- 1. Delivery of Dialysis TreatmentWithin theLong Term Care
Facility ESRD Special Study Delivery of Dialysis Treatment Within
the Long-Term Care FacilityProject ReportJuly 1, 2005 June 30,
2006Contract # 500-03-NW09June 30, 2006Submitted to:Glenda
PayneMarion Broderick Project Officer Project Officer CMS, Region
VICMS, Region VII Division of Clinical Standards &
QualityDivision of Clinical Standards & Quality 1301 Young
Street New Federal Office Buildingth Dallas, TX 75202601 E 12
Street, Room 242 Kansas City, MO 64106 Submitted by:The Renal
Network, Inc. ESRD Network 9/10th 911 E. 86 Street, Suite 202
Indianapolis, IN 46240 317-257-8265 Janeen Len, Project Manager
Mary Ann Webb, MSN, RN, CNN Susan Stark, Executive Director Jenny
Kitsen, Executive Director ESRD Network of New England The Renal
Network, Inc. 911 E. 86th Street, Suite 202 Indianapolis, IN 46240
317-257-8265 ESRD Network of New England 30 Hazel Terrace
Woodbridge, CT 06525 203=387-9332
2. The Renal Network, Inc.Special Project on the Delivery of
Dialysis TreatmentWithin the Long-Term Care Facility Table of
Contents 1.0 Executive Summary12.0 Literature Review....12.1
Methods... 12.2 Project Background.22.3 The Need for Dialysis for
LTC Facility Residents.22.4 The Need for Staff-Assisted Dialysis
Within a LTC Facility Setting. 22.5 Current ESRD Program...32.5.1
Approved Facility Types.. 32.5.2 Billing Considerations.. 32.5.3
Back-up Facility Considerations..4 2.5.4 Staffing
Considerations42.5.5 Facility Oversight Considerations52.5.6
Dialysis and Hospice52.6 Proposed Conditions for Coverage.52.7 LTC
Facility ESRD Patient Outcomes72.8 Other Considerations... 82.9
National Renal Administrators Association Recommendations.92.10 TRN
Dialysis in Nursing Homes Conference...93.0 Technical Expert Panel
(TEP).104.0 Recommendations for Staff-Assisted dialysis in the LTC
Facility Setting 114.1Rationale.. 114.2 Recommended Program
Structure..114.3 Minimum Staffing, Staff Qualifications and
Training Requirements. 124.3.1 Nursing. 124.3.1a Nurse Responsible
for Dialysis Subunit Program.. 124.3.1b On-Site Nurse. 134.3.2
Patient Care Technicians..134.3.3 Other Staff 144.4 Patient ESRD
Care Assessment..144.5 Patient ESRD Care Plan of Care. 154.6 Access
to Nephrologist154.7 Vascular Access Care..154.8 Infection
Control.154.9 Medications.164.10 End of Life Issues..16 i 3. 4.11
Physical Environment... 164.12 Water Quality 164.13 Coordination of
Care.164.13.1 LTC Facility Expectations.164.13.2 ESRD Provider
Expectations.174.13.3 Emergencies During Dialysis
Treatment...174.13.4 Back-up Treatment Facility.... 174.13.5
Utilities... 174.13.6 Communication.. 174.14 Internal
Oversight..184.15 External Oversight. 184.16 System for Data
Collection... 184.17 Certification Process. 184.18 Financial Model
Development..195.0 Conclusions.196.0 Technical Expert Panel,
Consultants, Staff & Observers 207.0 References... 21iiDialysis
in the LTC Facility Project Report 4. 1.0Executive Summaryhome,
skilled nursing facility, long term care facility, and hospice. The
table below The Centers for Medicare & Medicaid Serviceslists
total number of citations for each (CMS) contracted with The Renal
Network, Inc. combination, number of unique citations, (End Stage
Renal Disease (ESRD) Network 9/10) and number of possibly relevant
citations in collaboration with The ESRD Network of New based on
abstract review. There was England, Inc (Network 1) for a special
project to substantial overlap between search results. convene a
Technical Expert Panel (TEP) to develop recommendations for
providing dialysis in the long- SearchTotal Cited Possibly term
care facility. The need for more information TermsCitations in
Relevant focusing on quality of care, financial Other
responsibilities and structural issues was identifiedSearch
following a meeting of renal stakeholders in JuneNursing 54 0 39
2004. Convening a nationally focused Technical home Expert Panel to
develop recommendations forand providing dialysis in a nursing home
that ensuresdialysis quality of care for these patients represents
an Extended13 111 important first step in benefiting ESRD patients
care residing in LTC facilities. The model defined in facility this
project will begin to provide the benchmark for and quality
dialysis services within the LTC facility. dialysisSkilled 11 110
The contract period was from July1, 2005 to June nursing 30, 2006.
The contract specified nine key tasks to facility be completed
within the 12-month timeframe.anddialysisLong1244 Task Task
Requirementterm care 1Submit a detailed work plan to CMSfacility
2Conduct a focused literature review and 3Identify a Technical
Expert Panel dialysis 4Arrange TEP meeting Hospice 2419and
5Facilitate and Document TEPdialysisdiscussions 6Document proposed
recommendations Each possibly relevant article was retrieved
7Obtain input from renal community and references were reviewed to
yield 8Prepare Final Report additional relevant articles. All
relevant 9Obtain TEP evaluations articles were abstracted and
categorized into a customized database. Current ESRD program
requirements were obtained from documents available on the CMS
website and from the Code of Federal Regulations 2.0Literature
Review (CFR). 2.1Methods A MEDLINE search was conducted to Note:
For convenience, the term long-term review the literature to gain
ancare (LTC) facility will be used throughout understanding of the
current knowledge of this document to represent the terms skilled
the care and dialysis of ESRD patients in nursing facility,
long-term care facility, the nursing home. The MESH term extended
care facility, and nursing home. dialysis was combined with nursing
1 Dialysis in the LTC Facility Project Report 5. residents is
likely to grow as both the 2.2Project Background general and ESRD
populations continue to There are increasing numbers of dialysis
age.6-10 patients throughout the United States being dialyzed
within LTC facilities, however2.4The Need for Staff-Assisted there
are no officially recognized models ofDialysis Within a LTC
Facility treatment. A conference hosted by Setting Network 9/10 in
June 2004 resulted in theLTC facility patients may be transported
to successful collaboration of dialysis hospital-based or
freestanding dialysis providers, state agencies, Networks
andfacilities for treatment or obtain self- CMS and identified the
need for a structuredialysis treatment through a home program. of
quality management for patients Transporting LTC facility patients
to off- receiving dialysis in a LTC facility. This site dialysis
facilities is burdensome to both conference only touched on
describing thepatients and LTC facilities. LTC patients parameters
for a model delivery system for are often frail, sensitive to
temperature dialysis in residential settings.1 variations, and
uncomfortable while beingtransported to dialysis facilities.1, 11
Knowledge of dialysis in the LTC facilityPatients routinely miss
meals, medications, would benefit the ESRD program and its
rehabilitation services, resident activities, patients. The goal of
this project was toand other services provided by the LTC develop
recommendations for providingfacility due to the length of dialysis
dialysis in a LTC facility environment thattreatment, time
associated with preparing ensures quality of care for these
patients.for transfer to and from the dialysis facility,and actual
transportation time.1 Some 2.3The Need for Dialysis for LTCpatients
are unable to be transported due to Facility Residents their
complex medical needs such as There were approximately 1.6 million
ventilator dependency. individuals residing in nursing homes in
1999.2 The 2004 USRDS Annual dataTransporting LTC facility patients
to off- report estimated that in 1999, 16,408 pointsite dialysis
facilities is costly. CMS prevalent ESRD patients resided in LTC
recognizes the difficulty in transporting facilities. This
represents 4.8% of ESRD LTC facility patients and therefore allows
a patients.3 This appears to be a growingLTC facility to be
considered a patients trend. Data from a study of ESRD patientshome
for the purpose of payment of self- dialyzed in Network 5 between
April 1990 dialysis.11, 15 However, given that 57.5% of and
December 1991 suggested that a the incident nursing home ESRD
patients in minimum of 1000 to 1500 ESRD patients1999-2000 had
moderately to severely reside in nursing homes at any given time.
impaired decision-making ability, more The authors estimated that
2000 to 3000than 44 percent were unable to walk ESRD patients enter
a nursing home in theindependently and 25% were unable to United
States each year.4 Elderlytransfer from bed to chair3, it seems
likely individuals without ESRD recruited fromthat the majority of
LTC facility patients hospital geriatric wards and nursing homes
are unable to perform self-dialysis. were surveyed to determine
their desire for dialysis treatment should they need it.
