This week on the CMSCG Blog, we are wrapping up our review of F698 Dialysis. We will close out this “Ftag of the Week” with Mary Quinn, CMSCG Clinical Consultant, sharing some helpful information you need to know to provide compliant care and services related to dialysis.
First, let’s look at communication. There are many different people who need to be “in the loop” when it comes to dialysis – including staff at both the nursing home and dialysis facility, the physician, the resident and the resident representative.
Communication regarding Dialysis
As mentioned in prior posts for F698, the care of a resident on dialysis needs to reflect ongoing communication, coordination and collaboration between the nursing home and the dialysis center. While there is no requirement that spells out how communication will occur, the resident’s medical record must include evidence of this communication and responses.
Many facilities use communication books that consistently “travel” with the resident to and from his/her scheduled treatments. Here are two things to remember:
- Ongoing review of the content of the communication book (including by medical staff) should be conducted on a routine basis. The nephrologist may be sending a recommendation for a change to the plan of care.
- Any documentation/communication needs to be consistently entered and monitored – what can go wrong will go wrong – everything from the book being misplaced to omissions or the book remaining in the possession of the resident with no review.
Communication between the dialysis facilities and the SNF should include:
- Timely medication administration (initiated, administered, held or discontinued) by the nursing home and/or dialysis facility.
- Treatment orders, laboratory values, and vital signs.
- Advance Directives and code status; specific directives about treatment choices.
- Comprehensive nutritional/fluid management – including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered.
- Dialysis treatment provided and resident’s response, including declines in functional status, falls, the identification of symptoms such as anxiety, depression, confusion, and/or behavioral symptoms that interfere with treatments.
- Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site/PD catheter.
- Changes and/or decline in condition unrelated to dialysis. This would include communication related to care concerns such as a resident who is at risk for or who has a pressure ulcer, receiving appropriate interventions; and
- The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility.
If that list seems like a lot, that’s because it is – so ensure this information is being shared between the two providers routinely.
Another area where communication can be a problem is related to notification of changes in condition. Let’s look at the regulatory requirement.
Notification of Change in Condition
Nursing facility staff must immediately contact and communicate with the resident/ representative, attending physician, and designated dialysis staff (i.e., RN or nephrologist) regarding any significant changes to the resident’s status. Changes related to clinical complications and emergent situations that may impact the dialysis portion of the resident’s care plan need to be communicated, including:
- Change in cognition
- Sudden unexpected decline in condition
- Complications related to dialysis (i.e., bleeding, hypotension, adverse consequence to a therapy or med)
It should also be noted that any changes to the resident’ plan of care that are initiated by the dialysis provider must be communicated to the resident’s physician at the nursing home.
Speaking of care plans, let’s review some of the documentation and care planning areas that are prone for error – and some tips to avoid them.
Documentation and Care Planning
Facilities are being cited for not addressing dialysis on the Baseline Care Plan. If the CCP is not developed within 48 hours of admission, the Baseline CP needs to minimally include all healthcare information needed to provide care for the resident – including dialysis services.
Nursing facility staff must provide immediate monitoring and documentation of the status of the resident’s access site(s) upon his/her return from dialysis to observe for bleeding or other complications. Many facilities successfully utilize template pre-/post- dialysis notes which capture departure and return times, as well as information like access site assessment pre- and post- treatment, vital signs and weights.
When it comes to care planning, the resident’s individualized care plan needs to include many specifics about the resident, including:
For HD:
- Which arm is to be used to monitor blood pressure
- Monitoring of risk factors and emergency treatment
- Assessment and care of the access site – including the use of PPE, as indicated.
It is recommended that assessment of the access site is completed every shift. Some facilities only capture assessment of the access site on dialysis days.
For PD:
- Number of exchanges or cycles to be done during the dialysis session
- Volume of fluid for each exchange
- Duration of fluid in the peritoneal cavity
- Concentration of glucose/other osmotic agent to be used for fluid removal
- Which technique will be used – automated, manual or a combination of techniques
- Target pre- and post- dialysis weights
- Vital signs
- Other monitoring needed during the provision of dialysis treatment
Competencies/Training
The final area that we need to discuss related to F698 is competencies and training. As you can see from these posts, there is a lot of complexity to dialysis care – whether it’s the actual treatment, the monitoring, the communication or something else – so staff need to be competent to provide this type of care.
- Nursing home staff who have been trained to provide dialysis treatment must be trained to use the dialysis equipment and know how to identify if there are issues in order to ensure safe treatments.
- Staff must know dialysis-specific infection control policies, including, transmission-based precautions, placement/location, appropriate PPE use, handling/using/ disposing of equipment, supplies, medications or other products used. This includes proper disposal of needles, blood tubing, dialyzer and other equipment to minimize infection risk or injury to themselves or others.
- All clinical staff involved in the care of residents receiving dialysis should have current competencies completed/ on file.
What goes wrong? Competencies are not current or completed. Or, staff competency related to documentation/ assessment is not evident. This could be staff assessment/ documentation that is inconsistent with the type of access devices, for example, where it is documented bruit thrill present, but the resident has a Tesio catheter.
- If a resident/representative is permitted to participate in the dialysis treatment, it is recommended that an order be present. The resident’s care plan should address training and ongoing assessment of the continued ability to perform the task using appropriate infection control practices. Just because a resident or family member has been performing the task previously does not mean that they are using the appropriate technique.
One other thing to note. In Appendix PP, it clearly states that even if a nursing home employee has been trained by a qualified trainer from a dialysis facility, the nursing home employee cannot train another nursing home employee to perform dialysis services. Each employee must receive the appropriate training from the dialysis center and the nursing home must maintain documentation of this training for each employee.
About CMS Compliance Group, Inc.
CMS Compliance Group, Inc. is a regulatory compliance and quality improvement consulting firm with extensive experience servicing post-acute and long term care facilities and agencies. With the idea of continuous quality improvement in mind, CMS Compliance Group’s interdisciplinary team provides a unique approach to client service, ensuring that all departments can achieve and maintain compliance while improving quality of care. Our consultants provide proactive and reactionary compliance consulting services to clients across the country and have an established reputation for rapidly addressing and successfully resolving the most serious issues that occur in nursing homes, assisted living facilities, home health agencies and other post-acute providers. Visit our Services Overview to learn more about our consulting services for skilled nursing facilities or contact us to learn how we can work together.
