florida renal administrators association annual...

Florida Renal Administrators Association Annual Meeting

Presented by:

Ann Rizzuto, RN, BSN Registered Nurse Consultant

ESRD Program Lead Division of Health and Quality Assurance

Area 9 Agency for Health Care Administration

July 20, 2018

2017 Most Frequently Cited Deficiencies

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Most Common Health Deficiency Citations January 1, 2017 through December 31, 2017

Rank Tag Description

1 V0113*InfectionControl–WearGloves/HandHygiene(494.30(a)(1)),CFR

2 V0543 *PlanOfCare–ManageVolumeStatus(494.90(a)(1))CFR

3 V0403

*Equipment(includingemergency&dialysisequipment&watertreatmentsystemaremaintained/operatedinaccordancew/manufacturer’srecommendations(494.60(b)),CFR

4 V0544*PlanofCare–AchieveAdequateClearance(494.90(a)(1)),CFR

*Denotesin2016“TopTen”Findcitationtextat:http://ahca.myflorida.com/MCHQ/Current_Regs.shtml

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Most Common Health Deficiency Citations January 1, 2017 through December 31, 2017

Rank Tag Description

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V0147

*InfectionControl–StaffEducationCatheters/CatheterCare(494.30(a)(2)),CFR

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V0122

*ProceduresForInfectionControl-Disinfectsurfaces/Equipment/WrittenProtocol(494.30(a)(4)(ii)),CFR

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V0503

*Thepatient'scomprehensiveassessmentmustinclude,butisnotlimitedto,evaluationoftheappropriatenessofthedialysisprescription(494.80(a)(2)),CFR

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V0402

*PhysicalEnvironment-BuildingConstructedandMaintainedforSafety(494.60(a)),CFR

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V0547

PlanOfCare-ManageAnemia/H/HMeasuredEveryMonth(494.90(a)(4)),CFR

10 V0551PlanOfCare–VascularAccessMonitoring/PreventFailure/Stenosis(494.90(a)(5)),CFR

2018 Most Frequently Cited Deficiencies

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Most Common Health Deficiency Citations January 1, 2018 to June 30, 2018

Rank Tag Description

1 V0113*InfectionControl–WearGloves/HandHygiene(494.30(a)(1)),CFR

2 V0543 *PlanOfCare–ManageVolumeStatus(494.90(a)(1))CFR

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V0544

*PlanofCare–AchieveAdequateClearance(494.90(a)(1)),CFR

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V0403

*Equipment(includingemergency&dialysisequipment&watertreatmentsystemaremaintained/operatedinaccordancew/manufacturer’srecommendations(494.60(b)),CFR

*Denotesin2017“TopTen”Findcitationtextat:http://ahca.myflorida.com/MCHQ/Current_Regs.shtml

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Most Common Health Deficiency Citations January 1, 2018 to June 30, 2018

Rank Tag Description

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V0122

*ProceduresForInfectionControl-Disinfectsurfaces/Equipment/WrittenProtocol(494.30(a)(4)(ii)),CFR

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V0503

*Thepatient'scomprehensiveassessmentmustinclude,butisnotlimitedto,evaluationoftheappropriatenessofthedialysisprescription(494.80(a)(2)),CFR

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V0726

Complete,accurate,andaccessiblemedicalrecord(494.170)

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V0520

PatientAssessmentmonthlyforunstablepatients(494.80(d)(2)

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V0715

MedicalDirectorresponsibleforadherencetopoliciesandprocedures(494.150(c)(2)(i)

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V0401

Thedialysisfacilitymustbedesigned,constructed,equipped,andmaintainedtoprovidedialysispatients,staff,andthepublicasafe,functional,andcomfortabletreatmentenvironment(494.60),CFR

V0113 - #1 CITE five years in a row InfectionControl–WearGloves/HandHygiene

Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.

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CDC Dialysis Collaborative Audit Tool

CDC Dialysis Collaborative has an audit tool for hemodialysis hand hygiene observations: https://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-Hand-Hygiene-Observations.pdf

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Hemodialysis Hand Hygiene Opportunities for Staff

•  Prior to touching patient –  Prior to entering station to provide care to patient –  Prior to contact with vascular access site –  Prior to adjusting or removing cannulation needles

•  Prior to aseptic procedure –  Prior to cannulation or accessing catheter –  Prior to performing catheter site care –  Prior to parenteral medication preparation –  Prior to administering IV medications or infusions

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Hemodialysis Hand Hygiene Opportunities for Staff

•  After body fluid exposure risk – After exposure to any blood or body fluids – After contact with other contaminated fluids (e.g.,

spent dialysate) – After handling used dialyzers, blood tubing, or prime

buckets – After performing wound care or dressing changes

•  After touching patient – When leaving station after performing patient care – After removing gloves

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Hemodialysis Hand Hygiene Opportunities for Staff

•  After touching patient surroundings – After touching dialysis machine – After touching other items within dialysis station – After using chairside computers for charting – When leaving station – After removing gloves

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Hand Hygiene Opportunities for Dialysis Patients

•  Upon entering the facility treatment floor – Wash hands – Wash vascular access site (if applicable)

•  After holding access site for hemostasis – when glove is removed

•  After treatment is completed –  Preferably before touching the scale, door knobs, etc.

•  Prior to exiting the treatment floor –  Staff should encourage or remind patient to hand wash

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Emergency Preparedness Deficiencies

November 2017 through June 2018

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Most Common Emergency Preparedness Citations November 2017 through June 2018

Rank Tag Description

1 E0028 DialysisEmergencyEquipment

2 E0006 EmergencyPlanbasedonAllHazardsRiskAssessment

3 E0038 ESRDEmergencyPreparednessTrainingProgram

4 E0039 EmergencyPreparednessTestingRequirements

5 E0040 ESRDPatientOrientationTraining

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Most Common Emergency Preparedness Citations November 2017 through June 2018

Rank Tag Description

6 E0009 Local,State,Tribal,CollaborationProcess

7 E0020 PoliciesandProceduresforEvacuation

8 E0022 PoliciesandProceduresforShelteringInPlace

9 E0032 Primary/AlternateMeansforCommunication

10 E0036 EmergencyPreparednessTrainingandTesting

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Center for Clinical Standards and Quality/Survey & Certification

Group Updates

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Changes to the ESRD Survey Timeframe

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•  Initial Surveys –  Must be initiated within 90 days from the approval of the CMS-855 –  Effective August 9, 2018 –  Although there is federal legislation for deemed status for ESRD’s, there

are no applications at this time –  Life Safety Attestation

•  Tier 2 ESRD Surveys –  The redesign will focus on the identification of ESRD centers which are

most likely to present risk to patients such as hospitalization and infections.

–  The new list will be ready for FY 2019; CMS reported this should reduce the number of required surveys under this tier.

•  Relocation Surveys –  These will be conducted in conjunction with recertification surveys.

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Laurie’s Story

Diagnosed with acute kidney failure in 2008, no co-morbidities, and no warning signs. On hemodialysis for 2 years. Successful kidney transplant at the Mayo Clinic in Jacksonville, September 2010. Husband is living donor. Both donor and recipient are doing well at the 8-year mark. Life is truly a gift!

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Questions?

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Contact Information

Ann Rizzuto, RN, BSN

561-381-5840 Ann.Rizzuto@ahca.myflorida.com

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