ESRD Survey Training ESRD Core Survey Field Manual

Version 1.9

The new Core Survey Process changes the approach to ensuring safe care for Medicare beneficiaries.One of the most important messages for me was the need for all dialysis providers to develop and maintain a culture of safety that allows for open and honest communication between patients and facility staff as well as among the facility staff. Nephrology Nurse

I love the Core!!! It really keeps us focused on the most important things." ESRD Surveyor

"I think the Core Survey is great. It really streamlines the survey process yet picks up areas of concern." ESRD Surveyor

I think the way the surveyors are focusing on outliers, allowing everyone to see the interface between QAPI and Interdisciplinary Care is very instructive and useful. I can see how post survey we will focus on ways to make the tie between care planning and QAPI even closer. Medical Director

The new core ESRD survey stresses the importance of hearing the patient voice, and making sure the patient's perspective is evident when assessing the operations of each dialysis facilitywhat patients need, what we worry about, what makes our lives better relative to our dialysis treatments. The way the Core Survey is being administered encourages partnering with our care providers to identify and address concerns, so we can be vigilant together and continually improve the quality of care for everyone. Dialysis Patient

"I feel the new CORE survey process has created improved feelings that both providers and surveyors are working to improve patient care as well as keep patients safe and in a Culture of Safety." ESRD Surveyor

Revision History

Revision Effective Date Author Description of Change 1.6 04/30/2014 Helen Blakey This document had internal changes previously recorded

by the ESRD team and so identified with this version number. This table is for the purpose of recording future changes. This version is being released for the class offering beginning June 23, 2014.

1.7 10/22/2014 Darin Tambascio Multiple changes to the internal documents and cover were made.

1.8 09/29/2015 Darin Tambascio Multiple changes to the internal documents and cover were made.

1.9 09/29/2016 Darin Tambascio The following documents were updated for this version: ESRD Core Survey Process 1.6 Outline ESRD Core Survey Process 1.5 ESRD Core Survey Triggers 1.7 FY2017 ESRD Core Survey Data Worksheet 1.7 MAT 2.5 ESRD Core Survey Medical Record Review ICHD 1.5 ESRD Core Survey Medical Record Review PD 1.3 ESRD Core Survey Medical Record Review HHD 1.4 ESRD Core Survey QAPI Review Worksheet 1.5

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Disclaimer Web citations are accurate at the time of writing but may be subject to change.

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Centers for Medicare & Medicaid Services

ESRD Core Survey Field Manual Tab

ESRD Core Survey Process .......................................................................................................................... 1

ESRD Core Survey Laminates ...................................................................................................................... 2 a) Outline of ESRD Core Survey Processb) ESRD Core Survey Triggersc) ESRD Facilities V-Tags & Identifiersd) Measures Assessment Toole) Infection Control/Requirements for Isolation Room/Areaf) Critical Water and Dialysate Requirements/Water System Flow Diagramg) Personnel Requirements/National Commercial Dialysis Technician Certification Organizations

Presurvey Preparation & Introductions ......................................................................................................... 3 a) FY2016 ESRD Core Survey Data Worksheetb) CMS 3427 (05/2013)c) ESRD Core Survey Facility Worksheet: Personnel Filed) Presurvey Preparation Postere) Introductions Poster

Environmental "Flash" Tour ......................................................................................................................... 4 a) Signage: Routine Federal Survey in Progressb) Environmental Flash Tour Poster

Entrance Conference ..................................................................................................................................... 5 a) ESRD Core SurveyEntrance Conference Questionsb) Entrance Conference Poster

Observations of Hemodialysis Care and Infection Control Practices ........................................................... 6 a) ESRD Core SurveyObservations of Hemodialysis Care and Infection Control Practicesb) Observations of Hemodialysis Care and Infection Control Practices Poster

Patient Sample Selection ............................................................................................................................... 7 a) ESRD Core Survey Worksheet: Patient Rosterb) Patient Sample Selection Poster

Water Treatment and Dialysate Review ....................................................................................................... 8 a) ESRD Core Survey WorksheetWater Treatment and Dialysate Review Observation &

Interviewb) Water Treatment and Dialysate Review Poster

Dialyzer Reprocessing/Reuse Review .......................................................................................................... 9 a) ESRD Core Survey WorksheetReuse: Observation/Interview/Reviewb) Dialyzer Reprocessing/Reuse Review Poster

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Centers for Medicare & Medicaid Services

Dialysis Equipment Maintenance Review .................................................................................................. 10 a) ESRD Core Survey Interview/Review WorksheetMachine/Equipment/Maintenance Technicianb) Dialysis Equipment Maintenance Review Poster

Home Dialysis Training and Support Review ............................................................................................ 11 a) ESRD Core Survey Interview Worksheet: PD Training Nurseb) ESRD Core Survey Interview Worksheet: Home Hemodialysis Training Nursec) Home Dialysis Training and Support Review Poster

Patient Interviews ........................................................................................................................................ 12 a) ESRD Core Survey Interview Worksheet: In-Center Hemodialysis Patientb) ESRD Core Survey Interview Worksheet: Peritoneal Dialysis Patientc) ESRD Core Survey Interview Worksheet: Home Hemodialysis Patientd) Patient Interviews Poster

Medical Record Review .............................................................................................................................. 13 a) ESRD Core Survey Medical Record Review-In-Center Hemodialysis (ICHD)b) ESRD Core Survey Medical Record Review-Peritoneal Dialysis (PD)c) ESRD Core Survey Medical Record Review-Home Hemodialysis (HHD)d) Medical Record Review Poster

Personnel Interviews ................................................................................................................................... 14 a) ESRD Core Survey Interview Worksheet: Medical Directorb) ESRD Core Survey Interview Worksheet: Nursec) ESRD Core Survey Interview Worksheet: Patient Care Techniciand) ESRD Core Survey Interview Worksheet: Dietitiane) ESRD Core Survey Interview Worksheet: Social Workerf) ESRD Core Survey Interview Worksheet: CEO/Administratorg) ESRD Core Survey Interview Worksheet: Other Medical Staffh) ESRD Core Survey Interview Worksheet: Orienteei) Personnel Interviews Poster

Personnel Record Review ........................................................................................................................... 15 a) ESRD Core Survey: Surveyor Worksheet for Personnel Record Reviewb) Personnel Record Review Poster

Quality Assessment and Performance Improvement Review ..................................................................... 16 a) ESRD Core Survey: QAPI Review Worksheetb) Quality Assessment and Performance Improvement Review Poster

Decision Making & Exit Conference .......................................................................................................... 17 a) Decision Making & Exit Conference Poster

Acronyms and Abbreviations ..................................................................................................................... 18 a) Acronyms and Abbreviations

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ESRD Core Survey Field Manual

Tab 1: ESRD Core

Survey Process

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Centers for Medicare & Medicaid Services ESRD Core Survey Version 1.6 Page 1 of 27

ESRD Core Survey Process

Purposes: The ESRD Core Survey process is intended to efficiently utilize survey resources to identify deficient facility practices which most impact patient safety and clinical outcomes. The Core Survey focuses on clinical areas where performance improvement is indicated at the individual facility based on facility-specific data and information. Facility-based survey: The ESRD Core Survey process is intended to assess if the individual dialysis facility (i.e., single Medicare certification number) and the on-site staff who routine