ESRD NETWORK 6 2011 ANNUAL REPORT

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SKC reviews with CMS & StateSurveyorSanctionsupported?NoReturn tofocused reviewmonitoringYesBoard of Directors beginsSanction processSKC compiles documentationSKC sends Sanction Referral toRegional CMS officeDoes CMS concur?NoYesCMS determines type of sanction/ terminationCMS enforces sanctionNoHas facilitycomplied?YesSanction removedP a g e | 98
2011 Southeastern Kidney Council SanctionsThe Quality Improvement initiatives of the Southeastern Kidney Council identified a facility with pooroutcomes in anemia management, fistula placement and immunization. The Medical Review Boardworked with the facility to develop action plans and protocols in all three areas to assist the facilitywith improving their patient outcomes. However, the facility failed to show improvement in theareas. The Medical Review Board asked the State Surveyor to review the facility in December2010. The state confirmed the issues and cited four Immediate Jeopardy Conditions. Afterpermission from CMS, Network 6 conducted joint site visit with state surveyors and reviewed charts,QA/QI meeting notes and outcomes. The team identified multiple concerns with facility’s inadequateprotocols, failure to follow protocols, failure to review lab data and failure in documentation.Following the joint site visit, the State Surveyors opted to terminate Medicare coverage of the facilityand notified the facility and patients of planned Medicare termination. Network 6 staff went on site3/15/2011-3/17/2011 to assist with the placement of 50 patients from this clinic to alternate facilities.The facility closed on 3/17/2011.P a g e | 99
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“IMPROVING THE LIVES OF PEOPLE WI
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STATEMENT FROM THE BOARD OF DIRECTO
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Table of ContentsPREFACE ..........
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Contents of Figures and TablesFIGUR
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DATA TABLES LISTINGDATA TABLE 1: NE
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Network DescriptionESRD Network Pro
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Number of FacilitiesGENERAL POPULAT
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Number of PatientsGENERAL POPULATIO
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GENERAL POPULATIONESRD FacilitiesAt
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CORE VALUESIn achieving our Mission
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Quality ImprovementLeighann Sauls R
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Board of DirectorsThe Board of Dire
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Finance CommitteeIn 2011, the Board
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Medical Review BoardThe Medical Rev
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CMS NATIONAL GOALS & NETWORK ACTIVI
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The Quality of Care Commitment stat
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Network 6 Quality Improvement Progr
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Number of AVFsNumber of AVF in Use2
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Figure 15. AV Fistula Intervention
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Report 102 - VascularAccess Ranking
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Number of CathtersPROJECT 2: INCREA
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Intervention ImplementationSKC empl
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Figure 23. Progression of Network 6
Page 47 and 48: Feedback Reports to each focus faci
Page 49 and 50: Immunization Intervention overviewF
Page 51 and 52: Impact of the Southeastern Kidney C
Page 53 and 54: OverviewThe Network meets the expec
Page 55 and 56: Mental Healtho Living and Loving Li
Page 59 and 60: Medical Review Board and Board of D
Page 61 and 62: Patient Ambassador Pilot ProgramIn
Page 63 and 64: ole of Network 6, Dialysis Facility
Page 67 and 68: OverviewIn 2011, Southeastern Kidne
Page 69 and 70: CMS requires that Networks assume a
Page 71 and 72: Number of ContactsTechnical Assista
Page 73 and 74: Number of CallsNumber of CallsThe o
Page 75 and 76: CMS Goal 4Improve collaboration wit
Page 77 and 78: A collaborative project is a system
Page 79 and 80: State Survey AgenciesSoutheastern K
Page 83 and 84: OverviewSoutheastern Kidney Council
Page 85 and 86: Data ValidationSoutheastern Kidney
Page 87 and 88: Technical AssistanceThe Southeaster
Page 91 and 92: Background and OverviewSoutheastern
Page 93 and 94: § 488.606 Alternative sanctions.(a
Page 95 and 96: Congress extended Medicarecoverage
Page 97: Return to routine monitoringHas fac
Page 101 and 102: RecommendationsPeople with end stag
Page 103 and 104: DATA TABLE 1: NETWORK 6 ESRD INCIDE
Page 105 and 106: DATA TABLE 2: NETWORK 6 ESRD PREVAL
Page 107 and 108: DATA TABLE 3: NETWORK 6 HOME DIALYS
Page 109 and 110: DATA TABLE 3: Network 6 HOME DIALYS
Page 123 and 124: DATA TABLE 4: NETWORK 6 IN-CENTER D
Page 139 and 140: DATA TABLE 5: NETWORK 6 NUMBER OF R
Page 141 and 142: DATA TABLE 6: Network 6 NUMBER OF R
Page 143 and 144: DATA TABLE 7 Network 6 DIALYSIS DEA
Page 145 and 146: DATA TABLE 8: NETWORK 6 VOCATIONAL
Page 147 and 148: DATA TABLE 8: NETWORK 6 VOCATIONAL
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DATA TABLE 8: NETWORK 6 VOCATIONAL
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ESRD NETWORK 6 2011 ANNUAL REPORT

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