Eighty-three percent of nursing home residents indicated they would
want dialysis if it became necessary and 75% said they would prefer
home dialysis.5 The need for dialysis services to LTC facility 2
Dialysis in the LTC Facility Project Report 6. 2.5 Current ESRD
Program residing there, or locations in needof ESRD facilities
under 2.5.1 Approved Facility Typesemergency conditions.16 The
current ESRD program is defined in the Code of Federal Regulations,
Title 42, Inpatient dialysis is defined as Part 405, Subpart U
Conditions for dialysis furnished to an ESRD Coverage of Suppliers
of End-Stage Renal patient on a temporary basis in a Disease (ESRD)
Services. The ESRDhospital due to medical necessity. program is
comprised of five CMS Outpatient dialysis is defined as approved
facility types according to dialysis provided on an outpatient
405.2102 of the Conditions for Coverage basis at either a renal
dialysis including the renal transplantation center,center or
facility and includes staff- renal dialysis center, renal dialysis
facility,assisted dialysis or self-dialysis. self-dialysis unit,
and special purpose renalSelf-dialysis and home dialysis dialysis
facility.16 training is defined as a programthat trains patients
and/or their A renal dialysis center is defined asfamily member or
caregiver to a hospital-based unit that furnishes perform
self-dialysis or home the full spectrum of diagnostic, dialysis
with little or no therapeutic, and rehabilitativeprofessional
assistance. Services to services including inpatient dialysishome
dialysis patients are expected to ESRD patients. A renal dialysis
to be at least equivalent to those center may provide inpatient
orprovided to in-center patients.16 A outpatient dialysis either
directlyskilled nursing facility may be using its own staff and
employeesconsidered a patients home for or under arrangement. A
renalself-dialysis.15 dialysis facility is approved to furnish
dialysis services directly to 2.5.2 Billing Considerations ESRD
patients using its own staff The composite rate payment system is
used and employees, or through to pay for outpatient maintenance
dialysis individuals under direct contract toservices in
hospital-based centers and furnish such services for the
facilityfreestanding facilities. The composite rate (not through
agreements orsystem is also used for Method I payment
arrangements). A self-dialysisfor home dialysis services. Under the
unit is part of an approved renal composite rate system, the
dialysis facility dialysis program that furnishes self- must
furnish all necessary dialysis services, dialysis services.
Self-dialysis is equipment, and supplies for one set defined as
dialysis provided by anpayment. Physician patient care services,
ESRD patient who has completedcertain laboratory services, and
drugs are an appropriate course of self-billed separately.15
dialysis training. Lastly, a special purpose renal dialysis
facility Home patients must complete form CMS furnishes dialysis at
special 382 upon initiating home dialysis. The locations on a
short-term basis to aform requires patients to indicate the group
of patients who are unable to location where home dialysis will be
obtain treatment in the provided (private residence, skilled
nursing geographical area. The locationsfacility, or nursing home)
and to choose a must be special rehabilitativebilling method
(Method I or II). Method I (including vacation) locationspayment
utilizes the composite rate system serving ESRD patients
temporarily discussed above. Method II payment pays suppliers
directly for supplies and 3 Dialysis in the LTC Facility Project
Report 7. equipment. A patient may use only one payment provision
to reimburse a paid Method II supplier for all equipment
andassistant.11, 13 Also, reimbursement for supplies. The supplier
must have a writtenhome dialysis is based on one machine agreement
with a Medicare approvedbeing used for only one patient.18 dialysis
facility to serve as a provider for backup, support, and emergency
dialysis 2.5.3 Back-up Facility services. The dialysis facility
billsConsiderations separately for any backup, support, orAs stated
above, a Method II supplier must emergency dialysis services
provided. have a written agreement with a back-up There are payment
limits for supportdialysis facility to provide backup, support,
services. Support services include, but are and emergency dialysis
services (see not limited to: monitoring of the patients section
2.5.2 for details regarding required home adaptation, including
home visits; dialysis support services). The back-up consultation
for the patient by qualified provider is required to be within
reasonable social worker and dietitian; maintaining adriving
distance from the patients home. If medical record-keeping
system;the Method II supplier is unable to enter maintaining and
submitting all required into an agreement with a backup provider
documentation to the ESRD network;located within a reasonable
distance from assuring appropriate water quality; assuringthe
patients home, then the supplier may supplies are ordered on an
on-going basis;use a provider outside the geographical area
arranging for all ESRD laboratory testing;if the backup provider
enters into a written testing and appropriate water treatment for
agreement with a local dialysis facility to dialysis; monitoring
the functioning of provide in-facility dialysis should it become
dialysis equipment; documentation ofnecessary. In this case, the
out-of-area Method II supplier provided items and back-up provider
will provide dialysis services in the medical record; written plans
support services, coordinate care, and of care; and all other
dialysis servicesconduct frequent home visits. The signed required
under the ESRD Conditions foragreement must detail how these
support Coverage. If the patient receives homeservices will be
provided.15 CAPD, the facility must also provide observation of the
patient performing 2.5.4 Staffing Considerations CAPD and ongoing
training necessary toConditions for Coverage specify that one
assure proper administration of treatment;currently licensed health
professional documenting presence or absence of(physician, RN, or
LPN) experienced in peritonitis and related treatment;providing
ESRD care is on duty (present monitoring of catheter exit site;
changingand available) during dialysis. Qualified the connection
tubing. When a patient home training nurses are required to have
receives dialysis in a LTC facility, the12 months of clinical
nursing experience dialysis services are excluded from the LTC and
6 months of ESRD experience. Three facilitys consolidated billing
and homemonths of that experience must be in ESRD dialysis services
are billed by either theself-care training. 16 ESRD provider
facility or supplier, depending on the payment method Conditions
for Coverage specify selected.15 requirements for qualified social
workers and dietitians.16 The LTC facilitys social Home dialysis is
based on the assumptionworker and dietitian may not meet the that
the patient and/or a family member ordefinition of qualified.
caregiver has received thorough training by a qualified home
training nurse and the patient, family member or caregiver will
administer the treatment. 16, 17 There is no 4 Dialysis in the LTC
Facility Project Report 8. 2.5.5 acility Oversight F home training
can only be provided by a Considerationsdialysis facility certified
to provide home Home patients are considered as receiving dialysis
services. Therefore durable medical care through an approved
dialysis facility; equipment (DME) companies will continue
therefore ESRD Networks are required to to be prohibited from
providing home monitor the patients through data collectiondialysis
training. The training program and quality improvement activities
and to content is more fully defined in the process grievances. LTC
surveyors do notProposed Conditions compared to the survey dialysis
services provided on site atcurrent Conditions.11 LTC facilities;
this currently falls under the purview of ESRD surveyors, who may
notA summary of additional proposed changes know that dialysis is
occurring within arelated to home treatment follows. LTC facility.
