florida renal administrators association annual...
TRANSCRIPT
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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