ESRD Network 18 Annual Meeting:

Transcription

1 ESRD Network 18 Annual Meeting: What is New for Clinical Staff? ESRD Network 18 California Dialysis Council 27 th Annual Educational Conference, Palm Springs, CA April 17, 2009

2 Objectives: Provide an overview of the ESRD Network organizations mission and goals Outline major changes in the new ESRD Conditions for Coverage (CFC) Explain involuntary discharge process Update on the CROWN Web implementation status 2

3 Health Care Quality Improvement Program (HCQIP) The Center for Medicare & Medicaid Services (CMS) contracts with 18 ESRD Network Organization throughout the United States The ESRD Network perform oversight activities to assure appropriateness of services and protection for ESRD patients. This approach has been named the ESRD Health Care Quality Improvement Program (HCQIP) 3

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5 Number of Prevalent ESRD Patients in the US 400, , , , , , , ,000 50,000 59, , , US 5

6 ESRD Network National Goals Improve the quality of health services & quality of life for ESRD beneficiaries Improve data reporting, reliability, & validity between providers, NWs, and CMS Evaluate and resolve patient grievances Support the marketing, deployment, and maintenance of CMS approved software CMS, ESRD NW Organization Manual 6

7 ESRD Network National Goals Establish & improve partnerships & cooperate activities with Providers & Owners NWs, Quality Improvement Organizations (QIOs) State Survey Agencies Professional Groups & Patient Organizations CMS, ESRD NW Organization Manual 7

8 Network 18 Mission Statement To provide leadership and assistance to renal dialysis and transplant facilities in a manner that supports continuous improvement in patient care, outcomes, safety and satisfaction. 8

9 30,000 25,000 Network 18 Patient Distribution by Modality ,331 20, , ,000 6, ,000 2, , In-center hemo Home dialysis Transplanted Awaiting transplant 9

10 Definition of Healthcare Quality Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired outcomes and are consistent with current professional knowledge. Institute of fmedicine 10

11 What is the cost of Poor Quality? No show rates? Lost charts? Lost labs? Train wreck visits? Lost revenue improper billing? Staff turnover? 11

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13 Network 18 Definition of Quality Doing the right thing correctly the first time. 13

14 New ESRD Regulations: What are some of the major changes? 14

15 Special Thanks for the Content Contribution to the CMS Transition Team Glenda Payne, Judith Kari Teri Spencer, Kelly Frank Rosemary Miller, Bonnie Greenspan Beth Witten

16 The ESRD Regulation Timeline 1976: First ESRD regulations published 70 s-90 s: Technical updates 1994: Community Forum Meeting to begin complete rewrite of ESRD regulations 2008: New ESRD regulations published 16

17 Mj 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

18 Major Changes to Regulations Subpart C: Patient Care 6. Patients rights 7. Patient assessmente 8. Patient plan of care 9. Care at home 10. QAPI 11. Special purpose dialysis facilities 12. Laboratory services

19 Major Changes to Regulations Subpart D: Administration 13. Personnel qualifications 14. Responsibilities of the Medical Director 15. Medical records 16. Governance

20 Preparing for Implementation: Development of the Interpretative Guidance Community involvement Draft document to listserv of 10K+ stakeholders Community Forum (120 attended) Revised draft to listserv 1600 comments received and reviewed; used to craft final document 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

21 Development of the Interpretative Guidance Focus on defining terms for clarity Aim to ensure consistent interpretation by providers and surveyors 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 and resurveys Directed at the needs of the surveyors Will be part of the State Operations Manual

22 The Waivers New Facility: Isolation Room Based on distance and travel time to a facility with isolation capacity and willingness to accept patients Qualifications of the Medical Director Time limited,,potentially renewable Based on outcomes list Life Safety Code If compliance presents an unreasonable hardship If the waivered requirement will not present a risk to patient t safety

23 Phased-In Time Extensions Single-Use Vials (end of June, 2009) Water Storage Tanks (dependent on water cultures) Interdisciplinary Patient Assessment (October 14, 2009) CROWN Web Data Submission (phased-in time line)