LTC surveyors may generate494.100(b)(2) requires collection and a
complaint for the ESRD surveyors to review of patient data at least
every two investigate if potential problems are noted months. In
494.100(c)(1)(iii) CMS would during their LTC survey
process.18require the use of the same clinical performance measures
for home dialysis 2.5.6 Dialysis and Hospicepatients as used for
in-center patients. Hospice care is underutilized by ESRD
494.100(c)(1)(v) requires onsite patients.19, 20 If ESRD is the
reason for the evaluation of the water system for home terminal
illness, the hospice provider must hemodialysis patient.
494.100(c)(1)(vii) absorb the cost of dialysis treatments within
requires facilities to plan and arrange for their per diem
payment.19, 21 Because the backup dialysis services. hospice per
diem rate is insufficient to414.330(a)(2)(ii)(C) requires DME cover
the cost of dialysis treatments, most companies to report all
services and items hospice programs will not accept actively
supplied to the patient to the dialysis dialyzing patients if their
terminal illness is facility every 30 days.1, 11 due to ESRD.20 If
a patient withdraws from dialysis, he/she is a candidate for
hospice CMS requested input on whether current because death is
imminent. Hospice is alsohome dialysis regulations should be an
option for ESRD patients receiving modified to protect hemodialysis
patients dialysis if they have a terminal illness otherreceiving
dialysis within a LTC facility, than ESRD and a life expectancy
less than and ways to do so. Additionally, CMS 6 months. If the
terminal illness is notclarified the requirement that dialysis
related to ESRD, a patient may receivefacilities are to be
responsible for covered services from both the ESRD and
coordinating and providing patient care, hospice Medicare
benefits.19, 21rather than DME companies. CMS proposed requiring a
written agreement between the LTC facility, the dialysis 2.6
roposed Conditions for P facility, and DME company (if applicable).
CoverageCMS also requested input to determine if On February 4,
2005, CMS published thehome dialysis services provided in a LTC
proposed rule to update the Conditions forfacility must meet all of
the proposed Coverage for End-Stage Renal DiseaseConditions for
Coverage. CMS solicited Facilities in the Federal Register. input
regarding the requirement that a Comments regarding the proposed
registered nurse (RN) is on the premises conditions were accepted
until May 5, and available whenever in-center patients 2005. The
proposed Conditions for receive treatment, and if the RN can be a
Coverage contain a few changes related to LTC facility RN trained
by the ESRD home dialysis and dialysis provided in thefacility or a
RN provided by the dialysis LTC facility. 494.100(a) specifies
thatfacility. If a LTC facility RN is allowed, 5 Dialysis in the
LTC Facility Project Report 9. then limits on his/her other duties
whileresponsibilities in the event of emergency patients are being
dialyzed may be evacuation were specific examples cited.25
necessary. The competency and training The Advocate of
Not-For-Profit Services requirements for the LTC facility RN
mustfor Older Ohioans (AOPHA) requested also be determined. CMS
also requested clarification regarding who should be comments on
whether they should requireresponsible for arranging and paying for
the specific patient to staff ratios for dialysis of dialysis
caregiver services for patients in patients in this setting.11LTC
facilities since friends or relatives maynot be available to
provide services. Public comments to the proposedAOPHA reported
that ESRD or DME Conditions for Coverage are posted on theproviders
claim to be prohibited from CMS website. Many comments stated that
providing the caregiver service for free due home dialysis is
inappropriate for mostto fraud and abuse laws. As a result, LTC
residents in the LTC setting and urged facilities may arrange for
the services. CMS to consider the development of a AOPHA expressed
concern that LTC separate definition for the provision of
facilities may be subject to the federal anti- dialysis within LTC
facilities.22-29 kickback statute (42 USC 1320a-7a(a)(5);
Commenters reported that staff-assisted42 CFR 1003.102(1)(13) if
they provide the dialysis in the LTC facility is needed, but it
services for free. However, Medicaid must be economically feasible
and providepatients would be unable to personally pay reimbursement
for all staff who provide thefor the cost of caregiver services.30
The treatment.25-29 American Association ofCalifornia Dialysis
Council stated that the Kidney Patients (AAKP) stated that
staff-current recommendation for a written assisted dialysis
services in the LTC settingdocument describing the relationship may
be more costly due to the need for between the LTC facility and
ESRD more intense services,22 but other provider is sufficient to
define the commenters suggested that transportation coordination of
care arrangements between savings would be realized.26, 27, 29
parties.31 One commenter recommendedmonthly joint provider meetings
to review Both AAKP and the National Kidneypatients.32 Foundation
(NKF) acknowledged barriers to access to LTC facility care.22, 23
NKFSeveral commenters from hospitals and commented that the
increased requirementshospital associations asserted that CMS is
for LTC facilities will cause LTC facilities authorized under
Sections 1881(b)(1) and to either refuse admission of dialysis
1888(e)(2)(A)(i)(II) to pay LTC facilities patients or fall short
in meeting their the composite rate for dialysis services
responsibilities.23 AAKP stated thatunder Part B.26-29 These
organizations increased payment for LTC facility-based propose
three payment options: 1) ESRD dialysis may reduce barriers to
access toprovider provides dialysis services at LTC care.22facility
and is directly paid the compositerate; 2) LTC facility provides
dialysis The need for coordination of care wasservices and receives
separate payment for discussed by the commenters. The services
outside PPS for Part A; and 3) American Health Care Association LTC
facility provides dialysis services, (AHCA) stated that CMS must
delineatewithout separate ESRD licensure, for the responsibilities
between the ESRDbeneficiaries who have exhausted Part A provider
and the LTC facility and clarifybenefits.28, 29 The California
Hospital how the regulations for each party willAssociation
requested clarification to the interface. The areas of infection
control, questions of can a LTC facility prevent a staff
responsibility, physicianpatient from choosing Method II and can
communication, coordination of care and6 Dialysis in the LTC
Facility Project Report 10. they limit patients to specific
dialysis advised that patients dialyzing in the LTC providers or
DME providers?28facility be capable of being transported toand
safely dialyzed in an outpatient dialysis Concerns regarding the
clinical and legalfacility in the event back-up dialysis liability
to LTC facilities for providingservices are required.32 home
dialysis in the LTC facility were discussed by AHCA and AOPHA.25,
30 Commenters generally agreed that it is 2.7LTC Facility ESRD
appropriate to require a RN be on the premises when dialysis is
performed25, 28, 29,Patient Outcomes although AOPHA stated that
administrationAs noted in section 2.3, 4.8% of ESRD of
hemodialysis, not peritoneal dialysis,patients resided in nursing
homes in 1999.3 requires direct supervision by a RN.30 A No
information was provided to describe current LTC facility dialysis
provider statedwhere their dialysis was provided (off that an
experienced licensed practical nurse premise dialysis in approved
dialysis (LPN) is acceptable, and that a designated facility vs.
