1. Demystifying the New Regulations: A User’s Guide to the Conditions for Coverage Jan Deane, RN, CNN Network 11 Annual Meeting October 3, 2008

2. With a Special Thanks… To Glenda Payne and Judith Kari for their assistance in putting this presentation together.

3. Disclaimer Although this presentation has been reviewed by CMS, it does not substitute for facility’s responsibility to become familiar with all the regulations and make all necessary changes to be in compliance with the new regulations by October 14, 2008.

4. Chronic Hemodialysis First successful patient in 1960 Home hemodialysis became popular due to the high cost of treatment Patient selection became an important part of the process “Who shall receive care when not all can receive care?”

5. Medicare Coverage for Dialysis Public Law 92-603, Section 2991 Dialysis and transplant would be covered under the Medicare program regardless of age Dialysis became available for anyone …Then in 1976…

6. The Long Journey Began

7. 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 4

8. 1994 Community Forum: Outcome From First: Paper reviews To First: Patient safety –Water –Reuse –Infection Control –Physical Environment Change in Regulatory Focus

9. 1994: Change in the Survey Process From a focus on: To a focus on: Policies Procedures Personnel records Reviewing data Observing care Interviewing patients Interviewing the people doing the work

10. 1994: Change in the Survey Process From a focus on:To a focus on: StructureOutcomes Practices: water treatment results, dialysis adequacy Data: Dialysis Facility Reports Community-set minimum standards

11. Common Themes on the Long Journey CMS & Kidney Community partnership Survey process is driven by outcomes & data, not structure & paper Striving for consistency & common understandings

12. Rationale Behind the Changes

13. Rationale for ESRD Regulation Changes Increasing realization of the need for regulatory support for an outcomes focus across provider types Needed to drive improvements in care Critical if CMS moves to value-based pricing Necessary if CMS moves to bundled reimbursement for ESRD care

14. Reasons for Change Changes in technology –Water treatment: more complex –Changes in dialysis equipment Differences in care delivery –1970’s: few technicians; regulations are silent –2008: technicians provide most direct care; public is demanding regulation

15. Reasons for Changes Evidence Based Practice: ESRD community coming to consensus on minimum standards of care –RPA’s Adequacy of Dialysis Report –K/DOQI Guidelines –Fistula First Breakthrough Initiative QAPI: accepted process of quality assessment across provider types Electronic data submission required to keep pace with growing ESRD population & need for current data

16. Introducing the new Conditions for Coverage October 14, 2008 So what’s new??

17. Subpart A: General Provisions

18. Subpart B: Patient Safety

19. 494.30: Infection Control Official adoption of the CDC Guidelines –“Recommendations for Preventing Transmission of Infections Among Chronic Hemodialysis Patients” MMWR 4/27/2001 More focus – Condition level importance Moved higher in the survey process PPE Changes – GOWNS not APRONS!

20. 494.30: Infection Control Isolation rooms for HBV infected patients –All new facilities built after 2/9/2009 –Older facilities may use a separated area Infection control issues –Medical director involvement –QI process Develop tracking process Use comprehensive QI process to understand

21. 494.40: Water and Dialysate Quality Meet AAMI standards for water and dialysate purity –“Dialysate for Hemodialysis” ANSI/AAMI RD52:2004 Increased frequency of chlorine/chloramine testing Quality assurance plan for adverse occurrences that assures patient safety

22. 494.50: Reuse of Hemodialyzers and Bloodlines No reuse for HBV patients Adherence to AAMI Guidelines –“Reuse of Hemodialyzers” ANSI/AAMI RD47:2002 Expanded quality assurance processes including suspending reuse in the presence of clusters of adverse patient reactions

23. 494.60: Physical Environment Patient care environment –Comfortable temperature –Patient privacy –Patients within view of care staff including vascular access and line connections

24. 494.60: Physical Environment Emergency Preparedness –Staff training Medical emergencies – CPR certification Non-medical emergencies including weather related emergencies Emergency equipment Patient Education Disconnect procedure Where to go in the event of an emergency

25. 494.60: Physical Environment Emergency Preparedness –Equipment Oxygen, airways, suction Defibrillator or Automatic External Defibrillator –Exemption for hospital based units with access to hospital resuscitation team if response is within a timely manner (4-5 minutes)

26. 494.60: Physical Environment Fire Safety –Compliance with the applicable sections of the 2000 Life Safety Code (National Fire Protection Association) –Exemption to sprinklered section if facility was built before 1/1/2006 and state law permits –Must follow State law if State law is more strict than the LSC provisions.

