Colorado Dialysis Technician Training hearing February 1st

Discussions for Patients, Family, and Friends HD For Patients
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[QUOTE=Beth Witten MSW ACSW;13803]At this point, Medicare funding only allows a surveyor to walk through the door of a dialysis clinic on average once every 3 years unless there is a complaint or unless a survey is triggered by the State Agency because the facility is performing poorly on certain outcomes that Medicare is looking at. I believe there are regulations that require surveys of other types of healthcare settings like home health agencies and nursing homes annually. There are many complaints about nursing homes and home health agencies and that’s why they need to be surveyed as often as they are. I don’t believe that there is any federal regulation that requires states to survey dialysis facilities more often.

If you believe it would improve quality of care for dialysis patients to have dialysis facilities surveyed more often, there are a couple of ways I’ve heard of to advocate for this:
– Contact your federal elected officials and ask for regulation requiring that dialysis facilities be surveyed annually and increased funding in CMS (Medicare) specifically allocated for surveys of dialysis facilities. If the funds are not allocated for dialysis, State Agencies may end up using the funds to survey other health settings if there are complaints about problems in those areas.
– Contact your state elected officials and advocate for state legislation that would require licensing of dialysis facilities that would require that each facility pay a fee to the state that would be used to assure that quality care is being provided to renew the license.

Some people don’t like regulations and government oversight, but I believe if you’re doing a good job, having government oversight won’t be a problem for you.[/QUOTE]

Not only do dialysis facilities need to be surveyed much more often- the surveyors need to do an honest job with no slack given to regulation breakers. Any ideas for what to do when the surveyors are soft on uinits? Who monitors the surveryors??? Also, when it comes to contacting state legislators, this is no easy task as plugger’s story well illustrates. It takes someone who is not on dialysis who has the health and tenacity to pursue them. I believe every state needs a task force made up of dialysis patients and their non-dialysis family members/friends/commumity leaders who can stand in the gap for patients who are in too much of a weakened condition to fight for themselves.

And how would facilites paying a fee to the state assure that quality care is being provided to renew the license?

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[QUOTE=Dori Schatell;13806]Okay, that helps me at least. :smiley: Nursing homes (which are often inspected by the same folks who do dialysis centers) are required to be inspected every year. There are not enough surveyors to go around, at the moment, to survey dialysis centers every year, too, so as you point out, it would take a pretty concerted advocacy effort to get CMS to devote additional resources to this area and/or to obtain legislation to require annual inspections of dialysis centers. Of course, we’re all about home on this site, and CMS inspections are less relevant there.

Beth and I have both had some opportunities to help ensure that the CMS surveyors are exposed to self-management philosophy, home dialysis, and educational resources that they can share with staff in the centers they inspect (who may not have the chance to attend national meetings and find out about these things). It’s always a shock to find out how few people know about resources that we tell folks about every day.[/QUOTE]

Well as I stated earlier, it is essential to find a way to get surveyors to get tough on violators. From what I have heard, they take their jobs seriously in some regions, but in other areas are slack/corrupt even knowing the dialysis personel on a first name basis and calling ahead to pre-warn of a survey, thus giving them time to clean up their act and avoid any penalties. If I managed my home the way some of these surveyors do surveys, I’d have complete chaos! And eventhough CMS inspections are less relevant in regard to home patients, what the unit does and how it is handled affects home patients, too.

Glad you and Beth have educated surveyors and I note the same thing- few dialysis staff are up on current education and best modalities. Most are light years behind in their thinking and practice.

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Finished reading the Sunrise Report ( about 40 pages) and I was absolutely appalled at what I read! It was the same old song and dance that we patients and honest staff know oh so well. Nothing but a biased, arrogant pack of lies!!! And the worst part of all is the way the author of the report turns things completely around making it look like patients have exzaggerated the many problems due to the incomplete training/ed of techs. First he/she says that patients said they were arfaid to file grievances due to possible retribution/retaliation, and then he/she spins it around and says there must not be a need for tech certification based on the very low number of complaints. What kind of locgic is that??? Is it any wonder patients/honest staff are totally reluctant to file grievances?! Well it looks like the CO legislators didn’t buy the spin as they voted tech certification in!!!