home dialysis with treatment RN be on call at all times when
dialysis isprovided in the LTC facility directly). being
provided.32 AHCA recommended thatNetworks (and therefore USRDS)
cannot the RN present and providing supervision currently
distinguish patients dialyzing in during the dialysis treatments
not beLTC facilities from home patients.33 responsible for other
LTC residents during Therefore, quality oversight by Networks
dialysis treatments. AHCA noted that nurse for these patients
cannot occur. In a letter to recruitment is problematic for both
LTCThe Renal Network, Inc. from CMS, it was and ESRD providers due
to the nursingnoted that dialysis organizations are shortage, so
adequate reimbursement will requesting data be suppressed on the be
required.25 Dialysis Facility Compare website forpatients receiving
dialysis in the LTC Additional staff-related comments included
facility setting, billed through the home the need to specify
training requirements, program methods. The Renal Network, Inc. use
of a dedicated dialysis facility nurse,responded, infection control
nurse, and LTC facility- based Advanced Practice Nurse (APN).25
ItESRD providers must was recommended that LTC facility staff
betake responsibility for the required to be trained in the care of
ESRDoutcomes of all of their patients and that dialysis facility
staff patients. If an ESRD should monitor its own staff and not be
provider enters into an responsible for monitoring LTC facility
agreement with a DME or staff. It was suggested that a minimum of
nursing home to provide one year of hemodialysis experience
bedialysis treatment on-site at required for the licensed
nurse.32the nursing home and Commenters stated that CMS should not
allows the provider number mandate specific patient-to-caregiver to
be used for billing for ratios.28, 29 these patients, the provider
needs to realize that Lastly, commenters requested CMS
provideoversight of care for those guidance regarding what patients
arepatients remains with the appropriate for a LTC facility
dialysis ESRD provider. Patients program.25, 32 It was suggested
that thereceiving treatment within program be reserved for LTC
residents who the nursing home setting should not be transported to
an outside are entitled to the same ESRD facility25, yet another
commentertreatment as those being 7 Dialysis in the LTC Facility
Project Report 11. treated within the dialysis2.8Other
Considerationsfacilities The rate of LTC facility placement is
lower for ESRD patients than the general One published article
contained datapopulation, suggesting barriers to LTC regarding
outcomes of patients residing infacility placement such as
transportation, LTC facilities who received hemodialysisfinancial
difficulties, and a general treatments (86%) at in-center
dialysisreluctance of LTC facilities to admit ESRD facilities (not
in the LTC facility setting) or patients.4 The inability to provide
LTC peritoneal dialysis (13%). Three, six, andfacility-based
dialysis treatment may delay twelve-month survival rates from date
ofhospital discharge and reduce effectiveness LTC facility
admission were 74%, 56%, of rehabilitation programs.39 and 42%
respectively. Increasing age, poorer activity of daily living
score, andThere are practical advantages to allowing peritoneal
dialysis were independentLTC facility dialysis areas to be treated
as survival risks.4 Yearly survival rates from an extension of an
existing dialysis facility. date of first dialysis between years
one andIf a dialysis facility is built within a LTC five were 83%,
63%, 45%, 35%, and 24% facility, it must conform to all LTC
facility per year. These percentages are similar toregulations.
Additionally, adding a dialysis that of the general dialysis
population4 Thefacility to an older LTC facility may require
appropriate benchmark for dialysis patientit to upgrade its systems
throughout the survival rates from date of LTC facilityfacility to
meet current code, making it cost admission is unknown.
prohibitive. It may be possible to build a freestanding facility
adjacent to the LTC It may be useful to differentiate patients as
facility for less money,40 but a sufficient being admitted for
short- term rehabilitation number of patients would be needed to
vs. permanent placement in the LTCmake building a full unit cost
effective. facility. Length of stay may be an appropriate measure
for patients admitted The Renal Network, Inc. received for short
term rehabilitation.34comments from the California Dialysis Council
(CDC) in preparation for the TEP There have been seven published
articlesmeeting. The CDC recommended that the regarding outcomes of
patients receivingTEP discuss coverage for dialysis in a wide
peritoneal dialysis (PD) in LTC facilitiesrange of institutional
settings including (see Appendix A).6, 7, 10, 35-38 Two of the
SNFs, intermediate care facilities, LTC articles referred to the
same dataset.10, 38facilities, long term acute care centers, The PD
home programs analyzed variedcomprehensive outpatient
rehabilitation with one dialysis facility referring patients
facilities, and hospices. They also to either one LTC facility or
to many.recommended inclusion of non-ESRD Peritonitis rates
published in 5 papers patients who require dialysis on a varied
from 0.61 to 2.43 episodes/patienttemporary basis (such as in acute
renal year.6, 7, 10, 35, 37, 38 Exit site infection rate, failure).
CDC stated that patients requiring published in only two studies,
ranged fromsuch care in a lower-cost setting such as a 0.2
episodes/patient-year to 0.5SNF are unable to obtain this care, and
thus episodes/patient-year.6, 35Hospitalizationthe healthcare
system pays excessively for rates reported in 3 studies ranged from
18.5their care within the acute hospital setting. to 44.6
days/patient-year.6, 7, 35 In one study,CDC advised creating a
program separate patients who switched modality to from the home
dialysis program. The hemodialysis had better survival
rates.6organization suggested that most patients receiving dialysis
in institutional settings will have already been dialysis patients,
and therefore already have long-term programs, 8 Dialysis in the
LTC Facility Project Report 12. patient care plans, etc. They
requested on-site at least once each month. The RN avoiding
duplicative requirements for should also participate in care
planning patients who are in the alternate dialysismeetings as
specified in the Conditions for setting on a temporary basis. The
CDC Coverage.1 advised that special coding be created to allow
identification of the method of The NRAA recommended social workers
dialysis being performed in the alternate and dietitians with ESRD
patient site facility, and to use coding to distinguish experience
provide services to the dialysis between ESRD and non-ESRD
patients. patients. These clinicians could work They also advised
creating a coding directly for the nursing home (if they had
solution to reflect patient acuity (such as a adequate ESRD
experience) or be affiliated code for dialyzing
ventilator-dependent with the backup dialysis facility.1
patients).41 The LTC facility should have an 2.9 National Renal
Administrators arrangement with a medical director of an
Association Recommendations approved dialysis facility or home
program. In February 2003, the National RenalThe medical director
would be responsible Administrators Association (NRAA) for ensuring
appropriate care to patients and published a position paper on home
dialysis other requirements according to the for nursing home
residents. The NRAAConditions for Coverage. The position supported
the use of home hemodialysis forpaper recommended that each LTC
facility LTC facility patients on LTC facility have a backup
agreement with a nearby premises and encouraged CMS to ensure
Medicare-approved in-center dialysis that the services not become
cost facility in case the approved home dialysis prohibitive, and
therefore limit availability.provider is unable to provide
treatments. The position paper provided specificThey also
recommended each LTC facility staffing, support service, facility,
andhave an agreement with a nearby hospital to hospital coverage
recommendations.allow admission of hemodialysis patients Benefits
to patients for LTC facility-based when needed.1 hemodialysis
included avoidance of the physical and emotional strain ofThe NRAA
opposed any requirement that transportation to a dialysis facility,
missed the area within the LTC facility set up to meals, and missed
resident activities.provide dialysis be certified as a dialysis
Medicaid savings were estimated at $156 facility. Each individual
LTC facility is million per year in saved transportationlikely to
dialyze only a few patients, costs.1 making certification cost
prohibitive. Instead, they advocated the LTC facility- The NRAA
explicitly opposed defined based dialysis services be established
as an staffing ratios due to the potential economic extension of a
Medicare-certified ESRD burden. They recommended all staff have a
home program. The NRAA supported the minimum of two years prior
dialysis use of a central area within the LTC facility experience.
NRAA suggested a registered to provide dialysis services to
multiple nurse (RN) with at least two years dialysis patients, but
did not go so far as to experience supervise all on-site
staffrecommend multiple patients share dialysis (licensed practical
nurses or dialysismachines.1 technicians) and that the RN be
accessible at all times while dialysis treatments are2.10 TRN
Dialysis in Nursing Homes being administered. The RN would be
Conference responsible for all initial patient In June 2004, The
Renal Network, Inc. assessments, staff training, and be present
(TRN) convened a meeting of 279 Dialysis in the LTC Facility
Project Report 13. representatives from CMS, The Renal dialyzing in
LTC facilities from home Network Inc., the Illinois Department
ofpatients. It was recommended that LTC Public Health, Fresenius
Medical Care,facility patient data be identified to allow Gambro
Healthcare, and Circle Medical separate data analysis for quality
oversight Management to discuss dialysis in the LTC purposes.
