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

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

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. 3

US: Frequently Cited Tags 1276 Surveys of 5439 Providers #TagID# X’s Cited% of Surveys 1V113IC - WEAR GLOVES/HAND HYGIENE V122IC - CLEAN, DISINFECT SURFACES & EQUIPMENT/WRITTEN PROTOCOLS V403PE - EQUIPMENT MAINTENANCE - MANUFACTURER'S DFU V715MD RESP - ENSURE ALL ADHERE TO P&P V541PATIENT PLAN OF CARE - GOALS - COMMUNITY-BASED STANDARDS V401PE - SAFE, FUNCTIONAL, COMFORTABLE ENVIRONMENT V115IC - WEAR GOWNS, SHIELDS/MASKS; STAFF NOT EAT/DRINK IN TX AREA

US: Frequently Cited Tags 1276 Surveys of 5439 Providers #TagID# X’s Cited% of Surveys 8V117IC - CLEAN/DIRTY AREAS, MED PREP AREA, NO COMMON MED CARTS V402PE - BUILDING - CONSTRUCTED/ MAINTAINED TO ENSURE SAFETY V116IC - ITEMS TAKEN TO STATION DISPOSED/DEDICATED OR DISINFECTED V726MEDICAL RECORDS - COMPLETE, ACCURATE, ACCESSIBLE V407PE - HEMODIALYSIS PATIENTS IN VIEW DURING TREATMENTS V501PATIENT ASSESSMENT - INTERDISCIPLINARY TEAM MBRS/RESP V504ASSESS B/P & FLUID MANAGEMENT NEEDS

US: What About Water and Dialysate? #TagID# X Cited% of Surveys 17V196CARBON ADSORPTION - MONITORING, TESTING FREQUENCY V250DIALYSATE PROPORTIONING – MONITOR PH/CONDUCTIVITY From 1276 Surveys of 5439 Providers from Oct 2008 – April 2010

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) 7

What About Texas? 8

US: What About Water and Dialysate? #TagID# X Cited% of Surveys 17V196CARBON ADSORPTION - MONITORING, TESTING FREQUENCY V250DIALYSATE PROPORTIONING – MONITOR PH/CONDUCTIVITY From 1276 Surveys of 5439 Providers from Oct 2008 – April 2010

TX: Frequently Cited Tags 115 Surveys in 456 Providers #TagID# X’s Cited% of Surveys 1V715MD RESP - ENSURE ALL ADHERE TO P&P V541PATIENT PLAN OF CARE - GOALS - COMMUNITY-BASED STANDARDS V122IC - CLEAN, DISINFECT SURFACES & EQUIPMENT/WRITTEN PROTOCOLS V113IC - WEAR GLOVES/HAND HYGIENE V726MEDICAL RECORDS - COMPLETE, ACCURATE, ACCESSIBLE V117IC - CLEAN/DIRTY AREAS, MED PREP AREA, NO COMMON MED CARTS V501PATIENT ASSESSMENT - INTERDISCIPLINARY TEAM MBRS/RESP

TX: Frequently Cited Tags 115 Surveys in 456 Providers #TagID# X’s Cited% of Surveys 8V543MANAGE VOLUME STATUS V504ASSESS B/P & FLUID MANAGEMENT NEEDS V120IC - TRANSDUCER PROTECTORS: NOT WETTED/CHANGED V403PE - EQUIPMENT MAINTENANCE - MANUFACTURER'S DFU V750CFC – GOVERNANCE (# 23 = CFC Inf Control) V503APPROPRIATENESS OF DIALYSIS RX V507ASSESS ANEMIA 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.

TX: What About Water and Dialysate? #TagID# X Cited% of Surveys 25V250DIALYSATE PROPORTIONING – MONITOR PH/CONDUCTIVITY V228MIXING SYSTEMS – LABELING V196CARBON ADSORPTION – MONITORING, TESTING FREQUENCY From 115 surveys of 456 providers from Oct 2008 – April 2010

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

Some Root Cause Analysis Your ideas:.. 14

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 15

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 16

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

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 18

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

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

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) 21

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. 22

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

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? 24

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

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 26

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 27

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

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 29

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

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

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

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 33

Questions? 34