Plugger, I am so glad you shared this story with us of what you and your group there had to go through to get tech certification in Colorado. Interesting that the report stated that it is CMS that is opposed to mandating national standards and criteria for the certification of hemodialysis technicians. I will be most interested to read your follow up, because every state must get certification, and to do so, we must see what those in other states did to accomplish it.

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[QUOTE=Jane;13801]Oh my goodness…actually, my first question to Plugger was- “WHO” wrote this report and where did he/she get their information??? Describing ordinary dialysis techs and some nurses as “highly trained (Manager) experts in their individual areas of dialysis care and treatment” is highly misleading.
[/QUOTE]

An investigator from the Colorado Department of Regulatory Agencies wrote the report. “Mary” talked to him at great length and got the feeling his heart may not have been in writing this report, but he claims he had to write a report his boss would sign-off on. The boss was a political appointee the former governor made; the former governor was very against the government getting involved in this sort of thing - even when a vulnerable population is being taken advantage of. Fortunately Governor Owens and his appointee are gone.

Sometimes it feels like fighting the tobacco industry - only there is even less choice to partake or not.

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I’ve added a part 2 to my Colorado Tech bill story that contains an introduction I sent to many of the legislators around here – I thought it got a pretty good response. It is more in-depth than the fact sheet I posted in part 1 and has stats, a government report, an email, arguments, etc… I tried to give an overview of the industry and thought I would post it for anybody interested. I remember there was one legislator at one of the hearings ask “where is the fire?”. I think this might help show things are a little toasty!

Again, my topic is at:
Patient Rights Advocacy:
http://www.patientrightsadvocacy.org/index.php

My topic is in the Healthcare Forum, under “Dialysis Company” heading, and the “Colorado Tech bill story part 2” topic.

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All dialysis facilities must be certified by Medicare to bill for Medicare patients. However, most dialysis facilities are not licensed by the state because most states don’t require licensure of dialysis facilities. Where there is state licensure, there may be requirements that surveys are done more often and the fees go to support that. As you can imagine, when a clinic is surveyed once every 3 years on average, a lot can happen from survey to survey that could jeopardize patient health and safety as well as the overall quality of patient care and satisfaction with care.

For profit businesses, even in healthcare, are required by law to maximize the profits for their stockholders. At times maximizing profits runs counter to the goal of providing the best possible care so having oversight is important to make sure there is a balance.

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>>> PostPosted: Fri Jun 15, 2007 7:51 pm Post subject:
9. STATE INSPECTIONS

MEDICARE — 11/18/03
Quality of care: An issue for ESRD facilities

A large number of the approximately 4000 end-stage renal disease (ESRD) dialysis facilities do not achieve the minimum patient outcomes specified in clinical practice guidelines for a substantial number of their patients, according to a General Accounting Office (GAO) study. Furthermore, serious problems identified in CMS inspection reports would warrant termination from the Medicare program for approximately 15 percent of ESRD facilities.

The GAO identified 512 facilities that had 20 percent or more of their patients receivinginadequate dialysis treatment and almost 1,700 facilities that had 20 percent or more of their patients receiving inadequate treatment for anemia. Common problems include: improper clinical management, medication errors, improper use of reusable dialysis equipment, contamination of water used for dialysis, and insufficient physician involvement with patients.

In addition, GAO found that inspections conducted by state survey agencies often failed to detect or correct the ESRD facilities’ quality of care problems. Specifically, state survey agencies reported inconsistent results, allowed many facilities to go on for years without inspections, and permitted inexperienced surveyors to conduct the inspections. Also, many facilities have had problems maintaining compliance with Medicare’s minimum quality standards even after deficiencies had been recognized and corrected. Between 1998 and 2002, 18 percent of those facilities that had serious problems recognized and corrected had the same deficiencies present in subsequent inspections.

