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Slide 1 - NRAA_


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									NRAA & Implementation
of the ESRD Conditions
      for Coverage
          Judith Kari
 CMS National Technical Director
     Survey & Certification
Presentation is About:

•   NRAA & implementation partnerships
•   Major changes to the Conditions
•   Challenges of implementation
•   Most frequently cited deficiencies
•   Top 7 hints for NRAA re: surveys
     With CMS
NRAA Helps with…….

• Development of materials

• Distribution of materials
Anniversary of the Conditions:
 10,000 Received draft Interpretive Guidance
  6,400 Attended presentations on CfC
  2,500 Attended Webinars on CfC
  1,600 Comments received on drafts
  1,300 Written questions received
    286 Recertification surveys
Anniversary Report (cont.)

  200 Pages incorporated by reference/CfC
  193 Complaint surveys
  120 Attended the Community Forum on CfC
   67 PowerPoints developed for CfC
   56 Initial surveys
    7 Training sessions for surveyors
    7 Members of ESRD Support Team
Major Changes to Regulations
Subpart A: General
1. Compliance with Federal State & local laws
   and regulations

Subpart B: Patient Safety
2. Infection control
3. Water and dialysate quality
4. Reuse of hemodialyzers
5. Physical environment
Major Changes to Regulations
Subpart C: Patient Care
 6. Patients’ rights
 7. Patient assessment
 8. Patient plan of care
 9. Care at home
10. QAPI
11. Special purpose dialysis facilities
12. Laboratory services
Major Changes to Regulations

Subpart D: Administration
13. Personnel qualifications
14. Responsibilities of the medical director
15. Medical records
16. Governance
Preparing for Implementation:
Development of the Interpretative
 Evolutionary process
 • Began with a focus of surveyor guidance
 • Community feedback wanted more
 • Evolved in a broader way to address needs of
   community as well as the needs of surveyors
Development of the Interpretative
• Focus on defining terms for clarity
   • Aim: consistent interpretation by providers and
• Involvement of CDC / AAMI
   • Active on-going dialog with CDC
   • Repeated review of the Water & Dialysate portion by
     the AAMI RD Committee
• Survey Process separate
   • Developing specific process guides for initial surveys
     and resurveys
   • Directed at the needs of the surveyors
   • Will be part of the State Operations Manual
Development of the Interpretative
Guidance: Measures Assessment
Tool (MAT)
• Community based standards in an easily
  updated tool
• Presented as part of the IG
• Used by surveyors in reviewing PA/POC
  and QAPI
On-going Work of Implementation
For S&C letters:
1. Click on "Show only"
2. Click the box "Show only items containing the
   following word"
3. Type the S&C memo number in the field
4. Click the button "Show Items"

The database should find the S&C memo you want
On-going Work of Implementation

Survey & Certification Letters
• 09-01: Interpretative Guidance
• 09-13: Waivers & Phased-in Requirements
• 09-24: Life Safety Code
Administrative Information Letters
• 09-16: CROWNWeb Phased-in
On-going Work of Implementation

State Operations Manual
• Under construction
• Will include Survey Process for initial surveys
  and resurveys
• Will address Survey and Certification issues
   •   Adding services or stations
   •   Relocations
   •   Temporary closures
   •   Centralized reprocessing
On-going Work of Implementation

Implementation of LSC plan:
•   LSC survey required for all initial surveys
    effective 2/9/09
•   LSC surveys for complaint allegations related
    to LSC requirements
•   A % of resurveys will include LSC after the
    ASPEN system is updated with the LSC K-tags
    for ESRD (Summer 2009)
  Survey Outcomes
Early Report: April 2009
Most Frequently Cited
Infection control
•   Wear gloves/hand hygiene
•   Clean & disinfect surfaces
•   Wear gowns/PPE
•   Clean/dirty areas; med prep area
•   Items taken to station: D/D/D
Infection Control:
Why Would This Be Cited?
               All about
               • HANDS
               • Supplies
               • PPE
Water: Carbon Monitoring

• At the beginning of each treatment day
• Sample drawn after system has been
  operating at least 15 minutes
• Prior to beginning of each patient shift
  (or every 4 hours)
• Record results

Transportation and Handling
PE: Equipment Maintenance –
Follow DFU
Why would this be cited?
Equipment repair & maintenance

         *DFU= Directions for use
Patient Assessment/Plan of Care
Here is a REAL opportunity to CHANGE the way
  care is delivered!
Here is a REAL opportunity to:
• INCREASE patient involvement and
• INCREASE patient independence
= Improved Satisfaction & Better Working
  Conditions For Everyone!

This is about the PROCESS — not about the form!
Correlation of PA & POC
               PA                             POC
Current health status (V502)      Incorporated into all POC tags
Lab profile (V505)
Medication/immunization history
Appropriateness of dialysis       Provide adequate clearance
prescription (V503)               (V544)
BP/fluid management needs         Manage volume status (V543)
Assess anemia (V507)              Manage anemia (V547)
                                  Home pt ESA (V548)
                                  ESA response (V549)
Assess renal bone disease         Manage mineral metabolism
(V508)                            (V546)
 Correlation of PA & POC
               PA                             POC
Nutritional status (V509)         Effective nutritional status
Psychosocial needs (V510)         Psychosocial
Evaluate family support (V514)    counseling/referrals/
                                  assessment tool (V552)
Access type/maintenance           VA monitor/referral (V550)
(V511)                            Monitor/prevent failure (V551)
Evaluate for self/home care       Home dialysis plan (V553)
Transplantation referral (V513)   Transplantation status: plan or
                                  why not (V554)
Evaluate current physical         Rehab status addressed
activity level & voc/physical     (V555)
rehab (V515)
MD Responsibilities: All Adhere
To Policies & Procedures
Why would this be cited?
Admission policies
• Orders
• Baseline H&P
• Nursing evaluation prior to 1st treatment
• ―Adhere to P&P‖

Infection Control: Trend/Plan/Act
Most Frequently Cited Condition
Level Citations
•   Infection control
•   Governance
•   QAPI
•   Water & dialysate quality
•   Responsibilities of the medical director
•   Patient plan of care
•   Patient assessment
7 Top Hints for NRAA

 How to Learn to Love
  the Survey Process
#7: Know There are Exceptions
to the Rule
• What is the Rule?
  • 10 pages of regulations text
  • 200 pages of ―incorporated‖ technical text
  • 300 pages of Interpretive Guidance
• The Exceptions: Waivers
  • Isolation room/area
  • Life Safety Code
  • Medical director qualifications
More Exceptions?

Phase-In time Extensions
• Single-use vials
• Water storage tanks
• Interdisciplinary Patient Assessment &
  Plan of Care
• CROWNWeb data submission
#6: Take Action on Weapons of
Mass Destruction
• Water and dialysate have the capacity
  to threaten the health and life of an
  entire facility’s population
• Other safety hazards
  • Infection control
  • Reuse
  • Physical environment
#5: Use Data

• Data from CROWNWeb & Dialysis
  Facility Reports

• Data from QAPI
#4: Expect Consistency

CMS expects consistency & you should too
#3: Consider the Tasks at Hand

• There are 16 Surveyor Tasks

• Use the Surveyor Tools for practice
#2: Take it to the MAT

• The tool was developed for ease of
  reference and updating of standards
• Patient assessment & Plan of care:
  • Revise Plan of care if needed
  • Do a root-cause analysis if needed
#1: Stay Connected

• CMS needs your partnership, your
  comments, your questions

• Thank you for continuing to help
  with the ongoing implementation


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