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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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