| (E) Screening of HbsAg-positive or anti-HbsAg-positive
clients may be performed on a less frequent basis, provided that the
agency's policy on this subject remains congruent with Appendices
i and ii of the National Surveillance of Dialysis Associated Diseases
in the United States, 1993, published by the USDHHS.
(l) CPR certification. All direct client care employees
must have current CPR certification.
(m) Initial admission assessment. Assessment of the
client's residence must be made to ensure a safe physical environment
for the performance of dialysis. The initial admission assessment
must be performed by a qualified RN who meets the qualifications under
subsection (e)(1)(A) of this section.
(n) Client long-term program. The agency must develop
a long-term program for each client admitted to home dialysis. Criteria
must be defined in writing and must provide guidance to the agency
in the selection of clients suitable for home staff-assisted dialysis
and in noting changes in a client's condition that would require discharge
from the program. For the purposes of this subsection, Long-term program
means the written documentation of the selection of a suitable treatment
modality and dialysis setting, which has been selected by the client
and the interdisciplinary team.
(o) Client history and physical. The agency must ensure
that the history and physical is conducted upon the client's admission,
or no more than six months prior to the date of admission, then annually
after the date of admission.
(p) Physician orders. If home staff-assisted dialysis
is selected, the physician must prepare orders outlining specifics
of prescribed treatment.
(1) If these physician's orders are received verbally,
they must be confirmed in writing within a reasonable time frame.
An agency must adopt and enforce a policy on the time frame for the
countersignature of a physician's verbal orders. Medical orders for
home staff-assisted dialysis must be revised as necessary but reviewed
and updated at least every six months.
(2) The initial orders for home staff-assisted dialysis
must be received prior to the first treatment and must cover all pertinent
diagnoses, including mental status, prognosis, functional limitations,
activities permitted, nutritional requirements, medications and treatments,
and any safety measures to protect against injury. Orders for home
staff-assisted dialysis must include frequency and length of treatment,
target weight, type of dialyzer, dialysate, dialysate flow rate, heparin
dosage, and blood flow rate, and must specify the level of preparation
required for the caregiver, such as an LVN or RN.
(q) Client care plan. The client care plan must be
developed after consultation with the client and the client's family
by the interdisciplinary team. The interdisciplinary team must include
the physician, the RN, the dietitian, and the qualified social worker
responsible for planning the care delivered to the home staff-assisted
dialysis patient.
(1) The initial client care plan must be completed
by the interdisciplinary team within 10 calendar days after the first
home dialysis treatment.
(2) The client care plan must implement the medical
orders and must include services to be rendered, such as the identification
of problems, methods of intervention, and the assignment of health
care personnel.
(3) The client care plan must be in writing, be personalized
for the individual, and reflect the ongoing medical, psychological,
social, nutritional, and functional needs of the client, including
treatment goals.
(4) The client care plan must include written evidence
of coordination with other service providers, such as dialysis facilities
or transportation providers, as needed to assure the provision of
safe care.
(5) The client care plan must include written evidence
of the client's or client's legal representative's input and participation,
unless they refuse to participate. At a minimum, the client care plan
must demonstrate that the content was shared with the client or the
client's legal representative.
(6) For non-stabilized clients, where there is a change
in modality, unacceptable laboratory work, uncontrolled weight changes,
infections, or a change in family status, the client care plan must
be reviewed at least monthly by the interdisciplinary team. Evidence
of the review of the client care plan with the client and the interdisciplinary
team to evaluate the client's progress or lack of progress toward
the goals of the care plan, and interventions taken when progress
toward stabilization or the goals are not achieved, must be documented
and included in the client record.
(7) For a stable client, the client care plan must
be reviewed and updated as indicated by any change in the client's
medical, nutritional, or psychosocial condition or at least every
six months. The long-term program must be revised as needed and reviewed
annually. Evidence of the review of the client care plan with the
client and the interdisciplinary team to evaluate the client's progress
or lack of progress toward the goals of the care plan, and interventions
taken when the goals are not achieved, must be documented and included
in the client record.
(r) Medication administration. Medications must be
administered only by licensed personnel.
(s) Client records. In addition to the applicable information
described in §558.301(a)(9) of this chapter (relating to Client
Records), records of home staff assisted dialysis clients must include
the following:
(1) a medical history and physical;
(2) clinical progress notes by the physician, qualified
licensed nurse, qualified dietitian, and qualified social worker;
(3) dialysis treatment records;
(4) laboratory reports;
(5) a client care plan;
(6) a long-term program; and
(7) documentation of supervisory visits.
(t) Water treatment.
(1) Water used for dialysis purposes must be analyzed
for chemical contaminants every six months. Additional chemical analysis
must be conducted if test results exceed the maximum levels of chemical
contaminants listed in §3.2.2 (Maximum Level of Chemical Contaminants)
of the American National Standards for Hemodialysis Systems, March
1992 Edition, published by the AAMI. Copies of the standards are indexed
and filed in the Texas Health and Human Services Commission, 701 W.
51st Street, Austin, Texas 78751, and are available for public inspection
during regular working hours.
(2) Water used for dialysis must be treated as necessary
to maintain a continuous water supply that is biologically and chemically
compatible with acceptable dialysis techniques.
(3) Water used to prepare dialysate must meet the requirements
set forth in §3.2.1 (Hemodialysis Systems) and §3.2.2 (Maximum
Level of Chemical Contaminants), March 1992 Edition, published by
the AAMI. Copies of the standards are indexed and filed in the Texas
Health and Human Services Commission 701 W. 51st Street, Austin, Texas
78751, and are available for public inspection during regular working
hours.
(4) Records of test results and equipment maintenance
must be maintained at the agency.
(u) Equipment testing. An agency must adopt and enforce
a policy to describe how the nurse will check the machine for conductivity,
temperature, and pH prior to treatment, and describe the equipment
required for these tests. The equipment must be available for use
prior to each treatment. This policy must reflect current standards.
(v) Preventive maintenance for equipment. An agency
must develop and enforce a written preventive maintenance program
to ensure client care related equipment receives electrical safety
inspections, if appropriate, and maintenance at least annually or
more frequently if recommended by the manufacturer. The preventive
maintenance may be provided by agency or contract staff qualified
by training or experience in the maintenance of dialysis equipment.
(1) All equipment used by a client in home dialysis
must be maintained free of defects, which could be a potential hazard
to clients, the client's family, or agency personnel.
(A) Agency staff must be able to identify malfunctioning
equipment and report such equipment to the appropriate agency staff.
Malfunctioning equipment must be immediately removed from use.
(B) Written evidence of all preventive maintenance
and equipment repairs must be maintained.
(C) After repairs or alterations are made to any equipment,
the equipment must be thoroughly tested for proper operation before
returning to service.
Cont'd... |
