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

2010 CMS Regulatory Update

Glenda M. Payne, RN, MS, CNNESRD Technical Advisor

CMS, Dallas & Atlanta Regions

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

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“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.

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US: Frequently Cited Tags1276 Surveys of 5439 Providers

# Tag ID # X’s Cited % of Surveys

1 V113 IC - WEAR GLOVES/HAND HYGIENE 344 27

2 V122 IC - CLEAN, DISINFECT SURFACES & EQUIPMENT/WRITTEN PROTOCOLS

301 23.6

3 V403 PE - EQUIPMENT MAINTENANCE - MANUFACTURER'S DFU

269 21.1

4 V715 MD RESP - ENSURE ALL ADHERE TO P&P 232 18.2

5 V541 PATIENT PLAN OF CARE - GOALS - COMMUNITY-BASED STANDARDS

202 15.8

6 V401 PE - SAFE, FUNCTIONAL, COMFORTABLE ENVIRONMENT

177 13.9

7 V115 IC - WEAR GOWNS, SHIELDS/MASKS; STAFF NOT EAT/DRINK IN TX AREA

160 12.5

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US: Frequently Cited Tags1276 Surveys of 5439 Providers

# Tag ID # X’s Cited % of Surveys

8 V117 IC - CLEAN/DIRTY AREAS, MED PREP AREA, NO COMMON MED CARTS

156 12.2

9 V402 PE - BUILDING - CONSTRUCTED/ MAINTAINED TO ENSURE SAFETY

156 12.2

10 V116 IC - ITEMS TAKEN TO STATION DISPOSED/DEDICATED OR DISINFECTED

150 11.8

11 V726 MEDICAL RECORDS - COMPLETE, ACCURATE, ACCESSIBLE

140 11.0

12 V407 PE - HEMODIALYSIS PATIENTS IN VIEW DURING TREATMENTS

139 10.9

13 V501 PATIENT ASSESSMENT - INTERDISCIPLINARY TEAM MBRS/RESP.

138 10.8

14 V504 ASSESS B/P & FLUID MANAGEMENT NEEDS 136 10.7

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US: What About Water and Dialysate?

# Tag ID # X Cited % of Surveys

17 V196 CARBON ADSORPTION - MONITORING, TESTING FREQUENCY

133 10.4

18 V250 DIALYSATE PROPORTIONING – MONITOR PH/CONDUCTIVITY

125 9.8

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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)

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What About Texas?

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US: What About Water and Dialysate?

# Tag ID # X Cited % of Surveys

17 V196 CARBON ADSORPTION - MONITORING, TESTING FREQUENCY

133 10.4

18 V250 DIALYSATE PROPORTIONING – MONITOR PH/CONDUCTIVITY

125 9.8

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From 1276 Surveys of 5439 Providers from Oct 2008 – April 2010

TX: Frequently Cited Tags115 Surveys in 456 Providers

# Tag ID # X’s Cited % of Surveys

1 V715 MD RESP - ENSURE ALL ADHERE TO P&P 32 27.8

2 V541 PATIENT PLAN OF CARE - GOALS - COMMUNITY-BASED STANDARDS

29 25.2

3 V122 IC - CLEAN, DISINFECT SURFACES & EQUIPMENT/WRITTEN PROTOCOLS

25 21.7

4 V113 IC - WEAR GLOVES/HAND HYGIENE 20 17.4

5 V726 MEDICAL RECORDS - COMPLETE, ACCURATE, ACCESSIBLE

20 17.4

6 V117 IC - CLEAN/DIRTY AREAS, MED PREP AREA, NO COMMON MED CARTS

18 15.7

7 V501 PATIENT ASSESSMENT - INTERDISCIPLINARY TEAM MBRS/RESP.

18 15.7

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TX: Frequently Cited Tags115 Surveys in 456 Providers

# Tag ID # X’s Cited % of Surveys

8 V543 MANAGE VOLUME STATUS 16 13.9

9 V504 ASSESS B/P & FLUID MANAGEMENT NEEDS 15 13.0

10 V120 IC - TRANSDUCER PROTECTORS: NOT WETTED/CHANGED

13 11.3

11 V403 PE - EQUIPMENT MAINTENANCE - MANUFACTURER'S DFU

13 11.3

12 V750 CFC – GOVERNANCE (# 23 = CFC Inf Control) 12 10.4

13 V503 APPROPRIATENESS OF DIALYSIS RX 11 9.6

14 V507 ASSESS ANEMIA 11 9.6

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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?

# Tag ID # X Cited % of Surveys

25 V250 DIALYSATE PROPORTIONING – MONITOR PH/CONDUCTIVITY

9 7.8

66 V228 MIXING SYSTEMS – LABELING 5 4.3

69 V196 CARBON ADSORPTION – MONITORING, TESTING FREQUENCY

4 3.5

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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

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What Are Some of the Causes of These Findings?

Some Root Cause Analysis

Your ideas: • ..• ..• ..• ..

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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

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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

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

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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

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Gloves and Hand Hygiene

• Gloves: put them on• Use hand hygiene between gloves• Use clean gloves when approaching

vascular access

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Clean Surfaces

• Tilt chairs back to clean• When cleaning up blood spills: 1st clean,

then (with new supplies) disinfect• Treatment chairs: practice audits

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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)

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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.

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

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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?

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IDT Members Participate in PA

IDT includes:• Patient• RN• MSW• RD• Physician responsible for the patientExpected 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.

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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

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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

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

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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

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Did You Know?

• Practice audits are required: – for water treatment – dialysate preparation

• Don’t forget these when planning your audits

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

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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

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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

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Questions?

[email protected]