2010 CMS Regulatory Update Glenda M. Payne, RN, MS, CNN ESRD Technical Advisor CMS, Dallas & Atlanta...
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Transcript of 2010 CMS Regulatory Update Glenda M. Payne, RN, MS, CNN ESRD Technical Advisor CMS, Dallas & Atlanta...
2010 CMS Regulatory Update
Glenda M. Payne, RN, MS, CNNESRD Technical Advisor
CMS, Dallas & Atlanta Regions
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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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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
• 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
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
19
Clean Surfaces
• Tilt chairs back to clean• When cleaning up blood spills: 1st clean,
then (with new supplies) disinfect• Treatment chairs: practice audits
20
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
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
We Can Do Better! “How To” Avoid Deficiency Citations
23
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?
24
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.
25
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
27
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
29
Did You Know?
• Practice audits are required: – for water treatment – dialysate preparation
• Don’t forget these when planning your audits
30
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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