowsheets
    • Progress notes
    • Results of psychosocial surveys
    • Plan of care
timelines starting 10 14 08
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

then what
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
who is unstable
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
what about current patients
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
transfer of current patients
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
also in poc v 560
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
physical environment
Physical Environment

Life Safety Code (LSC) Requirements:

Must meet provisions of NFPA 2000

Grandfather clause for current facilities in non-sprinklered 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

physical environment81
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

care at home
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

home dialysis in residential institutions
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

condition 494 110 quality assessment and performance improvement project qapi
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!

pdca style
PDCA Style





v626 qapi condition statement
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

interdisciplinary team
Interdisciplinary Team:

Show Me The Progress

monitoring performance improvement
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

prioritizing improvement activities
Prioritizing Improvement Activities

(V639) Considerations in prioritization

Prevalence of problem

Severity of problem

Impact on clinical outcomes

Impact on patient safety

immediate correction
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

Defines individual qualifications:

Medical Director

Nurses: nurse manager, home training nurse, charge nurse, staff nurse


Social Worker

Defines group qualifications:

Patient care technicians

Water treatment system technicians


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

medical director
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 & non-physician providers “adhere” to all policies

Must be engaged in any involuntary patient transfer or discharge

medical records
Medical Records

Traditional rules on completeness & protection of medical records

Transfer requested records to the receiving facility within one day

staffing governance requirements
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)
condition governance
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)
emergency preparedness medical
Emergency Preparedness: Medical
  • Staff training/knowledge (V409 & V411)
  • Staff CPR certification (V410)
  • Patient orientation & training (V412)
emergency coverage
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)
kcer tools resources
KCER Tools & Resources
  • Response Team Pages
    • Information & education
  • Drills & education
  • Helpful links
    • ESRD & disaster-related information
emergency coverage101
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)
network relationship v772
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
condition laboratory services
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
condition special purpose dialysis facility
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
governance patient involuntary discharge
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

governance electronic data submission
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.


data collection today


Third PartyInterfacingUNOSREMIS


SIMS Local


Data Collection Today





Consolidated Renal Operations in a Web-Enabled Network

data collection goal
Data Collection Goal

Third Party Submitters



Third Party InterfacingUNOSREMIS




Consolidated Renal Operations in a Web-Enabled Network

what is crownweb
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
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
“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!

scope in crownweb
“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!
role and scope a visual
Role and Scope – A Visual
  • Facility Administrator
  • One user
  • One role
  • Supervises two facilities


-Facility Admin.

-Facility Editor

-Facility Viewer



-Facility Admin.

-Facility Editor

-Facility Viewer

  • CROWNWeb Authentication System
  • Requires validation of credentials for every administrative user.
    • ESRD Networks
    • Facilities / LDOs / Labs / Vendors
role assignment hierarchy
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 andother Facility users.
        • A Facility Administrator will set up users in their Facility.
what roles are available
What Roles are available ?
  • A total of 12 unique roles, grouped by:
  • System Administrator
  • CMS Roles
  • Network Roles
  • Facility Roles
network roles
Network Roles
  • Network Administrator
  • Network Facility Editor
  • Network Patient Editor
  • Network Viewer
facility roles
Facility Roles
  • Facility Administrator
  • Facility Batch
  • Facility Editor
  • Facility Viewer
all about crud
All About CRUD

CRUD is an acronym:

  • Create (or add)
  • Read
  • Update (or edit)
  • Delete

CRUD permissions are the core parameters thatdefine the functionality any user can accessin CROWNWeb!

helpful cms websites
Helpful CMS Websites

ESRD Open Door Forum listserv http://www.cms.hhs.govAboutWebsites/20EmailUpdates.asp

ESRD Center


Svetlana (Lana) Kacherova

Quality Improvement Director

Patrick Ciriello

Director of IT Services

6255 Sunset Boulevard • Suite 2211 • Los Angeles • CA • 90028

(323) 962-2020 • (323) 962-2891/Fax •