The CMS Survey Process for Dialysis Units (A MUST Read)

If you have anything to do with oversight of a dialysis unit - either as the facility administrator (FA) or Director of Nursing (DON) or as the Medical Director, I would highly recommend that you download and read certain documents on the CMS web-page "Survey and Certification: Guidance to Laws and Regulation". It is really a road-map to the survey process and is a "MUST-READ".

In particular, take a look at section D -ESRD Survey Laminates:

1. Outline of ESRD Core Survey Process: 4-page list of tasks in the ESRD Core Survey process (Version 1.0) NEW
2. ESRD Core Survey Process Triggers: 2-page list of tasks in the ESRD  Core Survey that lead surveyors further investigate or cite (Version 1.2) NEW
3. Measures Assessment Tool (MAT): 2-page summary of the standards used in assessing compliance with regulatory requirements formatted in 5 columns to include the referenced V tag, the measure, the expected value(s), reference for the value(s), and where the surveyor should find the information during a survey(Version 2.2) REVISED
4. Evidence of Recognizing and Addressing (ERA) Interdisciplinary Clinical Care of the Individual Patient: 2-page description of sample findings, what to look for, and why it is important (Version 1.0) NEW
5. End Stage Renal Disease Facilities V-Tags & Identifiers: 3-page list of V-Tags and ASPEN identifiers along with Condition statements from the Interpretive Guidance (Version 1.5) REVISED
6. Infection Control/Requirements for Isolation Room or Area: 2-page description of V-tags and descriptors plus requirements for all facilities, existing facilities and new facilities (Version 1.4) REVISED
7. Water System Flow Diagram/ Critical Water and Dialysate Requirements: 2-page summary of the ANSI/AAMI RD 62 water and dialysate requirements and a diagram of a typical water system (Version 1.1)REVISED
8. Personnel Requirements/National Commercial PCT Certification Organizations: 2-page summary of requirements for staff of a dialysis facility plus information on national commercial dialysis technician certification organizations (Version 1.3)
9. Helpful Web Sites for ESRD Surveyors: 2-page listing of recommended Web sites inside and outside CMS (Version 1.9) REVISED
10. Dialysis Lab Tests At a Glance: 2-page listing of common blood tests for people on dialysis, to include normal values, expected values in someone with kidney disease, and signs/symptoms if values are too high or too low (Version 1.4) REVISED
11. Components of Immediate Jeopardy/Guidelines for Citations: -2-page flow chart and guidelines to help the surveyor determine the level of citation (Version 1.1) REVISED
12. Principles of Documentation Overview: 2-page adaptation of the Principles of Documentation, the guidance surveyors must use in writing deficiency statements adapted from (Exhibit 7A), in the CMS State Operations Manual (Version 1.0)
13. Outline of the Traditional ESRD Survey Process: 4-page list of tasks in the survey process (Version 1.8)