CMS releases new rules on dialysis care in nursing homes

A long-anticipated set of rules on how dialysis providers can provide treatments to patients living in skilled nursing facilities and nursing homes was released by CMS on Aug. 10 as part of an update to guidelines used by Medicare surveyors to inspect dialysis facilities.

Revisions to the State Operations Manual were released to state survey agencies by David Wright, the director of the Quality, Safety and Oversight Group at CMS, and are effective immediately with no further changes. In addition to the nursing home guidelines, the revisions cover basic requirements for operating a dialysis facility, including definitions of modality types, guidelines for establishing a home dialysis training center, addition of stations, expansion of services and temporary closures; infection control considerations; and rules regarding medical director waiver considerations.

Staffing requirements and supervision
The nursing home requirements set definitions along with education and training requirements for staff providing dialysis care and are “to ensure that an ESRD facility, providing home dialysis services to a nursing home resident under a written agreement with the resident’s nursing home, maintains direct responsibility for the dialysis related care and services provided to the nursing home resident(s) consistent with the ESRD Conditions for Coverage (CfC) requirements as well as the terms of an applicable agreement with the nursing home,” CMS wrote.

Of particular importance in the new rules is the training and supervision of staff performing the dialysis treatment in the nursing home facility. The dialysis provider must, according to the new rules, ensure that:

  1. Onsite supervision of dialysis is provided by a trained registered nurse (RN) whenever a resident is receiving hemodialysis (HD) in the nursing home, and by a trained RN or licensed practical/vocational nurse (LPN/LVN) when PD treatment is provided;
  2. Qualified/trained dialysis administering personnel are present in the room and maintain direct visual contact with the resident receiving HD throughout the entire duration of the treatment (the supervising nurse may also be the dialysis administering personnel); and
  3. If a situation occurs in which the nursing home is unable to provide dialysis treatments due to reasons such as insufficient trained staff and/or supervision, the ESRD facility is notified and provides the dialysis treatments to avoid a delay or cancellation of treatment.

The ESRD facility providing the care “must ensure that a trained supervising RN is constantly present on-site at the nursing home and immediately available to respond to concerns or emergencies that may occur during a resident’s hemodialysis,” the policy states. “The supervising nurse must be present in the general area where the resident(s) are receiving dialysis and readily available. If the supervising nurse has other nursing duties in the nursing home, these other duties must not hinder or negatively affect his/her ability to respond immediately to the needs of the dialysis patient(s),” CMS wrote.

CMS letter QSO-18-24-ESRD to State Survey Agency Directors regarding the Survey Process for Reviewing Home Dialysis Services in a Long Term Care (LTC) Facility

  • Dialysis Services in a LTC Facility: Medicare participating End Stage Renal Disease (ESRD) facilities must comply with the Conditions for Coverage at 42 CFR Part 494. Under this provision, Medicare-approved ESRD facilities may provide dialysis services to LTC residents in a LTC facility with an approved Home Training and Support modality. ESRD facilities that provide home hemodialysis or peritoneal dialysis services to LTC residents must maintain compliance with these requirements, including the requirements set forth at §494.100: Care at home.
  • Survey Process for Evaluation of Home Dialysis in a LTC Facility: The ESRD Core Survey Process has been updated to include additional survey activities which address dialysis services provided by an ESRD facility to residents in a LTC facility.
  • Attachments: Included as an attachment to this memorandum is Exhibit IV: Survey Process for ESRD Surveyors Reviewing Dialysis in Nursing Homes for evaluation of home dialysis services provided in a LTC facility.