Volume 2025 | No. 2
SURVEYOR
RENAL DIALYSIS
Compliance tips for: Nerd Newbies
SECTION 6: QUALITY OUTCOMES/PERFORMANCE IMPROVEMENT RD6-A Frequency of the citation: 22% Overview of the requirement: The facility measures, analyzes, and tracks quality indicators to assess processes of care, services, and operations. Facility-wide performance improvement efforts focus on improving health outcomes and reducing medical errors. Comment on deficiencies: Surveyors evaluate compliance by reviewing documentation, direct observation, and response to interviews. Surveyors noted that QAPI was not sufficiently comprehensive of services provided and that when measured results indicated opportunity for improvement, there was no evidence of corrective action. Examples of ACHC Surveyor findings: ■ The organization did not present a written policy and procedure for a QAPI Program. ■ The facility did not track the incidence of infections to establish baseline information and identify trends. Additionally, there was no evidence of recommendations and action plans to minimize infection transmission. The only immunization information noted in the QAPI documentation was a column labeled “influenza” which contained the number of patients who had received a vaccine. There were no action plans noted to promote immunizations nor were there any other immunizations included in the data. ■ There was no evidence of medical record audits, patient satisfaction surveys, direct observation in a care setting or interviews with patients and personnel. ■ Identified goals were not met over the last six months and action plans had not been changed in the past four month for any of the unmet goals. ٝ Adequacy goal of 98% was not met with a percentage ranging from 75% to 87%. ٝ Catheter > 90 days goal of <30% was not met with percentage ranging from 33%-58%. ٝ A goal is not included in the QAPI vascular access section for AVFs or AVGs. The AVF percentage ranged from 22%-39% and AVGs from 3%-13%. ٝ The facility’s anemia goal for at least 50% of patients to have an Hgb between 9g/dl-11g/dl, has not been met with results ranging from 40%-48%. ٝ Transplant referrals do not have an established goal, and there is no evidence that referrals have been addressed over the last six months.
The intent of a QAPI Program is continuous quality improvement. The organization begins by identifying what and how it will measure important aspects of care. These metrics provide a performance baseline. Comparing initial results to industry norms gives an external benchmark for goal-setting. Tracking performance over time reveals internal trends. Use the data to identify and guide improvement efforts. ■ Audit QAPI documentation to ensure inclusion of expected metrics on a defined schedule. ■ Establish priorities for improvement projects that impact patient outcomes and safety. ■ Communicate the start and the goal of QAPI projects across the organization. Provide updates as each corrective action and remeasurement cycle is completed. Engaging staff in continuous improvement will build it as a cultural norm for your organization.
(understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL RD7-A Frequency of the citation: 48% Overview of the requirement: Written policies and procedures are established and implemented to include accepted standards of practice to prevent the transmission of infections and communicable diseases, including the use of standard precautions. Comment on deficiencies: Compliance is evaluated based on review of policies and procedures, direct observation, response to interviews, and review of personnel files. Most citations were the result of observed infection control breaches by staff when managing supplies and equipment. Examples of ACHC Surveyor findings: ■ The facility did not present an infection control policy that addresses the surveillance, identification, prevention, control and investigation of infectious and communicable diseases. ■ The exposure control plans did not include a current prevalence rate of TB in the communities
served or the rate of TB in patients serviced by the facility. ■ Some personnel records lacked evidence of TB testing.
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