24 Survey Outcomes Early Report: April 2009

25 Condition Level Citations Infection Control Water & Dialysate Quality Governance QAPI Responsibilities of the Medical Director Patient Plan of Care Physical Environment

26 2008 Citation i Frequency Report for California ESRD Facilities: Total Number of Surveys conducted = 490 Number of providers cited = 476 (97.1%) Source: CASPER report 26

27 Most Frequently Cited Deficiencies Infection Control Clean & Disinfect surfaces Wear gloves/hand hygiene Items taken to station: D/D/D Clean/dirty areas; med prep area Wear gowns/ppe

28 Infection Control: Why Would This Be Cited? All about HANDS Supplies Meds Saline Heparin PPE

29 Gloves & Hand Hygiene Hand washing is the most important measure to prevent contaminant transmission. --CDC V113 requires: Wear gloves Whenever caring for a patient or touching the patient s equipment. Remove/change gloves Must perform hand hygiene after removal of gloves between each patient or station. 29

30 PPE: Must Wear Gowns V115 requires: A gown or lab coat must be worn when the spurting or spattering of blood, body fluids, potentially-contaminated substances or chemicals might occur Aprons are not sufficient PPE during procedures that may result in the spurting or spattering of blood Clarifies when staff, patients, & visitors should wear PPE & when the PPE should be changed 30

31 Items Taken Into the Dialysis i V116 requires: Station Items taken into the dialysis station Dispose, dedicate, or clean & disinfect (DDD) Unused supplies or medications should not be returned to a common area or used on other patients 31

32 Clean/Dirty Areas & Medication Preparation Areas V117 requires: Separate clean from contaminated areas Prepare e individual dua patient t meds in a centralized ed area away from the treatment area Designate area only for medication prep Deliver separately to each patient Do not move the medication cart from patient station to patient station to deliver medications If trays are used, clean between patients 32

33 Single Use Vials = Single Use V118 requires: Single dose vials cannot be punctured more than once Must be used for only one patient Not entered more than once If entered, may not be stored for future use. BRAND NEW: MMWR August 15, 2008 retracts the 2002 CDC communication allowing multiple use of single use vials Multi-use vials: residual medication from two or more vials il must not be pooled ldinto a single vial il 33

34 Supply Cart & Supplies V119 requires: If a common supply cart is used, do not move the cart from patient station to patient station to deliver supplies Do not carry supplies, patient care items, or medications in pockets 34

35 Cleaning & Disinfecting of Contaminated Surfaces, Medical Devices, & Equipment V122 requires: Protocols for cleaning & disinfecting surfaces & equipment Manufacturer s DFUs followed CDC recommended disinfection procedures Cleaning & disinfection of environmental surfaces completed between patient uses Chi Chairs, beds, bd machines & containers ti associated itdwith prime waste, adjacent tables & work surfaces 35

36 Cleaning & Disinfecting of Contaminated Surfaces, Medical Devices, & Equipment V122 requires: Clean & disinfect medical devices & equipment after each patient Scissors, hemostats, clamps, stethoscopes, blood pressure cuffs Blood spills cleaned effectively & immediately Intermediate-level disinfectant 36

37 Hepatitis i BRoutine Testing, Vaccination, i Screening, & Seroconversion (V ) Routine testing for HBV (V124) HBV status of all patients known before admission to the HD unit Test all patients as required by the CDC schedule Results of HBV testing gpromptly p reviewed (V125) Vaccination of susceptible patients & staff members (V126) All susceptible patients t & staff are offered hepatitis B vaccination 37

38 HBV+ Isolation Room/Area V128 & V129: Isolation of HBV+ Patients Effective Feb 9, 2009, every new facility MUST include an isolation room for treatment of HBV+ patients, unless the facility is granted a waiver of this requirement For existing units in which h a separate room is not possible, there must be a separate area for HBsAg positive patients 38

39 Isolation of HBV+ Patients Dedicated machines, equipment, supplies, & medications (V130) Used only for HBV+ patients until patient is discharged from facility Staff assigned to care for HBV+ patient (V131): May only care for other HBV+ patients or HBV immune patients 39

40 Most Frequently Cited Deficiencies PA/POC Assess B/P & fluid mgmt needs Manage volume status Medical Director Responsibilities Ensure all adhere to P&P Physical Environment PM; follow manufacturer s DFU