GAO recommended that CMS: (1) reduce the time between state inspections for facilities with serious deficiencies; (2) publish facilities’ survey results on-line; (3) encourage states to hire surveyors that specialize in inspecting ESRD facilities; (4) increase the availability of training courses for state surveyors; (5) require networks to share facility data with state agencies; and (6) ensure that regional offices monitor state performance and provide state agencies with assistance on issues. In response to the GAO’s recommendations, CMS indicated that it would address one of the six recommendations — specifically, CMS stated that they would increase the number of training courses for ESRD facility surveyors.

SOURCE: General Accounting Office, GAO-04-63, Oct. 8, 2003.
http://health.cch.com/news/medicare/stories/111803a.asp <<<

Sounds like the next type certification mandated should be certification for state surveyors! AND, I don’t know what to think about CMS…

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What exactly is the role of the GAO when it comes to the ESRD program? Because as noted in the previous post, they wrote extensive recommendations to remedy the problems units were having and should be surveyed for and CMS rejected all but one. What was the point of the time and $$$ spent to research and write the recommendations just to have CMS veto the effort? Wasn’t that a huge waste of taxpayer’s $$$ ?

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The GAO (Government Accountability Office) conducts investigations. This study was apparently requested by Sen. Chuck Grassley (R-IA) who held a hearing with testimony from patients, professionals, renal organizations, dialysis providers, etc. This report was written in 2003 – four years ago and some things have changed since it was written. Here’s the link to the full GAO report:

Here’s what I know that CMS has done. I am not making excuses because I do think more needs to be done to assure that patients on in-center or home dialysis are receiving are receiving the best care possible.

Surveying more often

In past years funding was sufficient that facilities could count on being surveyed every year. I remember those days. Over time other providers’ poor performance led states to survey those facilities more often and let dialysis facilities go up to 10 years without being surveyed. This report refers specifically to nursing homes and home health agencies. Funding for ESRD surveys has been increased so states should be able to survey a dialysis facility on average once every 3 years. This is not enough in my opinion. A surveyor can only identify a problem and cite a facility if he/she observes a problem at the dialysis clinic, if patients or staff report problems, if the medical records that he/she reviews (only a percentage of charts are reviewed) indicate problems, if staff personnel records show they don’t meet qualifications in the regs, and from comparing the policy and procedures manual for how facilities are supposed to do things with the way they actually do them.

There are no staff-to-patient ratios in the ESRD regulation. A facility must have one social worker and one dietitian (don’t have to be full-time), and one licensed nurse (RN, LPN, LVN) on duty when patients are dialyzing. The rest of the patient care staff can be technicians. Therefore it’s important for surveyors to check to be sure that quality of care provided is sufficient.

Targeting surveys to low performers

The report refers to two efforts:
– Dialysis Facility Compare (http://www.medicare.gov/dialysis) was developed by a workgroup that included patients and professionals in the renal community and currently looks at 3 data elements: adequacy of dialysis, anemia management, and survival.
– Facility Data Report (see sample at http://www.sph.umich.edu/kecc/usr/usr.htm) was developed by a workgroup of professionals in the renal community, representatives from CDC and other federal agencies to develop a tool and a list of facilities with the ones that appear to have worse outcomes at the top.

States are supposed to survey 1/3 of their facilities per year. A certain percentage of the facilities that states survey are supposed to come from poor performing facilities. States are also supposed to survey facilities that had serious citations in the past to assure that they’ve corrected them, those with new complaints, and new facilities that need to be certified to accept Medicare patients.

Training surveyors

CMS conducts several trainings a year for surveyors that are held over a 3.5 day period in different areas of the country. CMS staff and/or experts in topic area (ESRD regulations, infection control, water quality, the dialysis process, equipment used in the clinic and at home, Fistula First, reuse, reviewing records, documenting citations, etc.) provide the training. At the time this report was given CMS committed to doing 2 basic trainings a year and an advanced training as needed. In 2006-2007 fiscal year, CMS is offering 4 basic trainings for 40 surveyors each, an advanced training for 40 surveyors, and it conducted an annual update for 140 surveyors at the ANNA (nurse’s) meeting.

