CMS SOM App. H, Tag V520

In accordance with the standards specified in

paragraphs (a)(1) through (a)(13) of this section, a comprehensive reassessment of each

patient and a revision of the plan of care must be conducted— (2) At least monthly for

unstable patients including, but not limited to, patients with the following: (i) Extended or

frequent hospitalizations; (ii) Marked deterioration in health status; (iii) Significant change

in psychosocial needs; or (iv) Concurrent poor nutritional status, unmanaged anemia and

inadequate dialysis.

Interpretive Guidance §494.80(d)(2)(i), (ii), (iii), and (iv)

The criteria listed in this section are the minimum criteria for classifying patients as “unstable.”

The IDT members have the flexibility to use their professional judgment to develop more

stringent policies and add other assessment criteria to the definition of “unstable,” based on

their unique patient population and patient characteristics.

Hospitalization and readmission rates will vary based on the characteristics of the patient

population. For the Medicare dialysis population, facilities and survey agencies may use the

most recently published Dialysis Facility Report to identify the national average for length of

stay (extended hospitalization) and readmission rates (frequent hospitalization).

Clinical and psychosocial deterioration is a key indicator in patient mortality and quality of life.

“Marked deterioration in health status” should be specifically identified and documented by the

IDT. The following conditions are examples consistent with deteriorations exemplified in the

renal disease patient:

• Change in ambulation severe enough to interfere with the patient’s ability to follow

aspects of the treatment plan;

• Hypotension, restlessness, pruritus, or other symptoms severe enough to prevent

completion of the majority of dialysis treatments;

• Sudden onset of recurrent cardiac arrhythmias;

• Recurrent infections (not recurring hospitalization);

• Chronic congestive heart failure with chronic hypotension;

• Advanced or metastatic cancer or other organ system disease that interferes with the

patient’s ability to follow aspects of the treatment plan;

• Chronic or recurrent peritonitis

“Significant change in psychosocial needs” would include any physical or mental health event

that interferes with the patient’s ability to follow aspects of the treatment plan. Such events may

include instability in one’s own or an immediate family member’s employment, physical or

emotional abuse, deterioration in mental or functional status, amputation, housing instability,

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death or major illness in the family, consideration of terminating treatment, and loss of

emotional support. In addition, any patient considered at risk for involuntary discharge or

transfer must be considered “unstable” and as such, must be reassessed monthly. Note that V767

requires patients at risk for involuntary discharge to be reassessed prior to actual discharge or

transfer from the facility.

“Poor nutritional status” would include failure-to-thrive symptoms, such as loss of body weight

and low serum albumin levels.

“Unmanaged anemia” would include continued lab findings of hemoglobin/hematocrit values

that are outside the range defined by community-accepted standards or the Centers for Medicare

and Medicaid Services (CMS) Clinical Performance Measures (CPMs). Refer to the Measures

Assessment Tool (MAT), which lists the current professionally accepted clinical standards and

current CMS CPMs.

“Inadequate dialysis” would include a trend of results for Kt/V or URR that do not meet the

minimum for a three-month period. Inadequate dialysis would also include symptoms related to

fluid management, such as volume overload or depletion; intradialytic symptoms, such as

syncope or congestive heart failure; hypertension; or the need for extra treatment(s) for fluid

removal.

Facilities must have a method for classifying patients as “unstable.” Documentation should be

available of a monthly reassessment and plan of care revision that addresses the issues related

to the classification of the patient as “unstable” until the issues have been resolved or the IDT

(including the patient if possible) determines that the condition is chronic and the active care

plan adequately addresses the issues.

Some changes leading to the patient classification of “unstable” are clearly within the purview

of a specific member of the IDT. For example, while housing instability falls within the realm of

the social worker, expect to see documentation of communication regarding a change in housing

between the social worker and other members of the IDT who can determine the specific impact

of that change on their specialty. The participation of some team members in some changes that

do not impact their specialty may be limited.