Volume 2024 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
Overall, standards from Section 7: Risk Management: Infection and Safety Control dominated the list of challenges. New compared to 2021 are RD7-B , RD7-J , and RD7-T . A range of infection prevention risks were noted by ACHC Surveyors, many related to the environment of care in which clean and contaminated equipment and supplies were not adequately separated to avoid cross-contaminations. Safety risks related to emergency preparedness were also noted. While most organizations did have emergency plans, in many cases staff was inadequately trained to maintain consistent readiness. Expired supplies or inaccessible equipment were prevalent among Surveyor findings. An Additional Offering for Providers I also wanted to bring attention to Long-Term Care Dialysis Certification that launched this year to address the growing number of providers offering dialysis within LTC/SNF facilities. Achieving this certification as an addition to accreditation, demonstrates an elevated standard of care for patients in these settings, highlighting an organization’s commitment to go above and beyond the federal requirements. Please reach out for more information.
ACHC has offered a CMS-approved program for Renal Dialysis Accreditation since 2019. Our program offers standards for in-center dialysis and for home dialysis training and support. For surveys included in the period from June 1, 2023 to May 31, 2024, the average number of standards noted as not compliant was six, although for some standards, multiple required elements may have been missed. Each deficiency noted must be corrected for an organization to receive accreditation. The Findings In 2021, there were seven standards cited on more than 20% of surveys. In 2024, a similar cohort of organizations was surveyed and all seven of these standards continue to be challenging for consistent compliance. I’m happy to report that five ( RD2-E, RD5-G, RD5-J, RD7-A, RD7-C ) were cited on fewer surveys in this cycle. Two others ( RD7-E, RD7-R ) appeared at a slightly elevated frequency compared to three years ago. Joining these seven are six additional standards that crossed the 20% frequency threshold. Standard RD4-M focuses on the accountability of the medical director. This individual is the liaison between those providing care and the governing body and as such, responsible for ensuring alignment of patient care with policy and procedure. The intent of standard RD5-L is to ensure equivalent quality of service between in-center and home-based dialysis. Surveyors noted missing documentation for home visit tasks. Standard RD6-A is the standard that drives continuous quality improvement for dialysis providers. It is essential that when performance monitoring data show opportunity for improvement, corrective action is taken. Documentation of the action and remeasurement provide evidence of its effectiveness.
RENAL DIALYSIS ACCREDITATION
In-Center Dialysis Home Dialysis Support Services
Distinction
Certification
Telehealth
Long-Term Care Dialysis
FREQUENT DEFICIENCIES FROM RENAL DIALYSIS SURVEYS
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% RD2-E RD4-M RD5-G RD5-J RD5-L RD6-A RD7-A RD7-B RD7-C RD7-E RD7-J RD7-R RD7-T
Teresa Hoosier Associate Program Director
Program/Service Operations
Provision of Care and Record Management
Risk Management: Infection and Safety Control
Human Resources Management
Quality Outcomes/ Performance Improvement
achc.org | (855) 937-2242 | 5
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