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When the state surveyors arrive, as you know, the first thing they do is hold an entrance conference, outlining for you what they will need and how the survey will roll out.   The facility is asked to complete the CMS- 3427 form, which helps the surveyors assure adequacy of staffing and ownership changes.  The surveyors also provide a list of the documentation the facility needs to provide for their review.  All this is summarized in material provided by CMS in their Survey Overview.

The surveyors from at least one state are going a step further, both expanding on that documentation list and specifying delivery time frames for the documents to be reviewed.

We can use that to better prepare for surveys.  Review the list and make sure that your facility is actually capturing the required data and can get that documentation in the format specified quickly and easily.

Self-surveying pays off, not only in actual preparedness, but also in peace of mind.

What the surveyors are looking for, with time frames, follows.

ENTRANCE CONFERENCE

REFERENCE MATERIALS LIST

DEPARTMENT OF HEALTH SERVICES INSPECTION SHEET

Needed within 4 hours

• List of current patients by name, separated into modalities, with admission dates
• Current hemodialysis patient listing by shifts with any isolation patients identified (seating chart or assignment sheet)
• Aggregate list of individual patients’ lab results for Kt/V (URR), HgB, Tsat%, ferritin, albumin, CA+, phosphorous, and PTH for the previous quarter
• Infection logs for the past 6 months
• Hospitalization logs for the past 6 months
• Vascular access information by patient name and access type in use as reported to the ESRD Network
• Any pediatric patient names and ages (<18 yo)
• Residents of Long Term Care facilities
• Any involuntary discharges since last survey

Needed within 24 hours

• Patient care staff schedule/timesheet for the current time period (last 2 weeks at a minimum)
• Policy and procedure manuals for patient care, water treatment, dialysate preparation and delivery, infection control, dialyzer reuse if applicable
• Facility identified target/threshold values for Kt/V (URR), HgB, Tsat%,  ferritin, albumin, CA+, phosphorous, PTH
• Facility specific fire/emergency and disaster preparedness plans and a log of drills conducted
• Patient grievance log for the past 12 months
• Adverse Occurrence documentation for the past 12 months
• List of Governing Body members and minutes of meetings for the past 12 months
• QAPI committee meeting minutes for the past 12 months and any supporting materials
• Any written agreements for services, e.g. Hospital Transfer Agreement, Laboratory, Infectious Waste Disposal, Skilled Nursing Facilities, Centralized Reuse Center, and any consultants (MSW, RD, etc.) used
• Documentation of the hemodialysis patient care technician program content and the plan for certification of the PCTs
• Copy of patients’ rights information provided to patients
• PD policies and procedures
• MD files

Additional Required

• Official tracking system for tracking transplant status, including referrals, names of those in the evaluation process and those who are listed
• List of patients who are in nursing homes
• Copies of transfer sheets being sent to nursing homes (can be maintained in a binder) that becomes part of the medical record.

Here’s another idea for survey readiness.  It makes sense to identify in writing where required material is kept and/or how it can be retrieved just in case the surveyors arrive during the one week of the year that you are on vacation in some isolated spot with no cell phone service or internet connection.

Dialysis Lines

CROWNWeb: Early news from the facilities selected to participate in the non-batched data entry is not good – complex, time consuming, labor intensive…all the things we feared.  Add to that the first hints that the government’s financial crunch may have an impact on the government’s ability to fully implement CROWNWeb and…stay tuned.  Somehow, I know you will.  In the meantime, if you haven’t already, you need to sign up for your CROWNWeb account.  The sign-up form is here.  As with most things federal, getting authorized access takes time and you want to avoid the last minute sign up delays.

Lufkin Nurse Indicted for Murder: Everyone in the dialysis world has no doubt heard or read about the licensed vocational nurse in Lufkin, Texas, who was allegedly injecting bleach into dialysis patient lines.  Her attorney claims she is being made a scapegoat.  Once the shock and sensationalism have died down and more of the facts are known, we’ll take a closer look at what, if anything, dialysis administration might have done to avoid this disaster.

Shameless Plug

This is tax season, so we’ve been busily getting taxes out for financial clients.  We also launched Dialysis Turn Over, a newsletter for our dialysis administration clients.  Unfortunately, there’s never a dearth of news in the field of healthcare.  You can sign up for our newsletters by clicking here.

We also took a break and went up to Valley of Fire to restore mental stability before the final pre-April 15th push, were impressed by the abundance of petroglyphs, and re-discovered hiking muscles we’d forgotten we had (ouch!).

Public Service Announcement:  Due to the recent economic crisis, stock market crash, budget cuts, and the rising cost of everything, including taxes, The Light At The End Of The Tunnel has been turned off.  Sorry for the inconvenience.

By the way, we also have self-survey training guide, Find & Fix.
Click here to learn more.

The opinions expressed herein are those of the author alone
and should not be considered accounting or legal advice, or state or federal regulation.

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