Volume 2025 | No. 2
SURVEYOR
RENAL DIALYSIS
Compliance tips for:
SECTION 5: PROVISION OF CARE AND RECORD MANAGEMENT RD5-G Frequency of the citation: 48% Overview of the requirement: Within a defined time frame, an interdisciplinary team prepares a comprehensive assessment of each patient admitted for dialysis. Written policies and procedures include the required components of each initial and subsequent assessment to ensure the adequacy of the dialysis prescription. Comment on deficiencies: Evaluation of compliance comes from reviewing policies and procedures, reviewing patient records, and responses to interviews. Surveyors noted a range of deficiencies related to required elements of the comprehensive assessment that were not included. Failure to act on monthly data for unstable patients was also an issue. Examples of ACHC Surveyor findings: ■ Patient records did not include evidence of a physician evaluation of health status or history and physical in the comprehensive assessment. All patient visits with the physician were confirmed to be conducted via telehealth, and there was no evidence of an initial physical assessment and review of systems conducted. ■ Comprehensive assessments did not include history of standard immunizations (pneumococcal, influenza, TB screening). ■ Organization policy requires monthly evaluation of nutritional status by the dietitian. This documentation was missing in some client records. ■ Comprehensive reassessments for stable patients, due at least annually, and conducted by the IDT were noted to be incomplete. MD and RN sections were completed on time, however the MSW did not complete the psychosocial portion until eight months later and the registered dietitian assessment was not completed. ■ There was no evidence that the facility revised the plan of care at least monthly for unstable patients. Patients with documentation of ongoing unmanaged anemia/frequent hospitalizations were not identified as unstable and assessed monthly as required. ■ For a patient hospitalized in December for a GI bleed, the nursing sections of monthly assessments in January and February did not address the hospitalization. Additionally, weekly Hgb results were not within acceptable range throughout January with ESA dosing on hold and no reason noted for the hold. ■ On reassessment, an RN documented the day of the IDT round, however the nursing portion of the assessment was blank in relation to lab work, goals, and head to toe assessment of the client.
■ Initial assessments must include all required elements and be performed within 30 days or 13 treatments by the interdisciplinary team that includes, at least, a physician, a registered nurse, a social worker, and a dietitian. ■ Comprehensive reassessment of unstable patients is conducted monthly, at minimum. ■ Comprehensive reassessment of stable patients is conducted annually, at minimum. ■ Create templates for patient assessments to ensure each required element is addressed in every patient record. ■ Audit patient records for inclusion of complete assessments. ■ Reeducate staff as needed to ensure full documentation is completed. ■ Communicate monthly assessment data for unstable patients to the interdisciplinary team for revisions in the plan of care.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
RD5-J Frequency of the citation: 52%
Overview of the requirement: The comprehensive assessment drives an individualized plan of care developed by the interdisciplinary team and implemented within 30 days of admission or 13 outpatient hemodialysis treatments. Minimum requirements for the plan of care are detailed in the standard. Dialysis patients are seen by a physician, nurse practitioner, clinical nurse specialist or physician assistant providing ESRD care at least monthly. Comment on deficiencies: Evaluation of compliance comes from reviewing policies and procedures, reviewing client/patient records, and responses to interviews. This standard includes many elements, each of which is required for compliance. Surveyor citations can be summarized as noting that monthly, interdisciplinary plan of care review and revision was insufficient. Examples of ACHC Surveyor findings: ■ Monthly progress notes were missing from patient records. ■ Home dialysis patient records did not include evidence of training for administration and refrigerated storage of erythropoiesis-stimulating agents. ■ Initial plans of care did not have signatures of all members of the interdisciplinary team as evidence of review.
achc.org | (855) 937-2242 | 7
6
Made with FlippingBook. PDF to flipbook with ease