41 Major Change new CFC: No LTP (Long-Term Plan) No expectation for a long term program or signature of transplant surgeon Requirements for patients to be informed of all modalities (transplant & therapies not offered at their current clinic) are addressed under: Patients Rights Pti Patient tassessment Plan of Care 41

42 Patient Assessment (V501) and Patient Plan of Care (V541) These 2 Conditions: Are interrelated ( can t have one without the other ) Address patient assessment & care delivery requirements in care areas associated with complications of ESRD 42

43 Correlation of PA & POC PA Current health status (V502) Appropriateness of dialysis prescription (V503) Lab profile (V505) Medication/immunization history (V506) BP/fluid management needs (V504) Assess anemia (V507) Assess renal bone disease (V508) POC Incorporated into all POC tags, including adequate clearance (V544) Manage volume status (V543) Manage anemia (V547) Home pt ESA (V548) ESA response (V549) Manage mineral metabolism (V546) 43

44 Correlation of PA&POC POC PA POC Nutritional status (V509) Effective nutritional status (V545) Psychosocial needs (V510) Evaluate family support (V514) Access type/maintenance (V511) Evaluate for self/home care (V512) Psychosocial counseling/referrals/ assessment tool (V552) VA monitor/referral (V550) Monitor/prevent failure (V551) Home dialysis plan (V553) Transplantation referral (V513) Transplantation status: plan or why not (V554) Evaluate current physical activity level & voc/physical rehab (V515) Rehab status addressed (V555) 44

45 How Is This Supposed to Work? PA: identifies intradialytic weight gains (IDWG) of greater than 12 pounds/treatment POC: IDT members (all) to work with patient on risks of excessive fluid gains and (RD) on ways to handle thirst Agree to a goal for IDWG to be reduced by 10% each week until goal of no greater than 5 pounds is reached Monitor IDWG each treatment. Praise positive actions (RN, PCT) If IDWG remains at same levels at end of one month, review and revise POC

46 Patient tassessment: Assess B/PAnd Fluid Management Needs Why would this be cited? Review of flow sheets = no evidence B/P is bi being monitored Post weight does not = goal and no comment is made Fluid removed and weights do not match and no comment is made Note: Surveyors are being taught to look at flow sheets for the implementation of the assessment- based plan of care

47 Another Word about PA/POC 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!

48 Interdisciplinary i Care vs. Multidisciplinary Care Interdisciplinary Work collaboratively Communication by regular discussions about patient status & the evolving plan of care Multidisciplinary Work sequentially Medical record is the chief means of communication 48

49 The Interdisciplinary Team (IDT) Includes at a minimum: The patient or their designee (if the patient chooses) A registered nurse A physician treating the patient for ESRD A social worker A dietitian 49

50 Show Me The Progress Interdisciplinary Team: 50

51 Timelines: Starting 10/14/08 Initial i lassessments for New Patients: PA=30 days/13 treatments whichever is later POC implemented within this same timeline Reassessment for New Patients: 3 months after initial assessment completed POC updated and implemented within 15 days of reassessment 51

52 Then what? Stable patients = Annual reassessment POC updated and implemented within 15 days All patients: Continuous monitoring = any aspect of care where the target t is not met = revise that t aspect of POC Unstable patients = monthly reassessment POC updated and implemented within 15 days 52

53 Who Is Unstable? Per V520, includes but is not limited to: Extended or frequent hospitalization (>8 days or > 3 X a month) Marked deterioration in health status Significant change in psychosocial needs Concurrent poor nutritional status, unmanaged anemia and inadequate dialysis i 53

54 What About Current Patients? As of October 12, 2008: Expect a plan to implement this new system Some assessments/pocs e completed each month until all are done All current patients to be included in the new system within 12 months of 10/12/08 Do not expect 3 month reassessment for current patients Expect updates for any aspect of care that does not meet targets 54

55 Transfer of Current Patients After 10/14/08, when a patient is transferred, expect: Copy of most current IDT assessment and POC from transferring facility in patient s medical record Reassessment within 3 months of admission Revision i and implementation ti of POC within 15 days of completion of the reassessment 55

