CMS Releases Updated Surveyor Guidance for Nursing Home Residents Receiving Home Dialysis Services

The Centers for Medicare and Medicaid Services (CMS) issued updated surveyor guidance on March 22, 2023 for end-stage renal disease (ESRD) facilities. The guidance specifically focuses on surveying for nursing home residents receiving “home dialysis services” in the nursing home. ESRD surveys will include visits to the nursing home to survey home dialysis services of nursing home residents.

Per the memo:

In 2018, CMS issued guidance that addressed care at home provisions for nursing home residents that were receiving home dialysis. Since that time, CMS has received questions, comments, and feedback from the state survey agencies, the dialysis provider community, as well as other Federal and non-Federal stakeholders.

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For individuals residing in nursing homes with dialysis needs, dialysis treatments may be provided in an in-center setting or they may receive dialysis in the nursing home, i.e., home dialysis. It is important to note that in-center dialysis may be furnished by a certified dialysis facility that is located offsite, adjacent to the nursing home, or occupying leased space within the nursing home itself. Nursing homes are not required to accommodate dialysis services on-site. Some State regulations may not allow dialysis services to be provided in a nursing home setting or may have additional requirements regarding the qualifications of personnel who provide dialysis treatments in a nursing home.

Residents of a nursing home may receive chronic dialysis treatments through two options:

1. In-Center Dialysis: This may involve either:

• Transporting the resident to and from an off-site or on-site certified ESRD facility for dialysis treatments; or
• Transporting the resident to a certified ESRD facility that is located within or adjacent to the nursing home building.

2. Home Dialysis: The resident receives dialysis treatments in the nursing home. Dialysis treatments may be administered by the patient, a family member or friend, dialysis facility staff, or nursing home personnel. Any individual(s) that administers dialysis treatments must be trained, competent, and knowledgeable in all aspects of dialysis care before initiating treatments, per §494.100(a). Home dialysis services in the nursing home are provided under the auspices of a written agreement between the nursing home and the ESRD facility.

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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. Offering home dialysis as a treatment option for nursing home residents that 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. These include:

1. Ongoing collaboration of care between the dialysis facility and nursing home;
2. Adequate training for anyone that administers dialysis treatments;
3. Appropriate monitoring of the dialysis patient’s status before, during, and after the treatments; and
4. Ensuring a safe and sanitary environment for the treatments.

An ESRD facility providing home dialysis services to a nursing home resident maintains direct responsibility for the dialysis-related care and such services provided to the nursing home resident(s) must be consistent with the ESRD Conditions for Coverage (CfC) requirements. 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.

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On-site visits to the nursing homes where ESRD patients are receiving home dialysis services will require surveyors to adequately evaluate the dialysis services and associated dialysis care being provided in the nursing home. The number of onsite visits that a surveyor must conduct will vary depending on how many nursing homes the dialysis facility has agreements with. The primary goal of the on-site visit is to evaluate the care and management of patients requiring dialysis, including adherence to infection control procedures, knowledge of the nature and management of ESRD, as well as the ability to detect, report, and manage potential dialysis complications.

The on-site visits at the nursing home will include observations of machine setup, vascular access care, and initiation and discontinuation of home hemodialysis (HD) treatments. Peritoneal dialysis (PD) may be administered in two ways: (1) Continuous Ambulatory Peritoneal Dialysis (CAPD) – manual exchange and (2) Automated Peritoneal Dialysis (APD) - cycler. Observations of actual peritoneal dialysis care are not required unless the survey team identifies concerns such as high rates of infection or complaints. If observations of peritoneal dialysis care are indicated, the surveyor should observe connection and disconnection procedures and evaluate the peritoneal dialysis exit site for signs of infection or improper care.

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The following guidance as well as the survey procedures for ESRD surveyors reviewing dialysis services in the nursing home will be incorporated into upcoming revisions to the State Operations Manual - Ch. 2 and Appendix H, respectively. Guidance regarding home dialysis in the nursing home setting contains information regarding (1) written agreement and the responsibilities of the ESRD facility and the nursing home, (2) qualifications and training of any dialysis administering personnel, and (3) coordination of care. The specifics of the agreement and requirements can be found in the memo.

The memo also contains an attachment for nursing home surveyors, “Survey Process for ESRD Surveyors Reviewing Dialysis in Nursing Homes.” Nursing home members are encouraged to read the memo and attachment in their entirety.

Contact: Amy Nelson, anelson@leadingageny.org, 518-867-8383 ext. 146