Conference attendees noted that facility setting. Discussion
focused on the state surveyors would need to be trained to
provision of hemodialysis. Attendeessurvey both LTC facilities and
ESRD expressed that there is a need forfacilities.33 hemodialysis
within LTC facilities and that the number of patients requiring
this service Billing and reimbursement issues were is likely to
expand. Attendeesdiscussed. Various medication recommended that a
new model for service, administration scenarios were suggested
dubbed Method 3, be developed with itssuch as LTC facility staff
give oral own set of regulations. Discussion at the medications
instead of IV medications meeting explored staffing, equipment,
when possible and LTC facility staff water treatment, quality
oversight, infection administer Erythopoeitin when the patient
control, medication administration, and is not on dialysis.
Regulations regarding billing issues related to hemodialysis on
reimbursement for medication and supplies LTC facility
premises.33would need to be adjusted to accommodate Method 3. It
was suggested that Most corporations provide their own
reimbursement policies also consider longer dialysis staff instead
of using LTC facilityor more frequent dialysis sessions and staff.
However, coordination of careincreased staff-to-patient ratios to
care for between dialysis staff and LTC facility staff high acuity
patients. Financial incentives to is essential. An experienced RN
typically promote expertise and excellence were oversees the
program, training of staff and recommended. Lastly, cost savings
could patients, and provides staff supervision. be realized by
eliminating the need to Current ESRD dietary and social
servicestransport patients to dialysis facilities.33 regulations
are appropriate for the LTC facility setting. It was recommended
that 3.0Technical Expert Panel (TEP) nephrologists and
geriatricians shouldA Technical Expert Panel was convened in round
on the patients at least once a month Baltimore on January 20 and
21, 2006 to and multidisciplinary care plan meetingsassist the
contractor (ESRD Network 9/10) should be held.33 in developing
recommendations for providing staff-assisted dialysis in the LTC
Dialysis of stable patients in a common facility. TEP members,
including patients room would allow a technician to dialyzeand
professionals, were sought to represent more than one patient at a
time. Attendeesvarious ESRD stakeholders involved in or unanimously
agreed that the one patientimpacted by dialysis in the LTC
facility. one machine rule be abolished. One Members were chosen by
the contractor attendee mentioned that a facility couldand CMS
based on their area of expertise more easily maintain fewer
machines. It and knowledge of the subject area. was felt that water
treatment should follow Individual TEP members were approved by
AAMI standards applicable to in-centerCMS. The final TEP membership
included dialysis facilities. The providers attendinga patient and
spouse, physicians, and the conference did not perform dialyzer
representatives from state departments of reuse.33health; CMS;
quality improvement organization; nursing home administration;
Quality oversight would begin at theLarge Dialysis Organizations
(LDOs); facility level. It was noted that NetworksDME
representative, and members of cannot currently distinguish
patients10 Dialysis in the LTC Facility Project Report 14. American
Nephrology Nurses Associationadmission was of a rehabilitative
nature. (ANNA) and NRAA. Observers includedDialysis care at the
nursing home would additional CMS staffers and representativesoffer
convenience to patients because they from nursing home
programs.would be less likely to miss meals andmedication doses.
TEP members believed The TEP was tasked with making patients may
experience increased quality recommendations on the following:of
life by avoiding the discomforts and recommended program structure;
minimum inconvenience associated with long waits staffing, staff
qualifications and trainingfor transportation to and from an
outside requirements; patient assessment; patientdialysis facility.
Coordination and plan of care; access to nephrologist;continuity of
care between dialysis facilities vascular access care; infection
control; and LTC facilities would likely increase medications; end
of life issues; back-up and overall access to nursing home care
treatment facility; physical environment;may improve for dialysis
patients. water quality; coordination of care;
internalAdditionally, hospitalized patients may be and external
oversight; system for datadischarged earlier if dialysis is
available in collection; certification process; and the LTC
facility setting. financial model development.4.2Recommended
Program 4.0 Recommendations for Staff-Structure Assisted Dialysis
in the Long-Term The TEP discussed how to structure the Care
Facility Settingstaff-assisted dialysis program within
LTCfacilities. The decision was made to use the The following
recommendations propose a newterm long-term care (LTC) facility
model of dialysis care: Staff-Assisted Dialysis(hereafter referred
to as LTC facility), (hemodialysis and peritoneal) in the
Long-Termconsistent with guidance in the CMS Care Facility. These
recommendations do notSurvey and Certification Group Addendum
eliminate current models of providing dialysis suchI to S&C
Letter 04-24 on the Care for as home dialysis or Medicare-certified
in-centerResidents of Long-Term Care (LTC) dialysis facilities
adjacent to LTC facilities.Facilities Who Receive End Stage Renal
Additionally, all recommendations were madeDisease (ESRD) Services,
dated July 8, considering the adult population, however the2004.18
The term LTC facility refers to recommendations do not preclude
provision of carenursing homes including skilled nursing to
pediatric patients under this proposed model.facilities and nursing
facilities. Institutionsfor persons with mental retardation or 4.1
Rationale rehabilitation facilities are not included. There are
increasing numbers of dialysis patients throughout the United
States beingThe TEP recognized that a large spectrum dialyzed
within long-term care (LTC) of ESRD patients require dialysis care
facilities, but there are currently no within the LTC facility: 1)
stable dialysis officially recognized models of staff- patients who
require LTC facility care; 2) assisted treatment in the LTC
setting. individuals with progressive renal failure Providing
dialysis care on the premises of that develop an acute illness,
start dialysis LTC facilities would provide cost savingsin the
hospital, and are discharged to a LTC by avoiding the need to
transport patients tofacility; 3) individuals who develop new
freestanding dialysis facilities. Theacute renal failure and are
discharged to a frequency and duration of dialysis LTC facility;
and 4) patients with multiple treatments could be more flexible
andorgan failure who are discharged to a LTC patients would be
available for services facility. The decision was made to define a
such as rehabilitation, possibly decreasingprogram inclusive of all
ESRD patients. the length of stay if nursing home 11 Dialysis in
the LTC Facility Project Report 15. Dialysis providers may
ultimately decide the level of medical acuity they are willingThe
TEP felt strongly that in the case of to accept into their program.
hemodialysis, the entire treatment must be visibly monitored by a
qualified caregiver. The TEP recommended that the staff- It was
recommended that properly trained assisted dialysis LTC facility
program be personnel be present and available in organized as a
subunit of a Medicare- adequate numbers to meet the needs of the
certified ESRD provider (hereafter referred patients, including
those arising from to as Dialysis Subunit). The Dialysis medical
and non-medical emergencies, Subunit may only provide hemodialysis
consistent with language in the Proposed treatments if the Dialysis
Provider mainConditions for Coverage of Suppliers of facility
offers hemodialysis. Likewise, anEnd-Stage Renal Disease (ESRD)
Services ESRD provider that only offers peritoneal 494.180(b), with
the exception that dialysis may only provide
peritoneal494.180(b)(2) incorporate the term LTC dialysis in the
LTC facility. A program facility. The revised Proposed language is
organized or affiliated with an ESRDas follows: The governing body
or provider that is certified for home dialysisdesignated person
responsible must ensure training only should not be permitted
tothat -- (1) An adequate number of qualified open a subunit.
personnel are present whenever patients are undergoing dialysis so
that the It was recommended that the Dialysispatient/staff ratio is
appropriate to the level Subunit only dialyze residents of the LTC
of dialysis care given and meets the needs facility. It is expected
that several patientsof the patients. (2) A licensed nurse, may be
dialyzed together in a common area educated in ESRD is present
onsite at the or dialysis room or patients may be LTC facility at
all times that patients are dialyzed in their rooms (e.g.
ventilator or being treated.(3) All employees have traction
dependent patients). appropriate orientation to the facility and
their work responsibilities upon Additionally, it was recommended
that employment; (4) All employees have an proposed Conditions for
Coverage be opportunity for continuing education and scrutinized to
ensure dialysis patients related development activities; and (5)
residing in nursing facilities are provided There is an approved
written training the same level of protection and ancillaryprogram
specific to dialysis technicians services as are provided to
patientsthat includes; (6) When State receiving care under the
staff-assisted in- requirements meet or exceed center model.