56 Frequent Citations: i MD Responsibilities: All Adhere To P&P Why would this be cited? Admission i policies i Orders Baseline H&P Nursing assessment prior to 1 st treatment Adhere to P&P

57 Frequent Citations: i Physical Environment: Equipment Maintenance; Follow DFU Why would this be cited? Equipment Repair & Maintenance *DFU= Directions for use

58 Physical Environment Life Safety Code (LSC) Requirements: Must meet provisions of NFPA 2000 Grandfather clause for current facilities in nonsprinklered buildings if built prior to 1/1/2008 State fire safety codes may be used in lieu of LSC Specific provisions of LSC may be waived in some cases 58

59 Physical Environment Every facility must have an AED or a defibrillator ill (& ACLS qualified staff) All equipment maintained & operated according to manufacturer s directions Emergency preparedness for staff & patients, including disaster prep get tto know your local l Emergency Ops Center 59

60 Condition : Quality Assessment and Performance Improvement Project (QAPI) Interdisciplinary team (IDT) Must report problems to Medical Director and QAPI Process continuous & on-going g Outcome focused: use community accepted standards as targets Include ld patient satisfaction, if i infection if i control, medical injuries & medication errors Plan/Do/Check/Act: Close the loop! Refer to the 2008 QI Manual for more QAPI Resounces 60

61 PDCA Style ACT PLAN CHECK DO 61

62 V626 QAPI Condition Statement The dialysis facility must develop, implement, maintain and evaluate an effective, data driven, quality assessment and performance improvement program with participation by the professional members of the interdisciplinary team... The dialysis facility must maintain and demonstrate evidence of its quality improvement and performance improvement program for review by CMS 62

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64 Performance Measures (See MAT) (V629) Adequacy (V630) Nutrition Kt/V, URR Albumin, body weight (V631) Bone disease PTH, Ca+, Phos (V632) Anemia (V633)Vascular access (V634) Medical errors Hgb, Ferritin Fistula, catheter rate Frequency of specific errors V635) Reuse Adverse outcomes (V636) Pt satisfaction (V637) Infection control Survey scores Infections, vaccination status 64

65 Monitoring Performance Improvement (V638) The facility must: Continuously monitor its performance Take actions that result in performance improvement Track to assure improvements are sustained over time 65

66 Prioritizing Improvement Activities (V639) Considerations in prioritization Prevalence of problem Severity of problem Impact on clinical outcomes Impact on patient safety 66

67 Immediate Correction Examples of serious health and safety threats: Unsafe water or dialysate Defective clinical equipment Unsafe reprocessing of dialyzers Epidemiological risks Insufficient number of competent staff to perform scheduled treatments: Preserve accesses Monitor patients Assure safe machine function 67

68 Personnel Defines individual qualifications: Medical Director Nurses: nurse manager, home training nurse, charge nurse, staff nurse Dietitian Social Worker Defines group qualifications: Patient care technicians Water treatment system technicians 68

69 Patient Care Technician Personnel High school diploma or equivalency or 4 years of employment Complete a (defined) training course, approved by Medical Director & Governing Body; under direction of RN Be certified by a State or national program New employees: within 18 months of hire date (starts after 10/4/08) Current employees: within 24 months of 4/4/08 69

70 National Organizations ations Approved by CMS to Certify Technicians: BONENT (Board of Nephrology Examiners for Nursing and dtechnology NNCC (Nephrology Nursing Certification Commission NNCO (National Nephrology Certification Organization) 70

71 Mdi Medical ldirector Accountable to the Governing Body Responsible for patient care and outcomes Responsible for effective QAPI and Infection Control programs Responsible to assure all staff, physicians & nonphysician providers adhere to all policies Must be engaged in any involuntary patient transfer or discharge 71

72 Medical Records Traditional rules on completeness & protection of medical records Transfer requested records to the receiving facility within one day 72

73 Staffing: Governance Requirements Adequate number of qualified & trained staff Patient/staff ratio appropriate to the level of care & meets the needs of the patients t (V757) RN, MSW, RD available to meet patient needs (V758) RN present at all times in-center patients are being treated (V759) All staff have orientation to the facility & their work responsibilities (V760) & continuing education (V761) 73

