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

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

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. 3

4. US: Frequently Cited Tags 1276 Surveys of 5439 Providers #TagID# X’s Cited% of Surveys 1V113IC - WEAR GLOVES/HAND HYGIENE34427 2V122IC - CLEAN, DISINFECT SURFACES & EQUIPMENT/WRITTEN PROTOCOLS 30123.6 3V403PE - EQUIPMENT MAINTENANCE - MANUFACTURER'S DFU 26921.1 4V715MD RESP - ENSURE ALL ADHERE TO P&P23218.2 5V541PATIENT PLAN OF CARE - GOALS - COMMUNITY-BASED STANDARDS 20215.8 6V401PE - SAFE, FUNCTIONAL, COMFORTABLE ENVIRONMENT 17713.9 7V115IC - WEAR GOWNS, SHIELDS/MASKS; STAFF NOT EAT/DRINK IN TX AREA 16012.5 4

5. 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 15612.2 9V402PE - BUILDING - CONSTRUCTED/ MAINTAINED TO ENSURE SAFETY 15612.2 10V116IC - ITEMS TAKEN TO STATION DISPOSED/DEDICATED OR DISINFECTED 15011.8 11V726MEDICAL RECORDS - COMPLETE, ACCURATE, ACCESSIBLE 14011.0 12V407PE - HEMODIALYSIS PATIENTS IN VIEW DURING TREATMENTS 13910.9 13V501PATIENT ASSESSMENT - INTERDISCIPLINARY TEAM MBRS/RESP. 13810.8 14V504ASSESS B/P & FLUID MANAGEMENT NEEDS13610.7 5

6. US: What About Water and Dialysate? #TagID# X Cited% of Surveys 17V196CARBON ADSORPTION - MONITORING, TESTING FREQUENCY 13310.4 18V250DIALYSATE PROPORTIONING – MONITOR PH/CONDUCTIVITY 1259.8 6 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) 7

8. What About Texas? 8

9. US: What About Water and Dialysate? #TagID# X Cited% of Surveys 17V196CARBON ADSORPTION - MONITORING, TESTING FREQUENCY 13310.4 18V250DIALYSATE PROPORTIONING – MONITOR PH/CONDUCTIVITY 1259.8 9 From 1276 Surveys of 5439 Providers from Oct 2008 – April 2010

10. TX: Frequently Cited Tags 115 Surveys in 456 Providers #TagID# X’s Cited% of Surveys 1V715MD RESP - ENSURE ALL ADHERE TO P&P3227.8 2V541PATIENT PLAN OF CARE - GOALS - COMMUNITY-BASED STANDARDS 2925.2 3V122IC - CLEAN, DISINFECT SURFACES & EQUIPMENT/WRITTEN PROTOCOLS 2521.7 4V113IC - WEAR GLOVES/HAND HYGIENE2017.4 5V726MEDICAL RECORDS - COMPLETE, ACCURATE, ACCESSIBLE 2017.4 6V117IC - CLEAN/DIRTY AREAS, MED PREP AREA, NO COMMON MED CARTS 1815.7 7V501PATIENT ASSESSMENT - INTERDISCIPLINARY TEAM MBRS/RESP. 1815.7 10

11. TX: Frequently Cited Tags 115 Surveys in 456 Providers #TagID# X’s Cited% of Surveys 8V543MANAGE VOLUME STATUS1613.9 9V504ASSESS B/P & FLUID MANAGEMENT NEEDS1513.0 10V120IC - TRANSDUCER PROTECTORS: NOT WETTED/CHANGED 1311.3 11V403PE - EQUIPMENT MAINTENANCE - MANUFACTURER'S DFU 1311.3 12V750CFC – GOVERNANCE (# 23 = CFC Inf Control)1210.4 13V503APPROPRIATENESS OF DIALYSIS RX119.6 14V507ASSESS ANEMIA119.6 11 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? #TagID# X Cited% of Surveys 25V250DIALYSATE PROPORTIONING – MONITOR PH/CONDUCTIVITY 97.8 66V228MIXING SYSTEMS – LABELING54.3 69V196CARBON ADSORPTION – MONITORING, TESTING FREQUENCY 43.5 12 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 13 What Are Some of the Causes of These Findings?

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

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 15

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 16

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

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 18

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

20. 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

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) 21

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. 22

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

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? 24

25. 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

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 26

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 27

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

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 29

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

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

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

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 33

34. Questions? 34 ESRDsurvey@cms.hhs.gov