CMS wants more ESRD-designated surveors and has been encouraging states to send those surveyors who will be inspecting dialysis clinics to trainings. CMS is keeping track of which surveyors have attended ESRD trainings. CMS has developed and is pilot testing a tool using software on a tablet PC that surveyors will carry into clinics and use to record what they observe. This tool is being rolled out to several states a year. The software should help to standardize surveys and make it possible to look at trends easier. Surveyors who use this technology must have attended the CMS ESRD training program and a training on how to use the tablet PC program. This should help assure that state surveyors that inspect dialysis facilities have had ESRD training.

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[QUOTE=Beth Witten MSW ACSW;13829]The GAO (Government Accountability Office) conducts investigations. This study was apparently requested by Sen. Chuck Grassley (R-IA) who held a hearing with testimony from patients, professionals, renal organizations, dialysis providers, etc. This report was written in 2003 – four years ago and some things have changed since it was written. Here’s the link to the full GAO report:

[/QUOTE]

Beth,

I hope things are getting better. The bottom line for me always has been the mortality rate; I haven’t seen it budge much yet, but then the latest stats always lag by two years which makes it hard to tell if things are getting better.

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I also thought adding a part 3 to my Colorado tech bill story might be nice; it has some of the testimony given: there is Mary’s testimony (a lady who spent a total of 11 1/2 years on dialysis), my daughter’s testimony, and my testimony.

And again, the topics are at:
Patient Rights Advocacy:
http://www.patientrightsadvocacy.org/index.php

They are in the Healthcare Forum, under “Dialysis Company” heading, and the “Colorado Tech bill story part 3 - testimony” topic is the latest topic.

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[QUOTE=plugger_;13925]I also thought adding a part 3 to my Colorado tech bill story might be nice; it has some of the testimony given: there is Mary’s testimony (a lady who spent a total of 11 1/2 years on dialysis), my daughter’s testimony, and my testimony.

And again, the topics are at:
Patient Rights Advocacy:
http://www.patientrightsadvocacy.org/index.php

They are in the Healthcare Forum, under “Dialysis Company” heading, and the “Colorado Tech bill story part 3 - testimony” topic is the latest topic.[/QUOTE]

Plugger,
Just read the testimony which was perfectly stated. Every dialysis patient, family member and all the honest dialysis professionals owe each of you a great debt of gratitude for your courageous advocacy. As far as I’m concerned you each are true heroes!!! I am so proud of each of you I could bust!!!

Do you know what is meant on your board where the admin. states dialysis patients will be protected if they come forward with their concerns? To me, this is STILL the weak point in this struggle. Protected by whom?

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I know there are a couple of lawyers with some impressive credentials: http://www.patientrightsadvocacy.org/legal.php . There is another lawyer who was working pro bono who successfully sued Columbia/HCA - a large hospital chain - for Medicare fraud; I think he is still around. I also recall Arlene mentioning a contact or two at Fresenius and CMS. I also know the Rev. Al Sharpton was very publicly involved for awhile with some patients who were dumped from their clinic - imagine Arlene can still get a hold of him. I’ve read he has a rather checkered past, but he did an excellent job for DialysisEthics!

Anyway, thank you for your kind words. It took awhile to get up the gumption to try this, but I got tired of hoping others would do it for us. I approached it with the attitude even if we got shot down, we were going to make a lot of people aware of what we were seeing. I also had the frame of mind where I hoped they could prove us wrong; we could have walked away with a little egg on our faces, but assured things were fine and dandy - didn’t happen. Actually getting it through was icing on the cake. I don’t know about heroes, I think we are just some people who were fed-up.

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I realized I was amiss in recognizing all the organizations that helped us with the Colorado tech bill - also thought some of these organizations might be helpful for anybody else who might want to try what we did, so I added a part 4 to the story I wrote:

Colorado_Tech_Bill_story_link