74 Condition: Governance Separate Standards within this Condition: Identifiable governing body/designated person (CEO/Administrator) (V ) Medical staff appointments (V762) Internal grievance system in place (V765) Involuntary discharge process (V ) Emergency coverage (V ) 770) Electronic data submission (V771) Relationship with the ESRD Network (V772) 74

75 Emergency Preparedness: Staff training/knowledge i (V409 & V411) Staff CPR certification (V410) Patient orientation & training (V412) 75

76 Emergency Preparedness (cont). Emergency preparedness Implement processes & procedures to manage medical & non-medical emergencies (V408) Staff & patient training Training & orientation, including what to do, where to go, & who to contact (V409) Emergency plans Evaluate/update annually, make contact with local Emergency Management (V416) 76

77 4K Keyes To Being Prepared dfor a Disaster (KCER) Determine what kind of disaster you may expect Evaluate the readiness of your dialysis facility Prepare your staff Prepare your patients

78 Northridge Earthquake ~ 1994

79 Northridge Earthquake ~ 1994

80 California Firestorms ~

81 Facility Readiness Secure the facility Keep patient and business records secure Have a back-up utility plan Refer to CMS Manual Emergency Preparedness Refer to CMS Manual Emergency Preparedness for Dialysis Facilities (CMS-11025)

82 Prepare Your Staff Identify the disaster Organizational Structure Develop a communication plan and test it regularly Educate key ypersonal in their role during disaster Have a back-up facility agreement Know in advance who to contact for assistance and information: - ESRD Network - City, County and State Emergency Response Teams - American Red Cross Chapter - Security Company

83 Prepare Your Patients Handing out a copy of a facility s disaster plan Disaster drills (do not discontinue dialysis treatment during a drill) Emergency disconnect (Clamp and Cut or Clam and Disconnect) Distributing medical emblems identifying patients as dialysis patients Patient Emergency ID Card (wallet-size) Distributing a copy of the CMS booklet: Preparing for Emergencies: A Guide for People on Dialysis.

84 Prepare Your Patients (cont) Gather and carry important medical information Awareness about alternative arrangements for treatment Preparing an emergency stock of supplies, food, and medication Know survival diet to follow if dialysis treatment must be delayed

85 Patient Provider Tracking ESRD Networks will be monitoring i facility Open/Closed status Web site on nephron.com Disaster Patient Activity Report Through ESRD Networks Begins DAY 5 post emergency Continues twice a week

86 KCER Tools & Resources Response Team Pages Information & education Drills & education Helpful links ESRD & disaster-related information 86

87 ESRD Network 18 Emergency Preparedness Efforts Collaborated with Medical and Health Coordination programs Developed the Annual Update form and the Document of Understanding Provided EMS Contact List to Facilities KCSC Coalition changed its focus from CKD to emergency preparedness Participated in the Great Shakeout Drill (November 13, 2008) 87

88 Network Relationship (V772) Receive and acts upon recommendations from their NW Participate in NW activities and pursue NW goals Improve the quality & safety of services Improve independence, QOL, rehab for all pts. Encourage activities to ensure achievement of these goals Improve the collection, reliability, timeliness and use of data 88

89 ESRD Network 18 Assistance: Survey tools and resources are posted on the Network 18 website at QI Manual has many CFC information Continue to provide educational opportunities for providers Conduct Quality Improvement Project to assist facilities with compliance to new CFC

90 Sign-up for 5-Diamond Patient Safety Program! Developed by ESRD Networks 1 & 5 Promotes commitment to patient safety, open communication and blame-free environment Builds a patient safety culture in every dialysis unit Employee & Physician Involvement & Accountability 90

91 Program Components Patient Safety Principles (required) Hand Hygiene Flu Vaccination Slips, Trips, and Falls Medication Reconciliation Emergency Preparedness Sharps Safety Decreasing Patient t & Provider Conflict Missed Treatments 91

92 Program Benefits: Supports QAPI Activities related to CFC Promotes staff development and education Supports national CMS goal to promote patient safety Participating facilities will be recognized Contact the Network is you are interested 92

