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Establishing an End Stage Renal Dialysis Forum

PDF Version of DQA 11-023  (PDF, 42 KB)

Date: August 5, 2011 -- DQA Memo 11-023
To: End Stage Renal Dialysis Facilities ESRD 08
From: Cremear Mims, Director
Bureau of Health Services

Otis Woods, Administrator
Division of Quality Assurance

Establishing an End Stage Renal Dialysis Forum

The purpose of this memo is to invite Wisconsin End Stage Renal Dialysis (ESRD) facility management staff to participate in Quarterly Forums with the Division of Quality Assurance (DQA) staff to discuss emerging issues in the facilities.


The Division of Quality Assurance is the State agency that is under contract with the Centers for Medicare and Medicaid Services (CMS) to conduct onsite inspections of ESRDs in Wisconsin. Federal ESRD Surveys are conducted by nurses and engineers on a regular basis, as directed by CMS, to ensure compliance with 42 CFR Part 494 Federal Conditions for Coverage (CfC). The ESRD CfCs are the minimum health and safety standards that all Medicare and Medicaid participating dialysis facilities must meet.

From January 2005 through December 2010, 38 onsite surveys resulted in the issuance of 75 deficiencies for situations being found out of compliance with the CfC's. From October 2008 through July 2011, a total of 32 surveys resulted in noncompliance with 68 CfC's. These finding reveal major problems and challenges for Wisconsin's ESRDs, as well as the need for a discussion forum to dialogue about potential solutions.

Quarterly Forum

Because we are concerned about the trend in survey outcomes, we would like to provide a venue where providers and DQA can work together to improve care delivered to vulnerable consumers, as well as to address the major compliance problems identified during survey. DQA representatives would be able to provide you clarification on the CMS survey process, current regulatory requirements, as well as to discuss relevant standards of practice within ESRDs. There are currently 115 ESRD providers in the State of Wisconsin. We welcome your feedback as to whether you would like to participate in this information-sharing opportunity. Once we confirm the amount of interest, we will proceed with planning the face-to-face and/or online forum discussions.

The ESRD final rule and the Department of Health Services (DHS) web link are listed below:

Please respond by September 2, 2011 to Ann Hansen, QAPS-Senior at if you are interested in participating.

Thank you for your consideration.

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Last Updated: August 25, 2011