As we mentioned in Part 1 of our CMSCG “Ftag of the Week” for F698 Dialysis, there are a lot of moving parts related to dialysis, so there are also a lot of requirements for associated policies and procedures. In this post, we will review what’s required for dialysis-specific policies/procedures. The nursing home must include its medical director and the dialysis facility in the developing its P&P, as well as ensure the policies are based on current standards of practice.
The Interpretive Guidance (IG) in Appendix PP notes that there are difference State licensure rules and/or limits to staff scope of practice that also should be considered when developing resident care policies and staffing. There are also some States that may have regulatory requirements specific to the provision of dialysis in the facility, so it is important to ensure any policies and procedures also consider those regulations/ limitations in addition to what will be discussed below.
Policy and Procedures
Staffing and Training
- Identify all staff (i.e., RN/ LPN/nurse aide/trained technician) who are allowed to provide HHD/PD and what training is required.
- The IG states that staff can provide dialysis treatments if it is not in conflict with a state’s scope of practice and they have been trained by a qualified dialysis trainer from a certified facility for the individual resident who is receiving services.
- Documentation of training and competency requirements for staff providing treatments.
- If a facility permits a resident, family member or other person to provide these treatments, there must be documentation that the person doing the treatments has been trained and had a competency provided by the certified dialysis facility.
- Procedures for the initiation, administration and discontinuation of HHD/PD treatments
- Type of monitoring required before, during and after the treatments, including documentation requirements. This is a problematic area for a lot of facilities that results in survey citations.
- Procedures for methods of communication between the nursing home and the dialysis facility including how it will occur, with whom, and where the communication and responses will be documented. This is also a commonly identified issue on survey.
Standard Survey Citation – F698 S/S: E
A facility was cited at F698 for failure to consistently complete ongoing records of communication between the facility for two residents receiving dialysis and failure to ensure a physician’s order was in place for one resident. For one resident, the dialysis center did not provide a communication form and thus the communications book was not completed. That resident also lacked physician’s orders for dialysis that included the days/ times of treatments even though the resident had been going to dialysis for nearly ten years. For another resident, the communication book was left at the facility and only one attempt to have the book sent back to the facility was made. The form the facility was using did not have a place to identify who was filling out the form and did not have space for the dialysis center to complete or document any changes or recommendations.
Plan of Care
- Development and implementation of a coordinated CCP that identifies both the nursing home’s and the dialysis center’s responsibilities and provides direction for nursing home staff. Ensure staff know who is responsible for what and that appropriate instructions for care, monitoring, etc. are provided by the dialysis center to nursing home staff.
- Development and implementation of interventions, based upon current standards of practice. Interventions should include documentation and monitoring of complications, pre-and post-dialysis weights, access sites, nutrition and hydration, lab tests, vital signs including blood pressure and medications. This is something CMSCG staff routinely identify on mock surveys. There needs to be consistent documentation pre- and post- dialysis treatments without omissions.
- How dialysis emergencies will be managed, including procedures for medical complications and the necessary equipment and supplies to address an emergency.
- How medications will be administered on treatment days.
- Procedures for monitoring and documenting the resident’s nutrition/hydration needs, including the provision of meals on days that dialysis treatments are provided. This is also an area that needs attention – especially when it comes to fluid restrictions being adhered to.
- Assessing, observing and documenting care of access sites, as applicable. Appendix PP includes a long list of considerations for areas such as skin integrity, bruising/hematoma and/or evidence of infection.
Standard Survey Citation – F698 S/S: D
A facility did not ensure that a resident who required dialysis received services consistent with professional standards of practice when it failed to document the resident’s care needs and provide evidence of on-going monitoring of access sites. There was no care plan developed to include the location of the access sites, to monitor for potential complications, or that a pressure dressing should be removed post-treatment. There was also a lack of associated physician’s orders for the resident’s permacath site that was present on admission.
- Safe and sanitary care and storage of dialysis equipment and supplies.
- Staff responsibility for reporting adverse events, including who to report the event to, how the event will be investigated and how identified problems will be corrected.
- Response and management of technical problems related to dialysis treatments, such as a power outage. The IG notes that for PD, P&P should include how to recognize impaired flow and drainage or failure of the PD cycler. If the HHD machine fails, the P&P should include what to do for clotting on the hemodialysis circuit, dialyzer blood leak and/ or line disconnection. Staff should also understand how and when to stop dialysis and when to seek help if there are significant issues that arise.
Since we are talking about adverse events and emergencies, this is a good spot to remind readers about the requirements for notification of change in condition. Staff are expected to immediately contact and communicate with the attending physician, the resident/representative, and designated dialysis staff if there are any significant changes to the resident’s clinical status.
Staff are expected to immediately contact and communicate with the attending physician, the resident/representative, and designated dialysis staff if there are any significant changes to the resident’s clinical status. Ensure staff are aware of this responsibility.
This includes clinical complications or emergent situations that could impact the dialysis plan of care, such as change in cognition, sudden, unexpected decline in condition and dialysis-related complications (i.e., bleeding, hypotension or adverse reaction to medication or other therapy). Don’t forget – any changes made to the resident’s care that are initiated by the dialysis provider must be communicated to the resident’s nursing home attending physician.
In our next post, we will review some of the areas outlined above, including meal/fluid restrictions, communication and orders.