dialysis in people on the equipment

Federal officials on Wednesday updated guidance meant to improve the delivery of nursing home dialysis, a service many providers have been adding to attract new residents and improve quality of life for those who need the time-consuming treatments.

The Centers for Medicare & Medicaid Services issued new directions in a 21-page memo to state surveyors, who must inspect both the facilities hosting dialysis services for end-stage renal disease patients and the companies that provide equipment and should be responsible for training staff. Among the additions are stricter requirements for written agreements between dialysis providers and skilled nursing operators, to include emergency plans.

“The number of patients receiving home dialysis services in the nursing home represents a small, but growing fraction of the total population of home dialysis patients. The characteristics of this group, such as age and multiple comorbidities, increase their risk of experiencing adverse health and safety events, such as hospitalization, infection and death,” CMS noted in its memo.

“Offering home dialysis as a treatment option for nursing home residents … addresses certain disadvantages of in-center dialysis, such as transportation times and disruption of the resident’s daily activities. However, due to the dynamics of the respective care teams (i.e., nursing home and ESRD facility care teams) and the varying clinical complexities of this population, ensuring protections are in place will secure effective and safe treatments.”

Research has shown patients receiving home dialysis in nursing homes have improved clinical outcomes, improved recovery times under 2 hours, and reduced risks of infection. Providers say the approach also gives patients more time to spend in their communities socializing or receiving other needed therapies.

Jonathan Paull is general counsel and chief compliance officer for Dialyze Direct, an 8-year-old company that has become a major provider of on-site dialysis for nursing. He told McKnight’s Long-Term Care News on Wednesday that he generally supported the new standards, saying they build on CMS guidance from 2018 that “served as a tremendously helpful resource in forming standards and structures for local regulatory agencies.” 

“We know these standards work, because we have been doing them since 2015,” Paull wrote in an email. “This specialty continues to grow nationwide, and as it does, it will be critical that all providers are abiding by the highest quality and safety standards. As such, we applaud CMS in refreshing this guidance with bolstered quality and safety standards, and we believe it is a win for all stakeholders in the industry.”

Of particular concern to CMS is ensuring ongoing collaboration of care between the two providers; making sure anyone who administers the dialysis treatment — including a resident who chooses to do so himself — has received adequate training; enforcing monitoring of a patient’s status before, during and after treatment; and maintaining a “safe and sanitary environment.”

The guidance outlines more specifically what to include in written agreements for the provision of care by an end-stage renal disease facility in each nursing home it serves. Those agreements, CMS said, should address clinical details including:

  • Methods for enabling timely communication and collaboration between both parties
  • Ensuring a safe and sanitary environment
  • Ensuring active participation of the nursing home care team in the development and implementation of an individualized care plan
  • Delineation of patient monitoring responsibilities any express recognition of any state scope-of-practice laws and limitations
  • A process to review the qualifications, training, competency and monitoring of any staff, patients or family caregivers who administer dialysis treatments in the nursing home.

Providers responsible for ‘dialysis dens’

CMS noted that patients retain the right to administer their own treatment, but said facilities must adapt if a resident’s cognitive or physical status changes over time and makes them less capable of managing the treatment or asking for help. If a resident receives dialysis in her room and is no longer able to independently request help, for example, she should have qualified dialysis personnel remain in the room throughout the entire treatment process.

The agency also reiterated dialysis providers’ responsibility for infection control in increasingly popular “dialysis dens.”

“The ESRD facility is responsible for determining that the staff’s level of skill and availability in a nursing home is adequate and the ESRD facility is responsible to ensure that home dialysis is not provided unless the safety of the patient can be guaranteed,” the memo states.

In keeping with greater emphasis on emergency planning in nursing homes, the guidance calls for additional preparedness efforts among dialysis providers working in nursing homes. Planning requirements will be expanded to include strategy for providing back-up dialysis, managing complications, navigating equipment failure and stocking emergency supplies within partner nursing homes “to prevent any delays or interruptions to a resident’s prescribed dialysis treatment.”

The guidance advances 2018 CMS instructions to surveyors, incorporating questions and feedback from state survey agencies, the dialysis provider community and other stakeholders.

“The goal of this guidance is to enable an effective and consistent approach to evaluate the quality of care and promote improvements in performance and outcomes for the nursing home dialysis population,” CMS said.