CMS SOM App. H, Tag V550

address, but not be limited to, the following: (5) Vascular access. The interdisciplinary

team must provide vascular access monitoring and appropriate, timely referrals to achieve

and sustain vascular access. The hemodialysis patient must be evaluated for the

appropriate vascular access type, taking into consideration co-morbid conditions, other

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risk factors, and whether the patient is a potential candidate for arteriovenous fistula

placement…

Interpretive Guidance § 494.90(a)(5)

Based on the comprehensive assessment, the facility IDT must develop and implement a plan of

care to facilitate each hemodialysis patient receiving and maintaining the most appropriate and

optimal vascular access identified for that patient.

A well-functioning vascular access enables the hemodialysis patient to receive efficient/adequate

dialysis treatments, enhancing their quality of life. The determination of which type of vascular

access is the most appropriate for the individual patient requires the integration and

coordination between the facility IDT, including the patient/designee, and may include referrals

for vessel mapping, surgical consult, Doppler studies, etc., enlisting the participation of other

facilities, such as primary care physicians, surgeons, interventional radiology, and surgical or

vascular access centers for access placement and maintenance.

To meet this requirement to “achieve and sustain” vascular access, the patient’s medical record

must include evidence of the evaluation and the basis for the decision for placement of the

current vascular access. If the records from the surgeon are not available, the patient’s

physician, advanced practice registered nurse, or physician assistant is expected to provide this

information from communication with the surgeon. If the patient’s vascular access is not an

arteriovenous fistula, the record should indicate why the patient was determined not to be a

candidate for a fistula. If a patient has been dialyzed with a central venous catheter for more

than 90 days, there should be an active plan in place for the placement of a more permanent

vascular access, or information in the record should demonstrate that a catheter is the most

appropriate vascular access for that patient. Some patients may not be candidates for a fistula or

graft; each patient has the right to make an informed choice. Patients must be informed and

educated about the benefits, risks, and hazards of each type of vascular access (V456). Repeated

education may be needed. The IDT must involve the patient/designee in the plan for vascular

access. The facility social worker should be involved and determine whether psychosocial

considerations, such as body image, needle fear, or anxiety, need to be addressed.

Vascular access monitoring is addressed in V551. Requirements for vascular access assessment

are at V511.