93 Changes in Regulations: New Requirements on Involuntary Discharges

94 Network Role To guide staff in dealing with conflict situations appropriately and consistently and in accordance with CMS guidelines To protect the rights of patients under the Federal Regulations Assist providers meet the New Conditions for Coverage 94

95 Involuntary Discharges Involuntary Discharges should only occur as a last resort and only when all other forms of intervention have been exhausted. 95

96 Definition of Involuntary Discharge Patient has been discharged or is asked to transfer-out from the facility against his/her will. A patient is considered involuntarily discharged if they have received written or verbal notice that they will no longer be allowed to receive dialysis at your facility. 96

97 Condition: i Patient s Right Be informed regarding transfer and discharging policies Be informed of facility's policies for transfer, routine or involuntary discharge, and discontinuation of services Receive written notice 30-days in advance of an involuntary discharge, after the facility follows the involuntary discharge procedure described in (f) (4) In the case of immediate threats to the health and safety of others, an abbreviated discharge procedure may be allowed 97

98 Condition: Responsibilities of Medical Director Policies and procedures the medical director must: Be responsible to assure all staff, physicians, and non-physician providers adhere to all policies Be engaged in any involuntarily patient transfer or discharge Must ensure that the reasons for involuntary discharge or transfer are consistent with the requirement 98

99 Condition: Governance Involuntary discharge, transfer policies, and procedures The medical director ensures that no patient is discharged or transferred from the facility unless 1. The patient or payer no longer reimburses 2. The facility ceases to operate 3. Is necessary for the patient s welfare; facility can no longer meet the patient s needs 4. The patient s behavior is disruptive and abusive to the extent that the delivery of care to the patient or the ability of the facility operations is seriously impaired 99

100 Condition: Governance (cont.) Efforts to resolve the problem are documented as well as on-going problems Must have a written physician order signed by both the medical director and patient s attending physician Provide a 30-day written notice to the patient with copy to the local ESRD Network Contact other facilities in attempt to place the patient and documents that effort Notify the local ESRD Network and State Survey Agency of the involuntary discharge or transfer 100

101 Reporting When the decision to involuntarily discharge a patient is made, please do the following: Notify the Patient Services Department at Network 18 to review the situation and decision Fax or mail a copy of the discharge letter and all documents on the involuntary discharge checklist after speaking with the Patient Services Department 101

102 Reporting (cont.) Report the involuntary discharge on the monthly Patient Activity Report (PAR) under event t 6 6c (category Cin the losses column) Use this event for all involuntary discharges regardless of where the patient received services after discharge. As the business rule for the Networks related to Transfer-out- Category C reads: Patient has been discharged d from facility against his/her will 102

103 Involuntary Discharge Guidelines Facility must have and follow written policies and procedures for involuntary discharge and transfers Surveyors will review patient s individual records to ensure compliance with regulation and facility policy 103

104 Involuntary Discharge Guidelines Facility can only involuntary discharge or transfer a patient for those reasons listed in of Condition for Coverage: 1. The patient or payer no longer reimburses the facility for the ordered services 2. The facility ceases to operate 3. The transfer is necessary for the patient s welfare because the facility can no longer meet the patient s documented medical needs 104

105 Involuntary Discharge Guidelines (cont.) 4. The facility has reassessed the patient and determined that the patient s behavior is disruptive and abusive to the extent t that t the delivery of care to the patient or the ability of the facility to operate effectively is seriously impaired. There must be a written order by the attending physician and the Medical Director for the facility to involuntary discharge or transfer a patient 105

106 Guidelines: Interpretive Guidance Non-Payment of ffees There must be evidence in the patient s medical record that facility staff (e.g. billing personnel, financial counselor, social worker) made good faith efforts to help the patient t resolve nonpayment issues 106

107 Guidelines: Interpretive Guidance (cont.) Facility Ceases to Operate Governing body must notify CMS, State Survey Agency and applicable ESRD Network Facility interdisciplinary team must assist patients to obtain another facility 107

108 Guidelines: Interpretive Guidance (cont.) Discharge or Transfer for Patient s Welfare Patient s medical record must include documentation of the medical need and reasons why facility no longer meet that need 108

