| (9) A registered nurse shall conduct the initial patient
assessment at the time of the patient's initial dialysis treatment
in the facility.
(e) This chapter does not preclude a licensed vocational
nurse (LVN) from practicing in accordance with the rules adopted by
the Texas Board of Nursing. If the LVN is acting in the capacity of
a dialysis technician, the facility shall determine that the LVN has
passed a training and competency evaluation curriculum which meets
the requirements in §117.62 of this title and §117.63 of
this title.
(f) A dialysis technician providing direct patient
care shall demonstrate knowledge and competency for the responsibilities
specified in §117.62 of this title and §117.63 of this title.
(g) Nutrition services.
(1) Nutrition services shall be provided to a patient
and the patient's caregiver(s) in order to maximize the patient's
nutritional status.
(2) The dietitian shall be responsible for:
(A) conducting a nutrition assessment of a patient;
(B) participating in an interdisciplinary team review
of a patient's progress;
(C) recommending therapeutic diets in consideration
of cultural preferences and changes in treatment based on the patient's
nutritional needs in consultation with the patient's physician;
(D) counseling a patient, a patient's family, and a
patient's significant other on prescribed diets and monitoring adherence
and response to diet therapy. Correctional institutions shall not
be required to provide counseling to family members or significant
others;
(E) referring a patient for assistance with nutrition
resources such as financial assistance, community resources, or in-home
assistance;
(F) participating in the facility's QAPI activities;
and
(G) providing ongoing monitoring of subjective and
objective data to determine the need for timely intervention and follow-up.
Measurement criteria include but are not limited to weight changes,
blood chemistries, adequacy of dialysis, and medication changes which
affect nutrition status and potentially cause adverse nutrient interactions.
(3) The initial contact between the dietitian and the
patient to assess nutritional status shall occur, and be documented,
within two weeks or seven treatments from admission to the facility,
whichever occurs later. A comprehensive nutrition assessment with
an educational component shall be completed within 30 days or 13 treatments
from the patient's admission to the facility, whichever occurs later.
(4) A nutrition reassessment shall be conducted no
less than annually or more often when indicated by a question relating
to a change in the patient's status, extended or frequent hospitalizations,
a change in the patient's modality, or at the patient's request.
(5) Each facility shall employ or contract with a dietitian(s)
to provide clinical nutrition services for each patient. One full-time
equivalent of dietitian time shall be available for up to 100 patients
per facility with the maximum patient load per full-time equivalent
of dietitian time being 125 patients for all modalities.
(6) Nutrition services shall be available at the facility
during scheduled treatment times. Access to services may require an
appointment.
(7) There shall be written physician standing orders
specific to the facility authorizing delegation of responsibilities
for the facility dietitian as determined by the Medical Director and
the facility. These standing orders shall be reviewed and approved
by the medical director at least annually, and be consistent with
the statutes and rules of the Texas Medical Board, the Texas Board
of Nursing, and the Texas State Board of Examiners of Dietitians licensure.
(8) If the facility is using a medication algorithm/protocol
for managing renal bone disease the nutritional care for each patient
shall be individualized.
(h) Social services.
(1) Social services shall be provided to patients and
their families and shall be directed at supporting and maximizing
the adjustment, social functioning, and rehabilitation of the patient.
(2) The social worker shall be responsible for:
(A) conducting psychosocial evaluations, which include
health-related quality of life surveys;
(B) participating in the interdisciplinary team review
of a patient's progress;
(C) providing an ongoing assessment and recommend changes
in treatment based on the patient's current psychosocial needs;
(D) providing social work interventions including counseling,
case work and group work services to patients and their families in
dealing with the special problems associated with end stage renal
disease;
(E) except in the case of social workers providing
service in correctional institutions, identifying community social
agencies and other resources, and assisting patients and families
to utilize them;
(F) participating in the facility's QAPI activities;
and
(G) assisting patients to achieve optimum levels of
productive activity and making rehabilitation referrals as appropriate.
(3) Initial contact between the social worker and the
patient shall occur, and be documented, within two weeks or seven
treatments from the patient's admission, whichever occurs later. A
comprehensive psychosocial assessment shall be completed within 30
days or 13 treatments from the patient's admission, whichever occurs
later.
(4) A psychosocial reassessment shall be conducted
no less than annually or more often when indicated by a significant
change in the patient's psychosocial needs, extended or frequent hospitalizations,
any event that would interfere with the patient's ability to follow
aspects of the plan of care, a change in the patient's modality, or
at the patient's request.
(5) Each facility shall employ or contract with a social
worker(s) to meet the psychosocial needs of the patients. Personnel
shall be assigned to assist a social worker(s) with ancillary tasks
(e.g., assistance with financial services, transportation, administrative,
clerical, etc.), when the patient load per facility, including all
modalities, exceeds 100 patients. The maximum patient load, including
all modalities, per full-time equivalent qualified social worker,
with assigned personnel assistance, is 125 patients.
(6) Social services shall be available at the facility
during the times of patient treatment. Access to social services may
require an appointment.
(i) Medical services.
(1) The medical director is responsible for:
(A) developing facility treatment goals which are based
on review of aggregate data assessed through QAPI activities;
(B) assuring adequate training of licensed nurses and
dialysis technicians;
(C) adequate monitoring of patients and the dialysis
process; and
(D) developing, implementing, and enforcing all policies
required by this chapter.
(2) Medical staff.
(A) Each patient shall be under the care of a nephrologist
on the medical staff.
(B) The care of a pediatric dialysis patient shall
be in accordance with this subparagraph. If a pediatric nephrologist
is not available as the primary physician, an adult nephrologist may
serve as the primary physician with direct patient evaluation by a
pediatric nephrologist according to the following schedule:
(i) for patients two years of age or younger--monthly
(two of three evaluations may be by phone);
(ii) for patients three to 12 years of age--quarterly;
and
(iii) for patients 13 to 18 years of age--semiannually.
(C) At a minimum, each patient receiving dialysis in
the facility shall be seen by a physician on the medical staff once
every two weeks during the patient's treatment time. Home dialysis
patients shall be seen by a physician, advanced practice registered
nurse, or physician's assistant no less than one time a month. If
home dialysis patients are seen by an advanced practice registered
nurse or a physician's assistant, the physician shall see the patient
at least one time every three months. This visit may be conducted
in the dialysis facility, at the physician's office, or in the patient's
home. The record of these contacts shall include evidence of assessment
for new and recurrent problems and review of dialysis adequacy each
month.
(D) A physician on the medical staff shall be on call
and available 24 hours a day (in person or by telecommunication) to
patients and staff.
(E) Orders for treatment shall be in writing and signed
by the physician. Routine orders for treatment shall be updated at
least annually. Any changes in patient treatment shall be per physician's
order.
Cont'd... |
