Need for Certification of Dialysis Patient Care Technicians Draws Near

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The clock started ticking for dialysis providers when the new Conditions of Medicare Coverage for ESRD facilities became effective October 14, 2008. Since the new regulations were published on April 15, 2008, dialysis providers have scrambled to put new processes in place to address changes the Conditions bring to patient safety, patient care, and administration in outpatient dialysis facilities. However, addressing the new requirements for training and certification of patient care technicians (PCTs) may have been deferred because the deadline of April 15, 2010, for certification of PCTs employed on the effective date of the new Conditions loomed far into the future relative to all other changes.

But facility leaders don’t have as much time to address these changes as it seems. Nor are facility leaders the only individuals who should be concerned about the changes. Dialysis PCTs comprise a large proportion of the staff at outpatient dialysis clinics. Should a high percentage of PCTs fail to meet the training and certification requirement of the new Conditions by the target deadline, daily operations in these facilities could be curtailed and patient care may suffer. Therefore, all members of the interdisciplinary team should understand the importance of the dialysis PCT certification requirement and be actively involved in plans to ensure that each PCT is successful in achieving the requirement.

History of the dialysis patient care technician

During the 1980s, hiring of unlicensed assistive personnel grew in acute care hospitals and chronic care facilities as cost containment measures were put into place to stem the rising cost of health care. As the shortage of licensed nurses grows, use of these caregivers continues to expand—as does the variety of tasks delegated to them.

State boards of nursing and other regulatory bodies joined professional organizations and consumer groups to call for federal regulations for nursing homes and home health agencies to ensure that these unlicensed assistive personnel receive appropriate training, are supervised by the licensed nurse, obtain and maintain state-regulated credentials, and work within defined, acceptable staff mix and ratios (1).

When the original Conditions for Coverage were published in 1976, dialysis technicians were an “emerging occupation.” Nurses provided much of the dialysis treatment, typically at ratios of one nurse to two patients. Today, dialysis PCTs are the primary caregivers of the dialysis treatment. It is accepted that a technician provides dialysis treatments to three or four patients at a time.

Until the new Conditions were published, there were no federal requirements for dialysis technicians, except for reuse technicians, who are covered by American Association of Medical Instrumentation (AAMI) guidelines (2). The regulation impacts more than 30,000 PCTs, working full-time and part-time, in dialysis facilities throughout the country, based on 2006 U.S. Renal Data System Provider Characteristics (3).

Prior to the publication of the new Conditions, as many as 15 states regulated the dialysis PCT by establishing minimum qualification requirements, mandatory competency testing, registration, licensure, or certification, so some dialysis facilities and PCTs meet the new criteria. However, ambiguity exists in some regulated states as to whether the competency testing satisfies the new requirements even though the final version of the interpretive guidelines for surveyors has attempted to clarify this: “If the state has a certification and competency testing program (which includes standardized tests reflecting the content listed in the regulation, administered in a proctored environment unrelated to any dialysis facility) in place that is specific to dialysis PCTs, then State certification also satisfies this requirement. If a PCT is currently certified, as described, to practice by the State in which he or she is employed as a PCT, then he or she meets the requirements at 42 CFR 494.140(e)(4)” (4).

A word of caution

Certification of PCTs will not replace the need to comply with state-specific laws, regulations, statutes, rules, and practice standards for the nephrology specialty that regulate the practice of each licensed member of the interdisciplinary team and their delegation to others. The relationship between the licensed nurse and the PCT, as outlined in the scope of nursing practice and delegation guidelines, does not change as a result of PCT certification.

In addition, the need for the individual PCT to take responsibility for obtaining and maintaining certification, including documentation, is essential and should not be understated. Most dialysis PCTs have years of experience and are very effective at providing the dialysis treatment, but many may be concerned with one or more of the following:

  • It may have been years since they have had to take a formal test.
  • Their training may fall short of the required curriculum and may not even be documented as it was conducted “on the job.”
  • The requirement of formal continuing education as a condition of recertification may strain their financial resources and time commitments.

Your facility’s plan to meet the requirement should address these areas of individual concern.

What are the changes?

The new requirements for PCT training and certification set forth in 42 CFR 494.140(e) (4) include:

  • high school diploma or equivalency.
  • completion of a training course approved by the medical director and governing body, under direction of RN, with content specifically described in the Conditions.
  • certification by a state or national program: PCT employed by Oct. 14, 2008, must be certified by April 15, 2010; PCT employed after Oct. 14, 2008, must be certified within 18 months of hire (5).
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Get started now

The following step-by-step guide is offered to help ensure that PCTs in your facility will be ready to meet the new requirements for dialysis PCT training and certification.