109 Guidelines: Interpretive Guidance (cont.) Determined that Patient s Behavior is Disruptive/Abusive Patient s should not be discharged for failure to comply pywith facility ypolicy unless the violation adversely affects clinic operation (e.g. violating facility rules for eating during dialysis should not warrent a discharge) 109

110 Guidelines: Interpretive Guidance (cont.) Patients should not be discharged for shortened or missed treatments unless behavior has a significant adverse effect on other patient s treatment Patient s should not be discharged for failure to reach facility set goals for clinical outcomes 110

111 Immediate Discharge (According to Interpretive Guidance) Defined: Immediate Severe Threat considered to be a threat or physical harm. The health and safety of other patients or staff are at risk. Ex: If a patient has a gun or a knife or is making credible threats of physical harm. (This considered an immediate severe threat ) An angry verbal outburst or verbal abuse is not considered to be an immediate severe threat. 111

112 Abbreviated Involuntary Discharge Procedure (According to Interpretive Guidance) Immediate protective actions: call 911 ask for police assistance No time or opportunity for reassessment, intervention, or contact with another facility for transfer Staff must notify the patient s physician and medical director (obtain signatures as soon as possible after the event) 112

113 Abbreviated Involuntary Discharge Procedure (cont.) (According to Interpretive Guidance) Staff must notify the State Agency and ESRD Network of the involuntary discharge (please also contact your risk management/legal department) Document the contacts made and the exact nature of the immediate severe threat Continue to follow remaining involuntary discharge guidelines (Provider may use their own abbreviated involuntary discharge procedure as long as it meets interpretive guidance) 113

114 Abbreviated Involuntary Discharge Procedure (cont.) (According to Interpretive Guidance) A 30- Day notice is not required in the case of imminent severe threat to safety of other patients or staff Goal of contacting another dialysis facility is for continuity of care, the HIPPA privacy rule does not require patient consent to contact another dialysis facility. However, does limit sharing of protected health information to medical records requested by the other provider and prohibits sharing information obtained through hear say. 114

115 Involuntary Discharge Requirements (According to the Conditions for Coverage) 1. Notify the Network of the potential IVD 2. Provide the patient with a 30- day notice planned discharge 3. Copy of medical records documented: On going problem Impact of the problem on other patients/staff, if any Steps to resolve the problem (include behavioral contracts and patient/staff meetings Patient response to each step taken and the reassessment of the situation 115

116 Involuntary Discharge Requirements (cont.) (According to the Conditions for Coverage) 4. Written physician s order signed by both medical director and patient s attending physician agreeing with the discharge 5. Send all contracts, letters of notification of discharge or other written communication with the patient to the Network 6. Contact another facility, attempt placement, and document efforts 7. Notify State Survey Agency 116

117 Involuntary Discharge Requirements (cont.) (According to the Conditions for Coverage) 8. In case of immediate severe threat to the health and safety of others, the facility may use an abbreviated procedure 9. Report the patient as an IVD (6c) in the monthly PAR (patient activity report) 117

118 C of C: Summary on IVD 1. Facility must have a 4. Attempts to find placement patient discharge/transfer for the patient and policy & procedure documents the effort 2. Medical Director has 5. Notifies the state t survey oversight to ensure appropriate reason for agency and ESRD Network discharge or transfer of the involuntary transfer or 3. Must have a written discharge physicians order that must 6. In case of immediate severe be signed by both the threats to the health and medical director and safety of others, the facility patient s attending may utilized an abbreviated physician concurring with involuntary discharge the patient s discharge or procedure transfer 118

119 Final Steps When the decision to involuntary discharge has been made, the following steps should be taken: The facility should inform their legal counsel of the decision to involuntary discharge and the reason (s) for it Notify the patient in writing. Send copies of the letter to the patient via certified mail, return receipt requested, and via regular mail, or present to the patient in person A last treatment date is set in writing. The patient must be given reasonable notice, thirty (30) days as directed by Conditions of Coverage Assure the patient t that t the facility will continue to provide treatment up to the termination date period, unless patient behavior warrants immediate discharge 119