494.180(b)(5) the State requirements must be met. 4.3 Minimum
Staffing, Staff Qualifications and Training 4.3.1N ursing
RequirementsThere was lengthy discussion regarding It was
acknowledged that no data addressesnurse staffing and coordination
of care with specific staff ratios for staff-assistedthe LTC
facility. TEP members discussed dialysis in nursing facilities and
that staff whether the licensed nurse must be a quality is more
important than staff quantity Registered Nurse (RN) and if the
nurse if a minimum is met. It was recognized that must be in the
building during dialysis centers providing more treatments will
have treatment. The recommendations that a higher level of staff
experience and skill. follow assume that LTC facility staff will As
a result, it may be possible to eventually take care of all patient
needs outside the establish Centers of Excellence based ondialysis
needs of the patient. treatment volume and staff skill level. 12
Dialysis in the LTC Facility Project Report 16. 4.3.1a Nurse
Responsible for Dialysis administration of manual and automated
Subunit Program peritoneal dialysis; access care including The TEP
agreed with the proposedsigns, symptoms, and treatment of catheter
Conditions for Coverage requirements forexit site infections;
signs, symptoms, and the responsible nurse and recommended
treatment of peritonitis; measurement of these apply to the nurse
assigned adequacy of dialysis; and infection control.
responsibility for the subunit(s) as well. It was recommended that
a qualified RN be4.3.2 Patient Care Technicians responsible for the
hemodialysis and/or The TEP recommended adoption of the peritoneal
Dialysis Subunit program. It was language proposed in 494.140(e)
and recommended that the Responsible Nurse494.180(b)(5)(i)-(viii),
with an increased must (i) Be a fulltime employee of
thehemodialysis experience requirement of dialysis facility; (ii)
Be a registered nurse two years and a training curriculum specific
who meets the practice requirements of theto either hemodialysis or
peritoneal dialysis State in which he or she is employed; (iii)
modalities, as applicable. Have at least 12 months of experience in
clinical nursing, and an additional 6 months Current proposed
language is as of experience in providing nursing care to follows
494.140(e): Patient care patients on maintenance dialysis.dialysis
technicians must - (1) Meetall applicable State requirements 4.3.1b
On-Site Nurse for education, training, In the case of hemodialysis,
a licensedcredentialing, competency, nurse educated in ESRD must be
present standards of practice, certification, on-site and readily
available during the and licensure in the State in which dialysis
treatment to assist in the event of he or she is employed as a
dialysis an emergency. In the case of peritonealtechnician; and (2)
Have a high dialysis, a licensed nurse educated in ESRDschool
diploma or equivalency. must be available to support staff-assisted
peritoneal dialysis. The on-site nurse mayThe TEP recommended
increasing the or may not be the same person as the nurseexperience
requirement of patient care responsible for the Dialysis
Subunittechnicians administering staff-assisted program. The
on-site nurse must meet thehemodialysis in a Dialysis Subunit to
two practice requirements of the State in which years because the
patient care technician she is employed, and for hemodialysis would
need to function more independently programs, complete a training
curriculumand with less back-up personnel on the that includes:
principles of dialysis; care ofpremises in the Dialysis Subunit
setting patient with kidney failure; an compared to patient care
technicians understanding of dialysis procedures andworking at
in-center dialysis facilities. The documentation, including the
initiation,TEP recommended the following language: monitoring, and
termination of dialysis;(3)(i) Have completed at least two years
possible complications of dialysis; water hemodialysis patient care
experience, treatment; infection control; safety; accessfollowing a
training program that is care; medications; and emergency take-off
approved by the medical director and procedures. governing body.
This training experienceCompletion of a training program inmust be
under the direct supervision of a manual and automated peritoneal
dialysis is registered nurse, and be focused on the required if
peritoneal dialysis is provided operation of kidney dialysis
equipment and by the Dialysis Subunit. The training machines,
providing direct patient care, program should be focused on the
types of and communication and interpersonal skills peritoneal
dialysis; understanding theincluding patient sensitivity training
and care of difficult patients.13 Dialysis in the LTC Facility
Project Report 17. TEP recommended that the ESRD provider The TEP
recommended adding an be required to periodically monitor
experience and training requirement for performance including at
least an annual patient care technicians administeringevaluation of
patient care technician skills peritoneal dialysis in LTC
facilities. Theand knowledge, including observation of TEP
recommended the following language: competency. (ii) If
administration of peritoneal dialysis (manual or automated) is
applicable, then 4.3.3Other Staff the patient care technician must
have three The TEP recommended that the Medicare- months peritoneal
dialysis patient care certified ESRD provider assign a Medical
experience, following a training programDirector that meets the
proposed conditions that is approved by the medical
directorlanguage in 494.140(a). The Medical and governing body.
This training Director may serve as the Medical Director experience
must be under the direct for other Dialysis Subunits or ESRD
supervision of a registered nurse trained infacilities. 494.140(a):
(1) The medical administration of peritoneal dialysis, anddirector
must be a physician who has be focused on the administration of
manualcompleted a board approved training and automated peritoneal
dialysis, access program in nephrology and has at least 12 care,
signs and symptoms of peritonitis and months of experience
providing care to catheter exit site infections, measurement of
patients receiving dialysis. (2) If a adequacy of dialysis,
infection control,physician, as specified in paragraph (a)(1)
providing direct patient care, andof this section is not available
to direct a communication and interpersonal skillscertified
dialysis facility, another physician including patient sensitivity
training andmay direct the facility, subject to the care of
difficult patients. approval of the Secretary.The TEP recommended
modifying The TEP recommended adopting language language in the
proposed condition that from the proposed Conditions for both
specifies training program requirements Dietitians (494.140(c)) and
Social 494.180(b)(5)(i)-(viii) as follows: (4)Workers (494.140(d)).
494.140(c) successful completion of a training specifies: The
facility must have a dietitian program that includes: (i)
Principles ofwho must (1) Be a registered dietitian dialysis; (ii)
Care of patients with kidney with the Commission on Dietetic
failure, including interpersonal skills; (iii)Registration; (2)
Meet the practice Dialysis procedures and
documentation,requirements in the State in which he or she
including the initiation, monitoring, and is employed; and (3) Have
a minimum of termination of dialysis; (iv) Possibleone years
professional work experience in complications of dialysis; (v)
Waterclinical nutrition as a registered dietitian. treatment; (vi)
Infection control; (vii)494.140(d) specifies: The facility must
Safety; (viii) Access care; (ix) Applicable have a social worker
who (1) Holds a medications; (x) Emergency take-off masters degree
in social work from a procedures; (xi) Dialyzer reprocessing,
ifschool of social work accredited by the applicable; and (5) have
completed aCouncil on Social Work Education; and (2) training
program in manual and automatedMeets the practice requirements for
social peritoneal dialysis, if applicable. (6) Whenwork practice in
the State in which he or state requirements meet or exceed (3) she
is employed. above, then the State requirements must be met.The TEP
recommended adoption of proposed Conditions language for Ongoing
high quality performance of Biomedical Technicians. Proposed
patient care technicians is essential. TheCondition 494.140(f)
Water treatment14 Dialysis in the LTC Facility Project Report 18.