  1. Determine whether your state has requirements for dialysis PCT training and certification. If certification is required, is a specific examination required following training? You should consult with your state’s regulatory bodies who have been working with CMS to clarify the use of certification and competency testing programs.
  2. Evaluate your current dialysis PCT training program to ensure it includes the required subjects (Table 1) and modify accordingly. The Core Curriculum and the Kidney School materials described elsewhere in this article are excellent resources for your training program. They are available by Internet download at low cost, and could be used as standalone training manuals if these are lacking.
  3. Review and update the dialysis PCT job description to incorporate the existing state requirements and new federal regulations. Have each dialysis PCT sign and place into the personnel record.
  4. Review the employee records of the PCTs to: 1) determine high school graduation, GED, or four years of experience working as a PCT (if employed on Oct. 14, 2008) prior to applying for a certification exam; and 2) ensure that documentation of dialysis training exists. Complete missing information. If a PCT employed for more than two years of the effective date of the regulations does not have documentation of having completed a training program, “competency may be demonstrated by successful completion of a facility’s written exam(s) over the required content and a skills checklist completed by observation of the PCT’s skills by a registered nurse (6).”
  5. Identify the certification exam options best suited for the PCT in your facility. There are currently three options (see Table 3 for a summary of exam options and Table 2 for web resources). Read each option carefully and recognize that you may choose to use more than one exam for your facility, although there are obvious benefits to choosing one exam.
  6. Assess each PCT to determine who may be at risk of failing the examination. Several certifying bodies offer sample tests for free or for a nominal fee. The 2007 Amgen Core Curriculum for Dialysis Technicians provides tests and posts test answers for the eight Learning Modules. Facility leaders could assign PCTs to study the content of specific modules in which low scores were obtained or designate volunteer facility “tutors” to review the content of modules identified by low scores.
  7. Determine what the facility policy will be for failure of the PCT to meet the eligibility requirements to apply for and successfully pass the certification exam. Dialysis facilities operate on narrow profit margins and cannot afford to keep on the payroll dialysis PCTs who cannot fulfill their intended role.
  8. Communicate information to facility dialysis PCTs in writing or during a special meeting. Emphasize the importance of the dialysis PCT in assuming personal accountability to ensure that certification is obtained. Address issues such as who will pay for the cost of taking the initial test or repeat exam if the individual does not pass the initial test, the ongoing cost of recertification, and the consequences of failure to meet the April 15, 2010, deadline for certification of PCTs working as of Oct. 14, 2008.
  9. Establish the last week of August 2009 as a deadline for the PCT to apply to sit for the certification exam. This deadline takes into consideration the fact that the “application–results cycle” could take up to 16 weeks (application deadlines are seven to 10 weeks prior to the exam dates and written results are received by the applicant within four to six weeks from the exam date). If the individual is unsuccessful in passing the initial exam, there is sufficient time for the individual to apply for a retest and to receive the examination results before the April 15, 2010, deadline.
  10. Collaborate with interdisciplinary dialysis team members of your facility and other facilities in your area or local chapters of professional nephrology organizations such as the American Nephrology Nurses Association (ANNA), the NKF Council of Dialysis Nurses and Technicians, the National Renal Administrators Association, and the National Association of Nephrology Technicians (NANT) to present a review course and investigate the requirements for “hosting” an exam site in your community. Investigate the availability of computer-based testing offered by two of the certifying organizations.
  11. Obtain an “acknowledgment of understanding” and a “commitment date to register for the initial exam” completed and signed by each PCT as early as possible.
  12. Monitor the progress of each individual and post a summary in a public area, such as a staff lounge.
  13. Celebrate milestones and success. Consider making a contest with a nice prize for the dialysis PCT who is first to bring in evidence that he or she has completed certification.
  14. Make new name tags for PCTs, once certified, to include the new certification credentials and make a “ceremony” of presenting the new name tags in the presence of patients and other facility staff.
  15. Use the certification process as a springboard to encourage participation in professional associations such as NANT and the NKF Council of Dialysis Nurses and Technicians. Identify materials, resources, and local meetings that can provide continuing education and contact hours. It is never too early to begin the process of meeting requirements for recertification.
  16. Institute a plan to incorporate all the changes above to hire the right individuals without dialysis experience to work as dialysis PCTs in your facility after October 14, 2008. Focus on the minimum educational requirement, the expectation of completion of the facility training program, and the successful completion of national certification within 18 months of the date of hire. Screening tools to assess the ability of the new hires to comprehend didactic material, to transfer this basic training into clinical practice, and to pass the certification exam should assist in the selection of the right individuals for dialysis PCT positions who will be successful and add value to your facility.

Table 1

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Table 2

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Table 3

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Conclusion

Although it may seem a daunting task to work through the changes brought about by the new Conditions, with a proper attitude about the rationale for the changes and a timely, well-thought-out plan, the requirement for dialysis PCT certification can be viewed as an opportunity to improve the value of a precious asset in the outpatient dialysis facility . . . the growth and development of the dialysis PCT.

References

1. 

The Continuum of Care: A Regulatory Perspective—A Resource Paper for Regulatory Agencies, National Council of State Boards of Nursing, 1998, retrieved December 31, 2008, from http://www.ncsbn.org/contcarepaper.pdf.

2. 

Renal Disease: NPRM of Coverage of Suppliers of End Stage Services. Proposed Rules and Regulations: Subparts A, B, C, and D: Conditions of Coverage of Suppliers of End Stage Renal Disease (ESRD) Services. Federal Register 70, Centers for Medicare and Medicaid Services, February 4, 2005.

3. 

U.S. Renal Data Systems Annual Report 2008 (Provider Characteristics), National Institutes of Health and National Institute of Diabetes and Digestive and Kidney Diseases, retrieved December 31, 2008, from http://www.usrds.org/2008/ref/J_Provider_Characteristics_08.pdf.

4. 

FAQs ESRD Conditions for Coverage (CfCs) Final Rule Rollout, Centers for Medicare and Medicaid Services, 2008, retrieved December 31, 2008, from http://www.cms.hhs.gov/CFCsAndCoPs/downloads/FAQsESRDRolloutFINAL082808.pdf.

5. 

42 CFR Parts 405, 410, 413 et al. Medicare and Medicaid Programs; Conditions for Coverage for End-Stage Renal Disease Facilities: Final Rule, Centers for Medicare and Medicaid Services, 2008, retrieved December 31, 2008, from http://www.cms.hhs.gov/CFCsAndCoPs/downloads/ESRDfinalrule0415.pdf.

6. 

Advance Copy—End Stage Renal Disease (ESRD) Program Interpretive Guidance Version 1.1, Centers for Medicare and Medicaid Services, 2008, retrieved December 31, 2008, from http://www.cms.hhs.gov/EOG/downloads/EO%200526.pdf.