120 Final Steps (cont.) Attempt to find placement for the patient. If patient refuses assistance provide a list of facilities for the patient to contact for placement Emphasize to the patient t importance of finding another facility and/or physician for continued care The Administrator/Medical Director should ensure that all steps taken are consistent with federal regulations, state law, and corporate/facility policy Involuntary Discharge should not be used by the facility to remove a patient who is non-adherent with diet, medication, etc. Not the responsibility of the dialysis staff to end the physician/patient relationship 120

121 Physician Terminates Relationship Physician (Nephrologist) provides a 30-day notice on his/her letter head with date of last day Documents in medical record reason for discharge Provides the patient/family a list of other nephrology groups in the area Involuntary Discharge should not be used to remove a patient who is non-adherent with diet, medication, etc. Follows the rest of the involuntary discharge requirements 121

122 CROWNWeb Implementation QIPS Forms Phase I Results Phase II Preparation 122

123 WebEx Training Overview and Agenda for QIPS/CROWNWeb Training The following schedule outlines each day s content for the three day QIPS/CROWNWeb WebEx Training Sessions. In this three day session, we will cover the following QIPS / CROWNWeb information: QIPS Workshop Did you know you still need to submit your QIPS form to get your accounts set up for CROWNWeb, even if you re not currently using CROWNWeb? This module will walk users through the process of submitting QIPS forms, and will show Security Administrators the process of setting up users in QIPS. Facility Workshop Once you re logged into CROWNWeb, what are the first things you need to do? This section covers setting up your facility in CROWNWeb so that you can start managing your patients in the system. Network 3 4/21-4/23 1:00p - 3:00p ET Day 1 - Day 2 - Day 3 Network 12 4/28-4/30 1:00p - 3:00p CT Day 1 - Day 2 - Day 3 Network 8 5/5-5/7 1:00p - 3:00p ET Day 1 - Day 2 - Day 3 Network k17 5/12-5/14 10:00a 00-12:00p PT Day 1 - Day 2 - Day 3 Network 5 5/19-5/21 1:00p - 3:00p ET Day 1 - Day 2 - Day 3 Network 15 5/26-5/28 1:00p - 3:00p MT Day 1 - Day 2 - Day 3 Network 4 6/2-6/4 1:00p - 3:00p ET Day 1 - Day 2 - Day 3 Network 14 6/9-6/11 1:00p - 3:00p CT Coming Soon... Network 2 6/16-6/18 1:00p - 3:00p ET Coming Soon... Network 13 6/23-6/25 1:00p - 3:00p CT Coming Soon... Network 1 6/30-7/2* 1:00p - 3:00p ET Coming Soon... Network 18 7/7-7/9* 10:00a - 12:00p PT Coming Soon... Network 9/10 7/14-7/16* 1:00p - 3:00p CT Coming Soon... Network 11 7/21-7/23* 1:00p - 3:00p CT Coming Soon... Network 6 7/28-7/30* 1:00p - 3:00p ET Coming Soon... Patient Admit Workshop Your facility is set up in CROWNWeb, now it s time to bring patients in. But how? This section covers the process of admitting patients and managing the entire admit/discharge process. Patient Treatment Workshop With patients in your facility in CROWNWeb, we ll now show you how to manage the treatment information for these patients, including changes in prescription and clinical data entry. Note: The QIPS Workshop is RECOMMENDED for all users. However, if you have already been through the QIPS training, submitted your QIPS forms, or otherwise do not feel that you need to attend, you can dial in only for the CROWNWeb portion of the training, which will start a half hour after each day s scheduled start time. 123

124 Communication! PHI PII 124

125 COMPLIANCE CMS-2728 CMS-2746 CMS-2744 Monthly PAR Involuntary Discharge Patient Address Facility Information Vascular Access Log Emergency Preparedness 125

126 126

127 Harriet L. Edwards, MSW/ MSG, Executive Director Svetlana (Lana) Kacherova, RN, MPH, CPHQ, QI Director Cecilia Torres-Correa, RN, BSN Patient Services Director Patrick Ciriello, MSIM, IS Director 6255 Sunset Boulevard Suite 2211 Los Angeles CA (323) (323) /Fax 127