system technicians states: Technicians who Dialysis Subunit and the
LTC facility and perform monitoring and testing of the
waterintegrate the LTC facility plan of care. treatment system must
complete a training program that has been approved by theThe TEP
recommended modification of medical director and the governing
body. Proposed Condition 494.90(b)(4) asfollows: The dialysis
facility must ensurethat all dialysis patients are seen by a 4.4
Patient ESRD Care Assessment physician providing the ESRD care at
least The TEP recommended patient ESRD caremonthly, and at least
every other month assessment (which includes assessment of during
the patients treatment in the appropriateness of modality
selection) beDialysis Subunit, as evidenced by a consistent with
proposed Condition monthly progress note placed in the 494.80, with
modifications of patients medical record. interdisciplinary team
members and frequency of assessment.4.6Access to Nephrologist The
Condition defines the facility LTC facility patients receive
24-hour care interdisciplinary team as including at a and are more
closely monitored than other minimum, the patient or the
patientsdialysis patients. The TEP felt it would be designee, a
registered nurse, a nephrologist overly burdensome to expect a
nephrologist or the physician treating the patient forto travel to
Dialysis Subunits to see patients ESRD, a social worker, and a
dietitian. Theon a weekly basis, particularly because TEP
recommended the interdisciplinarypatients may be located within
several team also include member(s) of the LTC Dialysis Subunits
across a wide facility staff.geographical area. As a result, the
TEPrecommended that patients be assessed by The TEP recommended the
initialthe nephrologist in the Dialysis Subunit comprehensive
assessment be completedwithin the first two weeks of admission or
within two weeks of admission to the readmission to a Dialysis
Subunit. The Dialysis subunit and reassessment everyTEP advised
that stable patients be seen by month thereafter due to the short
length ofthe nephrologist monthly thereafter, with stay of many
patients and their high level ofthese visits being in the dialysis
subunit at acuity.least every other month. Unstable patientsshould
be seen more frequently. The TEP 4.5 Patient ESRD Plan of Carefelt
it would be acceptable for Nephrology The TEP recommended the
patient ESRD Nurse Practitioners or Physicians Assistants plan of
care be consistent with proposed to see the patients in addition to
the Condition 494.90, with modifications of monthly visit by the
nephrologist. It was interdisciplinary team members,suggested that
CMS consider reimbursing communication and frequency of
nephrologists at the home dialysis rate, assessment.since the
frequency of nephrologist visits islikely to be similar to the
frequency of The TEP recommended thevisits of home dialysis
patients. interdisciplinary team developing the plan of care also
include member(s) of the LTC4.7Vascular Access Care facility staff.
In addition to the proposedThe assessment and care of patient
vascular Condition, it was recommended that the access is covered
by the Patient ESRD Care ESRD plan of care demonstrateAssessment
and Patient ESRD Plan of Care communication between the staff of
the (see sections 4.4 and 4.5 above). It will beimportant for
communication to occur15 Dialysis in the LTC Facility Project
Report 19. between the Dialysis Subunit and the LTCfamilies. The
TEP recommended that facility regarding the care and
monitoringpatient advance directives be of vascular access. The TEP
advised thatcommunicated from the LTC facility staff LTC residents
who receive long-term to the Dialysis Subunit staff. Decisions to
dialysis services should have the goal of a terminate dialysis
treatments should be functioning fistula as their dialysis access,
discussed with the nephrologist. however the TEP recognized this
may often not be possible. It was recommended thatThe TEP discussed
barriers to providing all ESRD data related to patients receiving
hospice care for dialysis patients. If ESRD care in LTC facilities,
including vascularis the cause of the terminal illness, then access
data, be reported and reviewed dialysis services cannot be billed
under the separately from in-center data. Medicare Part B payment
system, but would need to be covered under the hospice 4.8Infection
Controlbenefit. Dialysis patients with terminal The TEP recommended
adoption of illnesses unrelated to their kidney failure language
consistent with proposed may continue dialysis under Part B and
Condition 494.30 Infection Control.receive the hospice benefits.
Communication and coordination of care between the LTC facility and
Dialysis 4.11 Physical Environment Subunit will be critical. It
wasThe TEP recommended that the Dialysis recommended that dialysis
providers beSubunit comply with all applicable federal, required to
educate LTC facility staff aboutstate, and local regulations
related to Center for Disease Control and Prevention physical
environment for LTC facilities requirements specific to
dialysis.(including the requirement for a functional emergency call
system in the room(s) used 4.9 Medications for dialysis) and for
dialysis facilities (see Administration of medications may
beproposed Condition 494.60). handled in various ways. For example,
Erythropoietin could be administered4.12 Water Quality
subcutaneously or intravenously duringThe TEP recommended that
facilities meet dialysis or subcutaneously by the LTC standards for
water and the practice facility when the patient is off
dialysis.guidelines for dialysate as published by the Coordination
of care will require thatAssociation for the Advancement of
medication administration be well defined Medical Instrumentation
(AAMI). in terms of who administers the medications, what form of
medication is to4.13 Coordination of Care be given (e.g. IV or
oral), and when theThe TEP believes that coordination of care
medication will be administered.is critical to the success of
staff-assisted Medications given by the dialysis providerdialysis
within the Dialysis Subunit setting. must be reported to the LTC
facility so thatResponsibilities must be clearly delineated the
pharmacy can monitor care as is and useful or necessary information
in the required by LTC facility regulations. The care of the
patient must flow bidirectionally quality of care should equal that
providedbetween the LTC facility staff and Dialysis to in-center
dialysis patients. Subunit staff on a routine basis.4.10End of Life
IssuesThe TEP recommended that the Conditions The LTC facility and
Dialysis Subunit carerequire a Letter of Agreement between the
providers should work together to facilitateESRD provider and the
LTC facility advance care planning discussions and specific to this
service. This letter of decision-making by patients and their
agreement should clearly define areas of 16 Dialysis in the LTC
Facility Project Report 20. responsibility and how care will be
maintenance of patient dialysis records at coordinated between
parties to safeguardboth the LTC facility and ESRD provider the
health and safety of ESRD patients. offices. The Letter of
Agreement should be reviewed and signed by both parties 4.13.3
Emergencies During Dialysis annually. The TEP recommended
specificTreatment items be required within the Letter ofThe parties
should define their Agreement as follows. responsibilities for
emergencies during dialysis. Both the ESRD provider and LTC 4.13.1
LTC Facility Expectationsfacility must have specific policies and
The LTC facility will be responsible for theprocedures in place to
handle medical and overall care delivered to the
patient,non-medical emergencies that may be monitoring of the
patient prior to and afteranticipated during dialysis. The ESRD the
completion of each dialysis treatment,provider must have a protocol
that and providing for all non-dialysis needs of identifies the
arrangements for physician the patient including during the time
periodand hospital services in the event of an when the patient is
receiving dialysis. emergency during dialysis.The LTC facility
Medical Director should be responsible for each patients 4.13.4
Back-up Treatment Facility comprehensive plan of care, which
shouldESRD providers should be required to have address dialysis.
The LTC facility Medicala written plan for back-up dialysis
Director is expected to be involved in thetreatment. If a Dialysis
Subunit cannot coordination of ESRD patient care.provide treatment
on site, there must be capacity to provide dialysis elsewhere The
Letter of Agreement should specifyeither directly by the ESRD
provider or that ESRD staff be educated on applicable under
arrangement. These back-up LTC facility protocols and that LTC
facilityfacilities must be within a reasonable staff be educated
regarding ESRD. LTC geographic distance of the LTC facility.