27. Subpart C: Patient Care

28. 494.70: Patient Rights Not a lot of changes but mostly expansion and clarification of existing patient rights Addition of several new patient rights –Advance Care Planning discussions –Information regarding all treatment modalities and including scheduling options –Grievances – expanded to 3 tags

29. 494.70: Patient Rights Involuntary Discharge –Included in Patient Rights Condition as well as patient assessment and governance –Under this Condition, specifically information regarding the facility policy for involuntary discharge AND the right to written 30 day notice

30. 494.80: Patient Assessment Interdisciplinary team involvement – at a minimum –Patient or patient’s designee –Registered nurse –Patient’s nephrologist –Social worker –Dietitian

31. 494.80: Patient Assessment Comprehensive initial assessment –All new patients within 30 days or 13 treatments Follow-up comprehensive reassessment –All new patients within 3 months following the initial assessment Additional reassessments –Stable patients – annually thereafter –Unstable patients – monthly until stable

32. 494.80: Patient Assessment What is an unstable patient? –Extended or frequent hospitalizations –Marked deterioration in in health status –Significant change in psychosocial needs –Concurrent poor nutritional status, unmanaged anemia, and inadequate dialysis Facilities need to have a method of classifying patients

33. 494.80: Patient Assessment -Current health status -Appropriateness of dialysis prescription -BP and fluid management -Laboratory tests -Immunization and medications -Family and support -Physical activity -Anemia management -Renal bone disease -Nutritional status -Psychosocial needs -Dialysis access -Patient’s desired level of participation in care -Suitability for transplant

34. 494.80: Physical Assessment Caveats –Emphasis is on TEAM – everyone working together – patient included –Interdisciplinary is different from multidisciplinary: more collaborative, more congruent –Policies and procedures are fine – they need to be operationalized. –Breakout session this afternoon will look at ways in which providers are making this work in real life.

35. 494.90: Patient Plan of Care Interdisciplinary team involvement – at a minimum: –Patient or patient’s designee –Registered nurse –Patient’s nephrologist –Social worker –Dietitian –Be signed by all team members, including the patient or designee

36. 494.90: Patient Plan of Care Implementation must begin within 30 days or 13 treatment of initiation of dialysis Implementation of monthly or annual updates to the plan must be performed within 15 days of the completion of additional assessments or reassessment.

37. 494.90: Patient Plan of Care Dose of dialysis Meet and sustain Kt/V of 1.2 (HD) or 1.7 (PD) Nutritional status Mineral metabolism Anemia Home assessment for home patients Response to ESAs Vascular access type Vascular access monitoring Psychosocial status Modality Transplant status Rehab status

38. 494.90: Patient Plan of Care What QOL tool is recommended? –CPM to be implemented in 2009 calls for KDQOL –The CrownWeb system will require KDQOL domains to be entered. –So…

39. 494.90: Patient Plan of Care Additional points to remember –If expected outcome for any area is not achieved and sustained Documentation of revision for that portion of the POC and QI process –Nephrologist visits required monthly Can be Advanced practice RN or physician assistant –Transplant referral tracking Workup process Waitlist tracking

40. 494.90: Patient Care Planning Patient education –Dialysis experience –Dialysis management –Infection control –Home dialysis and self dialysis –Quality of life, rehabilitation –Transplantation –Vascular access

41. 494.100: Care at Home New as a Condition Home dialysis services must be at least equal to that provided for in-center patients Interdisciplinary team oversees training Be conducted by a registered nurse who meets qualifications Specific areas to be covered in the training

42. 494.100: Care at Home Periodic monitoring of home adaptation including home visits Assessment and care planning same as for in-center patients Meet specific water and dialysate testing requirements – refer to conditions for specifics Planning for back-up services

43. 494.110: Quality Assessment and Performance Improvement “The 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.”

44. 494.110: Quality Assessment and Performance Improvement Facility-wide – all services must be included –In-center hemodialysis –Home hemodialysis –Peritoneal dialysis –Reprocessing –Water quality …Just to mention a few…

45. 494.110: Quality Assessment and Performance Improvement Use of professionally accepted clinical practice guidelines to track health outcomes Identification, prevention, and reduction of medical errors Action towards improving outcomes not meeting target levels Patient satisfaction is included – CAHPS tool is recommended by CMS

46. 494.110: Quality Assessment and Performance Improvement Use of principles of CQI –Monitor data/information –Prioritize areas for improvement –Determining potential root causes –Developing, implementing, evaluating, and revising plans that will result in improvements in care

47. 494.110: Quality Assessment and Performance Improvement Adequacy of dialysis Nutritional status Bone and mineral metabolism Anemia management Vascular access Medical errors Hemodialyzer reuse Patient satisfaction and grievances Infection control including surveillance and immunization status

48. Measures Assessment Tool

49. Subpart D Administration

50. 494.140: Personnel Qualifications Registered nurse –Nurse manager RN, full time, 12 months nursing + 6 months dialysis –Home training nurse RN, 12 months nursing + 3 months in home therapy –Charge nurse RN, LPN/LVN, 12 months nursing including 3 months dialysis –Staff nurse RN, LPN/LVN

