CMS SOM App. H, Tag V585

dialysis patient and address the specific needs of the patient, in the following areas:

(i) The nature and management of ESRD.

(ii) The full range of techniques associated with the treatment modality selected, including

effective use of dialysis supplies and equipment in achieving and delivering the physician’s

prescription of Kt/V or URR, and effective administration of erythropoiesis-stimulating

agent(s) (if prescribed) to achieve and maintain a target level hemoglobin or hematocrit as

written in patient’s plan of care.

(iii) How to detect, report, and manage potential dialysis complications, including water

treatment problems.

(iv) Availability of support resources and how to access and use resources.

(v) How to self-monitor health status and record and report health status information.

(vi) How to handle medical and non-medical emergencies.

(vii) Infection control precautions.

(viii) Proper waste storage and disposal procedures.

Interpretive Guidance § 494.100(a)(3)(i)-(viii):

The training must be individualized to the needs of each home dialysis patient. Patients and/or

their caregivers may be trained in small groups or individually, as long as the individual patient

needs are identified and addressed. The information provided should be tailored to the

individual’s level of understanding. Each of the subject areas listed here should be addressed in

the training record. Examples for clarification of the subject areas are as follows:

The “full range” of home dialysis techniques would include:

1. Specific (step-by step) instructions on how to use the patient’s prescribed dialysis

equipment (e.g. hemodialysis machine and water treatment components, peritoneal

dialysis cycler);

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2. Specific (step-by step) instructions in home dialysis procedures (e.g. self-cannulation,

peritoneal dialysis exchange) to facilitate adequate dialysis as prescribed by the

physician; and,

3. Training in proper storage and administration of ESAs, if applicable. Refer to V548 for

anemia management requirements for home patients.

Peritoneal dialysis patients must be taught to recognize, manage and report dialysis

complications, including, but not limited to: catheter, tunnel or exit site infection; peritonitis;

catheter dislodgement; hypotension; hypokalemia; failure of sufficient dialysate to drain from

the peritoneal space; and, protein malnutrition. Home hemodialysis patients must be taught to

recognize, manage and report such potential complications as vascular access problems (e.g.,

difficulty with cannulation, a change in bruit or thrill, bleeding), infections, hypertension or

hypotension, hyperkalemia, etc.

Technical problems to be recognized, managed, and reported would include: power outages;

failure of the PD cycler or HD machine; failure of water treatment components (e.g.,

chlorine/chloramine breakthrough); clotting of the hemodialysis circuit; dialyzer blood leaks;

line disconnection; water supply problems or leaks; and, problems with supply delivery.

The facility training program should include instruction aimed at enabling patients/caregivers to

detect, prioritize and report problems and to ensure that they are prepared to recognize and

promptly act upon those situations which could present hazards to patient safety. Training home

dialysis patients/caregivers to handle medical emergencies that may be anticipated (e.g.,

syncope, significant blood loss, cardiac events) would include immediate responses/actions and

methods for contacting emergency medical systems. Refer to V768.

Training for non-medical emergencies may include those related to mechanical/technical

equipment failures (as listed above), as well as preparing for natural or man-made disasters that

may result in the inability to dialyze at home as scheduled and/or delays in supply delivery. Refer

to V412.

Support services such as mentorship, renal community engagements, and ways to get answers,

information, and other resources exist for individuals with renal failure. Patients need to

understand how to contact and use their support resources, including access to their assigned

facility staff coordinator, physician, home training nurse, dietitian, social worker, dialysis

equipment suppliers, machine manufacturers, and water treatment personnel. As with in-center

patients, facilities must provide home dialysis patients with contact information for the

applicable ESRD Network and State survey agency.

Training for home patients to monitor their own health status should include: the use of

equipment to monitor heart rate, blood pressure, temperature, and weight; assessment of

vascular or peritoneal dialysis access; recognizing adverse signs and symptoms; and, when,

how, and whom to contact if they experience problems with their health or treatment. Recording

treatment and health status information for home dialysis patients includes documentation of the

dialysis process, using hemodialysis or peritoneal dialysis specific treatment records.

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Training for infection control precautions should include, at a minimum, indications for the use

of gloves, masks, and other personal protective equipment, methods for hand hygiene, vascular

access or peritoneal catheter care and dressing changes, cleaning and disinfecting dialysis

equipment, and, cleaning and disinfection procedures for spills and splashes of blood or effluent.

Patients/caregivers need to understand how to properly dispose of needles, effluents, disposable

items, blood tubing, and dialyzers to minimize risks of infection or injury to self and others and

to prevent environmental contamination (e.g. using impervious puncture resistant containers for

disposal of sharps, placing empty dialysate bags and dialysis tubing and other contaminated

items in intact plastic bags before discarding). The training staff must ensure that patients

understand local waste management rules.

According to AAMI, as part of their training for home hemodialysis, the patient/helper should be

instructed in any water/dialysate sample collection or any water/dialysate quality tests that they

will be expected to perform in their homes. AAMI also states that the patient/caregiver shall be

trained how to perform the chlorine analysis and shall be trained regarding what action to take

if chlorine is detected above the specified limit. Depending upon the chlorine test used, the

patient/caregiver should be capable of distinguishing between different shades of pink or a

digital meter should be used to indicate the chlorine concentration. Digital meters should be

calibrated to zero prior to testing to ensure accurate measurements.

Home dialysis training materials should address the training content listed in this regulation, at

a minimum.