facility staff should be prepared to assist in the event of an
emergency during dialysis. The LTC Facility record of care should
4.13.5 Utilities The Letter of Agreement should specify include
dialysis treatment records. who is responsible for the provision of
utilities. 4.13.2 ESRD Provider Expectations The Letter of
Agreement should specify that the ESRD provider will be responsible
4.13.6 Communication The Letter of Agreement should specify for
providing dialysis staff; dialysis that the LTC facility and the
ESRD subunit treatments; monitoring the patient during share state
survey statements of treatment; oversight of dialysis care and
deficiencies. Other areas of coordination dialysis staff; dialysis
staff training; LTC that should be carefully defined in the letter
facility staff training regarding ESRD; of agreement include
interdisciplinary patient and family ESRD education and patient
assessment and plan of care modality selection; dialysis orders;
patient (sections 4.4 and 4.5), vascular access care ESRD
assessment and plan of care; (section 4.7), infection control
(section 4.8), provision of qualified social worker and provision
of medications (section 4.9), and registered dietitian services;
installation, end of life issues (section 4.10). testing, and
maintenance of the water and dialysate systems and all dialysis
There was significant TEP discussion equipment; appropriate
reporting; and regarding the coordination of care between17
Dialysis in the LTC Facility Project Report 21. parties to meet the
nutritional needs of the reported to ESRD Networks on a unit by
patient. In theory, the provision of dialysisunit basis, but not be
posted on the Dialysis at the LTC facility should automatically
Facility Compare (DFC) website, because improve communication and
planning patient numbers could be very small. DFC between the LTC
facility dietitian and renal reports could aggregate provider
Dialysis dietitian. However, given scheduling Subunit data as a
report separate from the restraints and the fact that many
LTCprovider in-center data, if applicable. facility dietitians are
consultants who are at Additionally, DFC should report that staff-
the LTC facility on a limited basis, and thatassisted dialysis in
LTC facilities is a the ESRD RD may seldom visit the LTC service
offered by the ESRD provider. The facility, particular effort
should be made toTEP recommended that Dialysis Subunit- ensure real
dialogue and joint care-planning specific quality standards should
be occur. Dialysis patients are at high risk of defined, however it
was recognized that malnutrition. LTC facility dietary servicesdata
identifiable as Dialysis Subunit data should be expected to provide
a variety of must first be collected and analyzed to palatable
meals that provide sufficientdevelop specific standards. protein
and calories, are nutritionally complete, and renal-compatible
while taking into account patient preferences. 4.16 System for Data
Collection Creative menu writing has the potential to The TEP
recommended that current data overcome the common problem of lack
of collection methods be changed so that variety and insufficient
food choice.analysis can distinguish treatment type,treatment
setting, patient residency, 4.14 Internal Oversightfrequency of
treatment, and modality type. The TEP recommended that Dialysis
Subunits meet proposed Condition 4.17 Certification Process 494.110
Quality assessment andThe TEP recommended the following performance
improvement. 494.110(a)(2)process to certify ESRD providers for the
specifies the program must include, but notprovision of
staff-assisted dialysis within be limited to, the following: (i)
Adequacy oflong-term care facilities. Providers would dialysis;
(ii) Nutritional status; (iii) Anemiasubmit an application to the
state agency management; (iv) Vascular access; (v)for service. The
application should require Medical injuries and medical errorsan
estimate of patient capacity. The new identification; (vi)
Hemodialyzer reusecertification of a provider or the addition of
program, if the facility reusesa Dialysis Subunit to existing
providers hemodialyzers; (viii) Patient satisfaction would require
an onsite survey prior to and grievances. The TEP
recommendedinitiating Dialysis Subunit dialysis that data from
Dialysis Subunits be reported treatments. After the initial
Dialysis and reviewed separately from in-center Subunit is
approved, if an ESRD provider data. Dialysis Subunits should report
theirchooses to open additional Dialysis quality assurance results
to both the LTCSubunits, they would need to notify the facility and
the ESRD facility.state agency of this intent. After the
stateagency acknowledges the intent to open, 4.15 External
Oversightthe certified ESRD facility could open the The TEP
recommended that Dialysisadditional Dialysis Subunits,
understanding Subunit data be included in qualitythat a survey
would occur as soon as reporting by the provider, but a
Dialysispossible. Waiting for a survey would not Subunit identifier
should be added to thehold up opening of additional Dialysis
dataset to facilitate separate data analysis.Subunits. It is
expected that a transition The Dialysis Subunit data should
beperiod will be required to certify existing18 Dialysis in the LTC
Facility Project Report 22. LTC facility Dialysis subunits under
the provide staff-assisted dialysis within the new regulations. A
request for expansion LTC facility setting. A WebEx call was by an
existing Dialysis Subunit to add held on January 9, 2006 to
familiarize all dialysis stations when dialysis is
providedparticipants to the issues and tasks for the in a common
area would need to be sent toproject. Strategies to structure the
dialysis the state agency.program, staffing issues,
patientcoordination of care issues, physical If a Dialysis Subunit
is out of compliance atenvironment and technical considerations, a
Condition level, the Dialysis Facility and oversight, facility
certification process, and all Subunits under that dialysis
providera financial model were further discussed would be
considered out of compliance. Ifduring a two day face- to- face
meeting on the facility failed to correct the deficient January 20
and 21, 2006 in Baltimore. A practice(s), the provider would lose
draft report containing TEP certification for their entire ESRD
program. recommendations was then prepared and The CMS Regional
Office must be notified made available for public comment through
when a provider with a Dialysis Subunit is May 15, 2006. The
recommendations were determined to have Conditional level nonsent
to representatives of major renal compliance. It was recommended
that theorganizations as well as state departments ESRD Network be
informed if an ESRDof health, quality improvement provider with a
Dialysis Subunit is out of organizations, and leadership of the
large compliance.dialysis organizations. Public feedback
wascollated and sent to the TEP members to 4.18 Financial Model
Development review. The TEP reconvened by WebEx in The TEP
recommended that a separateJune to discuss the public comments and
to section be created on the Medicare Costdecide how to revise the
final report. Reports to identify LTC facility dialysisThe TEP
urged CMS to consider creation services. The TEP suggested that CMS
of this new model because the need for simultaneously develop a
case-mixstaff-assisted dialysis in the LTC setting is adjustment
methodology and conduct a anticipated to grow as the population
pilot project. The composite rate for thesecontinues to age and the
current use of the higher acuity patients is expected tohome
dialysis method in the LTC setting incorporate the cost of labor.
does not appropriately meet this need.5.0 Conclusions In summary, a
TEP was convened to formulate recommendations for the development
of a definition and method to 19 Dialysis in the LTC Facility
Project Report 23. 6.0Technical Expert Panel, Consultants,
Observers & StaffTechnical Expert Panel Susan Cronin, Dialysis
Consultant, representing American Nephrology Nurse Association,
Elkhorn, WI Marlene Demers, CMS Region 1, Nurse Consultant, ESRD
Lead, Boston, MA Marilyn Duncan, Fresenius Medical Care North
America, Westchester, IL Kathy Hybarger, Health Care Excel, Terre
Haute, IN Stephen M. Korbet, MD, Circle Medical Management,
Chicago, IL Veronica Marotta, Illinois Department of Public Health,
Bellwood, IL Cecilia Meehan, DaVita, Rocky Hill, CT Maureen
Michael, National Renal Administrator Association, Orlando, FL Gail
Palmeri, MA Department of Public Health, Boston, MA Lana Price,
Chronic Care Policy Group, CMS, Baltimore, MD Joan Rogers,
Independent Dialysis Foundation, Baltimore, MD Anita Rowan,
Hemodialysis Patient, Nurse, Zion, ILCMS Representatives Condict
Martak Glenda PayneObservers: Curt Anliker, Executive Director,
Renal Therapies, IL Steve Bucher, Chief Executive Officer, Renal
Therapies, IL Sheri Floramo, Circle Medical Management, Chicago, IL
Judi Kari , CMSStaff: Susan A. Stark, Executive Director, Network
9/10 Jenny Kitsen, Executive Director, Network 1 Jay W. Wish, MD,
President, Network 9/10 George Aronoff, MD, MRB Chair, Network 9/10
Bridget Carson, Assistant Director, Network 9/10 Mary Ann Webb,
MSN, CNN, Quality Improvement Coordinator, Network 9/10 Raynel
Kinney, RN, CNN, CPHQ, Quality Improvement Director, Network 9/10
Janeen Len, MS, RD, LD, Project Assistant, MetroHealth Medical
Center Alan Kliger, MD, Nephrologist, Forum Representative, New
Haven, CT 21 Dialysis in the LTC Facility Project Report 24. 7.0
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