CMS SURVEY PROCESS

Presenter: Marie Rose RN, CSS

November 8, 2018
I have no disclosures to report.

DISCLOSURES
 www.cms.gov/GuidanceforLawsAndRegulations/05_dialysis.asp
www.medicare.gov/dialysis

DaVita. Survey Outcome

Supporthttps://intranet.davita.com/depts/sos/Pages/default.asp

www.medicare.gov/dialysis/

REFERENCES
Review practices in caring
for dialysis patients and
developing action plans

OBJECTIVES
 The CMS is a facility visit to ensure the dialysis facility is in compliance with
Federal and State Regulations to maintain a culture of safety for all patients in
the facility. The surveyor is also a support to the clinic to help educate the team
on expected practices to help drive clinical outcomes.

CMS SURVEY
 CMS SURVEYS

INITIAL CERTIFICATION SURVEY

RECERTIFICATION SURVEY
ADDITIONAL SERVICES SURVEY
RELOCATION/RENOVATION
COMPLAINT OR GRIEVANCE SURVEY
FOLLOW UP ON COMPLAINT SURVEY

CORE SURVEY PROCESS IS TO ENSURE SAFE PATIENT CARE

AND A SAFE ENVIRONMENT IS MAINTAINED
Facility Preparation
Entrance Interview
Flash Tour of the Facility
Observations of Care
Review of Facility Census and Outcomes
Medical Records Review
Facility Logs and PM’s
Water and Dialysate Review
Interviews: Patient/Staff/Medical Director
Personnel Record Review
Emergency Management Plan
QAPI/Governance/Decision Making
Exit Interview

FACILITY SURVEY
17 CONDITIONS FOR THE ESRD SURVEY
Basis and scope
Condition: Compliance with Federal, State, and local laws and regulations (V100)
Condition: Infection control (V110-148)
Condition: Water and dialysate quality (V175-278)
Condition: Reuse of hemodialyzers and bloodlines (V300-383)
Condition: Physical environnement (V400-420)
Condition: Patients’ rights (V450-470)
Condition: Patient assessment (V500-529)
Condition: Patient plan of care (V540-562)
Condition: Care at home (V 580-599)
Condition: Quality assessment and performance improvement (V625-640)
Condition: Special purpose renal dialysis facilities (V660-667)
Condition: Laboratory services (V675-676)
Condition: Personnel qualifications (V680-696)
Condition: Responsibilities of the medical director (V710-716)
Condition: Medical records (V725-733)
Condition: Governance (V750-773)
VTAG511: DIALYSIS ACCESS AND MAINTANCE/PATIENT
ASSESMENT
 Evaluation of dialysis access type and maintenance (for example,
arteriovenous fistulas, arteriovenous grafts and peritoneal catheters).
VTAG 550: DIALYSIS ACCESS SURVELIIANCE
 Vascular access. The interdisciplinary team must provide vascular access
monitoring and appropriate, timely referrals to achieve and sustain vascular
access.
 The hemodialysis patient must be evaluated for the appropriate vascular
access type, taking into consideration co-morbid conditions, other risk factors,
and whether the patient is a potential candidate for an arterial vascular access

CONDITIONS FOR COVERAGE VTAGS

VTAG 551:
 The patient’s vascular access must be monitored to prevent access
failure, including monitoring of the facility program for vascular access
including monitoring and surveillance for early detection of failure
 The facility must have an on-going program

REGULATION INTERPRETIVE GUIDANCE

 arteriovenous grafts and fistulae are monitored for symptoms of
stenosis
 timely referral of patients for intervention when indications of
significant stenosis are present
 Patient education should address self monitoring of the vascular access
 “Monitoring” strategies may include physical examination and For
patients with grafts and fistulas, the medical record should show
evidence of periodic monitoring and surveillance of the vascular access
for stenosis and signs of impending failure.

VTAG 551 ACCESS SURVELLIANCE

 THE
DIALYSIS FACILITY SELF IDENTIFIES
PROBLEMS
 THEY HAVE A PLAN OF CORRECTION
 THEY
HAVE AN ONGOING PROCESS TO
MONITOR

SURVEYOR EXPECTATIONS
TYPES OF CITATIONS

STANDARD LEVEL

CONDITON
LEVEL

IMMEDIATE
JEPORDY
FREQUENTLY CITED CITATIONS

INFECTION CONTROL

PATEINT ASSSESMENT

PLAN OF CARE
WHAT IS NEXT?

FACILITY RECIEVES A STATEMENT OF DEFICENCY WITH IN 10

DAYS

FACILITY SUBMITS A PLAN OF CORRECTION WITH IN 10 DAYS

CMS APPROVES THE PLAN OF CORRECTION

CMS MONITORS FACILITY THROUGH PUBLIC REPORTED DATA

DIALYSIS FACILITY REPORT

FIVE STAR RATINGS
RENAL NETWORK
THE CMS SURVEY:
 SETS STANDARDS FOR THE FACILITY
 DRIVES GOOD CLINICAL PRACTICE
 CREATES SAFE ENVIRONMENT FOR PATEINTS AND STAFF
 ADVOCATE FOR ESRD PATEINT
Questions?