51. 494.140: Personnel Qualifications Dietitian –Must now have 1 year experience clinical experience AFTER registration Social Worker –Has not changed but there are more specific directions as to the educational preparation –Council of Social Work Education www. cswe.org

52. 494.140: Personnel Qualifications Patient Care Technicians –High school diploma –Completed formal training program Facility-based or college based –Obtain certification National approved program (there are 3) State certification programs if –Curricula meets regs –Standardized test –Proctored exam not given by dialysis facility

53. Patient Care Technicians Formalized training program –Written program –Approved by medical director –Under the direction of a registered nurse –Meets specific components of the dialysis procedure and patient care –Demonstrated competency Written exam Skills validation

54. Patient Care Technicians National certification –Current PCTs – by 4/15/2010 –Newly hired PCTs after 10/14/2008 – 18 months after hire date –Nationally accepted program Nephrology Nursing Certification Commission Board of Nephrology Examiners for Nursing and Technology National Nephrology Certification Organization

55. Patient Care Technicians FAQs: –PCTs with > 4 years experience with NO high school diploma may use work experience in lieu of diploma –Non-certified PCTs must complete formal training program before independently providing care –PCTs with > 2years experience as of 10/14/08 do not need to go through formalized training BUT must demonstrate competency with test and skills validation

56. 494.150: Medical Director Responsibilities Medical Director is specifically responsible for the following: –Quality assessment and performance improvement program –Staff education, training, and performance –Policies and procedures All P/P related to patient care are adhered to Interdisciplinary team adheres to discharge/transfer policies and procedures – including involuntary discharge

57. 494.180: Governance CEO/Administrator is responsible for –Staff appointments –Relationship with the ESRD Network Pursuing the goals and objectives of the Network – including the electronic submission of data – Crown Web –Allocation of staff resources for QAPI program –Adequate staffing –An RN is present in the facility at all times when patients are being treated

58. 494.180: Governance Internal Grievance Process –Also addressed under Patient Rights –Clearly defined procedure including time frames –Processes for communicating with the patient –Those complaints or grievances that involve patient safety must be addressed immediately

59. 494.180: Governance Involuntary Discharge –The medical director assures that no patient is discharged or transferred from the facility except for the following reasons: Failure to pay for ordered services The facility ceases to operate The transfer is necessary for the patient’s welfare because the facility can no longer meet the patient’s documented medical needs OR

60. Involuntary Discharge The facility has reassessed the patient and determined that the patient’s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired.

61. Involuntary Discharge The Medical Director ensures that the interdisciplinary team 1.Documents the reassessment and on-going problems 2.Provides the patient and ESRD Network with 30 day notice 3.Obtains a written order from patient’s physician and the medical director

62. Involuntary Discharge 4. Makes contact with at least one other facility and attempts to place the patient there 5. Notifies the State Survey Agency of the discharge And… Document, Document, Document

63. Involuntary Discharge In the event of immediate severe threats to the health and safety of others, the facility may use an abbreviated involuntary discharge procedure –Threat of physical harm –Calling 911 or otherwise seeking police involvement –After emergency is addressed, medical director and patient physician are notified as well as Network and State Agency

64. Involuntary Discharge Interpretive Guidelines strongly suggest the use of the Decreasing Dialysis Patient Provider (DPC) tools to proactively address conflict in the dialysis facility.

65. 494.180 Governance Electronic forms submission for the ESRD program administration –Working with ESRD Networks in the Crown Web process February 1, 2009 process will begin for ESRD forms 2728 Medical Evidence Form 2746 Death form Clinical Performance Measures Cost report and Administrative data

66. 494.180: Governance Relationship with the ESRD Network –Improve the quality and safety of dialysis related services –Improve independence, quality of life, and rehabilitation through encouragement of transplant, self care dialysis, and home dialysis therapies –Encourage and support collaborative activities to achieve goals through the most efficient and effective means possible –Improve collection, reliability, timeliness of data to measure processes of care, maintain the patient registry, and support the ESRD Network program

67. Implementation of the Conditions: Moving from paper to practice

68. Where Do I Start? Get to know your regulations –What is new and will have an effect on the day-to-day operation on the dialysis unit? Ask the questions –How do we put this into practice? –What changes need to be made? Develop the policy/procedure Put it into practice!

69. How am I going to get everything done? Creative thinking –What is the best way to make this work? Ground up – Bottom down –Supportive leadership –The best ideas come from those who are closest to the work Use the team –Delegate, delegate, delegate!

70. The Goal is… Safe Effective Patient Centered Timely Equitable Efficient The Right care for every patient every time

71. Important Links Conditions http://www.cms.hhs.gov/CFCsAndCoPs/13_ESRD.asp#TopOfPage Interpretive Guidelines http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCletter08-31.pdf ANNA/NKF Comprehensive Assessment Form http://www.annanurse.org/download/reference/health/cmpa.pdf

72. Thank you!! Questions? jdeane@nw11.esrd.net