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Responding With a United Voice to the Conditions of Coverage!
by ANNA President Suzann VanBuskirk
On
May 5th, 2005, ANNA joined many nephrology organizations, stakeholders,
and individuals by submitting its comments on the proposed Conditions
for Coverage for End Stage Renal Disease Facilities. Due to the
significance of the event, I feel compelled to use another President’s
Message to write about our response.
In her President’s Message in the January-February 2005 issue of
Nephrology Nursing Journal, Lesley Dinwiddie chronicled the importance
of the “Regulations” for nephrology nurses and for the citizens and
dependents with kidney failure who qualified for Social Security. She
proclaimed the Notice for Proposed Rule Making (NPRM) as a “historic
event for ANNA and Nephrology Nursing!” At the time that message was
written, the task force assigned to prepare the response had just begun
the arduous job of digesting the 292-page document.
The process of preparing our response is indicative of the manner in
which the members of our Association have met many challenges and
opportunities over its 37-year history. It is significant that,
as diverse and varied as our membership is, we were able to use
collective and collaborative efforts to respond with a united voice to
represent nephrology nursing.
I am proud to have been part of the task force, led by Caroline Counts,
who carefully crafted a plan, in anticipation of the release of the
NPRM, to have ANNA’s National Office prepared to copy and distribute
the documents to our elected and appointed volunteer leaders who, in
turn, worked as small committees to study the document and offer
written recommendations for the task force to consider in our response.
In the final days of the response period, Lesley Dinwiddie, ANNA State
Legislative consultant Kathleen Smith, and ANNA Secretary Glenda Payne
met the challenge of writing and editing the final response to be
consistent with the ANNA’s mission, goals, strategic plan, and position
statements as well as our scope, standards, and guidelines for
practice.
Highlights of 14-Page Response
ANNA’s
14-page response is available on in the Legislative/Regulatory
Activities portion of the Health Policy section of our website,
www.annanurse.org. Following are highlights from the document that are
of particular importance to nephrology nursing:
ANNA, in general, supported the Centers for Medicare and Medicaid
Service’s fundamental shift in its regulatory approach to create a
patient outcome-oriented environment and the goal of eliminating
unnecessarily prescriptive and process-oriented requirements; however,
we felt that many of the requirements of the Rule were not consistent
with Medicare payment policies (e.g., requirements in
§494.90(a)(4) for vascular access monitoring and
§494.90(a)(6) for rehabilitation) and often imposed additional
regulatory burden on facilities.
ANNA requested that the definitions (§494.10) expand the
definition of “home” to include institutional settings such as nursing
facilities and skilled nursing facilities, and that definitions for
“direct supervision” and “immediate supervision” be included to avoid
problems at the facility level in determining compliance with some of
the rules.
ANNA does not agree with a requirement for an infection control officer
(§494.30(b) (2)) and believes that facilities should determine
such a need through their “Quality Assessment and Performance
Improvement” (QAPI) program and has, therefore, recommended that
Infections be a required performance component of the QAPI program.
With the current international concern about bioterrorism, ANNA
believes the final rule should address this by requiring dialysis
facilities to incorporate bioterrorism preparedness procedures in their
disaster plan (§494.60(d).
ANNA suggested a different approach to the section on Patient Rights,
stating that “rights are accompanied by responsibilities” such as
adherence to treatment time and dietary/fluid restrictions. In
§494.70(a)(5), we recommended language that sets forth an
expectation of patient participation in care.
ANNA suggested that the patient assessment (§494.80) be eliminated
as a condition and subsumed under Plan of Care, since an assessment is
fundamental to the establishment of any such plan. Based upon the fact
that dialysis professionals have been performing patient assessments
and developing care plans for over 30 years, our comments were very
specific in this area and included a recommendation to add
“non-physician provider” as an optional part of the interdisciplinary
team.
ANNA provided extensive comments to §494.90, Plan of Care,
regarding more specific language for patient care outcomes that would
recognize the National Kidney Foundation’s Kidney Disease Outcome
Quality Initiative (K/DOQI) or other standards that may be developed by
recognized health care standard-setting organizations. Also in
this section, ANNA recommended the elimination of the language relating
to the ESRD facility requirement to ensure that all patients are seen
by a physician at least monthly and the establishment of a transplant
data base accessible to ESRD and transplant centers for monitoring
patients on transplant waiting lists.
In §494.100, Care at Home, ANNA supported CMS in the initial home
training of the patient and caregiver by a qualified registered nurse.
Further ANNA stated that peritoneal dialysis should be the modality of
choice for the frail elderly, and the dialysis facility approved for
home training should retain oversight responsibility for the patient
and the caregiver as per current home training/home dialysis standards,
regardless of whether the caregiver is a paid employee of the training
facility, the institution, the patient, or a DME company.
ANNA supported the inclusion of a condition requiring a QAPI program
(§494.110) and applauded the requirement for prioritizing
improvement activities and having a plan for immediate correction of
identified problems that jeopardize patients’ health and/or safety.
Under Personnel Qualifications, ANNA’s response sited that it is more
appropriate to say dialysis technicians are the predominant direct
patient caregivers in most dialysis facilities and to recognize that
they function as extensions of the facility’s professional nursing
staff. Further, ANNA agrees that it is essential that a
registered nurse provide the “hands-on” direct (as distinct from
immediate) supervision to technicians during the clinical component of
their training, using our recommended definitions. We did not support
the need for a clinical pharmacist and opposed the language in
§494.140 allowing LPN/LVNs to function as charge nurses.
In §494.180, ANNA wholeheartedly endorsed the inclusion of a
requirement for an acuity-based staffing plan, strongly supported the
requirement (§494.180(b)(2)) to have a registered nurse in the
facility at all times while patients are receiving treatment, and
agreed with the minimum patient care technician training program
content areas in §494.180(b)(5)(i) through (viii). In addition,
ANNA strongly recommended a requirement that all patient care
technicians should be certified through a nationally recognized
certification program.
Followup to ANNA’s Comments
In
conclusion, I would like to thank all the ANNA volunteers who provided
comments and participated in the review of the NPRM for the new ESRD
Conditions for Coverage and ANNA’s draft and final response. I
encourage all of you to view our entire response to the ANNA website. I
would also remind you that CMS will have 3 years to study all the
comments, respond, and consider the incorporation of some of the
suggestions. Then, CMS will publish the Final Rules, with effective
dates 30 – 60 days following publication. ANNA will also deliver
comments to the Hospital Conditions for Participation: Requirements of
Transplant Centers to Perform Organ Transplants by the June 4, 2005
deadline.
Suzann VanBuskirk, BSN, RN, CNN
President, ANNA 2005-2006
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