Volume 2024 | No. 2
SURVEYOR
RENAL DIALYSIS
SECTION 6: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT RD6-A Overview of the requirement:
The facility must develop, implement, maintain, and evaluate an effective, data- driven, QAPI program that reflects the complexity and scope of the services provided and demonstrates participation by the professional members of the interdisciplinary team. Surveyors evaluate compliance through review of policies and procedures and the QAPI plan, observation and response to interviews. Surveyors cited missing evidence of corrective actions.
Comment on deficiencies:
Frequency of citation:
32%
Examples of surveyor findings:
n The facility did not show evidence of continuous performance monitoring. Outcomes reported were not producing positive results and there was no evidence of corrective action to promote improvement for: nutritional status, mineral metabolism, renal bone disease, anemia management, vascular access or hospitalization rate. n The facility did not show evidence of priorities set for performance improvement based on prevalence and severity of identified problems. The QAPI minutes provided for two quarters and included no improvement activities related to clinical outcomes or patient safety. n The QAPI Program did not include a measure to address medical injuries and errors. n The QAPI Program states that the facility will analyze and document the incidence of infections, identify trends and establish baseline information on infection incidents. The documentation noted an action plan to promote immunization to reduce further incidents. There was no immunization data included in subsequent documentation. Identifying opportunities and taking action toward improvement is the essence of the QAPI Program. Initial measurement establishes baseline performance, then specific actions must be taken, and remeasurement used to assess improvement over time. n Identify items to be measured, based on the standard and the services provided. n Set priorities for improvement and take one corrective action at a time. Simultaneous changes make it hard to identify what drove improvement.
RD5-L Overview of the requirement:
For organizations that support home dialysis patients, the services must be equivalent to those provided in-center. Note: This standard is only applicable to home dialysis services. Compliance is evaluated by review of contracts and patient records, direct observation of home visits, response to interviews. Most prominent in Surveyor finds was a lack of documentation for quarterly bacteriological and endotoxin testing in patient homes.
Comment on deficiencies:
Frequency of citation:
24%
Examples of surveyor findings:
n Missing documentation that a nurse made a home visit prior to the patient’s first treatment per organization policy. n Quarterly evaluation and testing to ensure water and dialysate quality meets AAMI quality limits was not documented. n The plan of care was not completed by all members of the interdisciplinary team. n Ensure equivalence between home-based and in-center services. n Create checklists for scheduled activities to be performed during home visits. n Audit files for compliance.
Tips for compliance:
Tips for compliance:
achc.org | (855) 937-2242 | 11
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