End Stage Renal Disease (ESRD) Setting


1. How can Dialysis Technicians (DT) trained several ago years and who are certified as a CNA get DT added to his/her certificate? 

The CNA who was trained several years ago as a DT is eligible for the additional certification of DT when the Dialysis employer provides a written letter on the agency’s letter that includes the following: 
  • Name and social security number of the CNA-DT
  • Name of training program and date the CNA-DT was trained
  • Copy of training program certificate if available (required for anyone trained after 2002)
  • Previous employers and dates of employment as a CNA-DT
  • Current employment as a CNA-DT including employer name, dates of employment, and full or part time status
  • Dates of completion of the required 2 year Clinical Update.
  • Letter signed by Maryland Supervising RN with RN’s license number.

This information is placed in the computer file of the CNA-DT and also maintained in a paper file at the Board. The correspondence may be directed to Jaray Jarvis, Dialysis Technician Program, MBON, 4140 Patterson Avenue, Baltimore, MD 21215. Please remember that the training program completion award must denote Dialysis Technician not PCT.

2. Is there a dialysis RN to dialysis patient ratio specifically a patient ratio for the charge nurse? 

The MBON does not have a nurse-patient ratio or charge nurse to patient ratio for any setting. Patient outcome, missed orders, change in patient condition that were not followed up on etc, would serve as evidence that the nurse to patient ratio was insufficient. The MBON would not investigate unless the MBON had a complaint.

The charge nurse to patient ratio would be examined by the same elements as above. The following elements would also be considered: number of patients the charge nurse RN is assigned to; number of unlicensed nurses the charge nurse RN must supervise; the experience that each licensed nurse may have in hemodialysis; the acuity level of each client; how brittle each client may be in responding to the dialysis procedure; number of CNA-DT and experience level of each CNA-DT that each staff nurse must supervise; etc.

3. Does the Office of Health Care Quality (OHCQ) and the Commission on Kidney Disease (CKD) surveyors have the authority to interpret the Nurse Practice Act and cite such interpretations as grounds for survey deficiencies at Kidney dialysis centers?

Yes, both OHCQ and the CKD have authority through COMAR and COMAR to require the dialysis facility to meet all local, state and Federal requirements. These state agencies do not interpret another agency’s laws and regulations, instead they cite the other agency’s regulations and laws.

4. If an RN assess that there is an inadequate number of staff available to provide patient care that day (e.g. CNA-DT call out) What can the RN do? Can the RN refuse the assignment of the day until adequate staff is provided (e.g. contact agency for supplemental staffing?

The RN should alert the facility CEO to the staffing issue. According to Federal regulation V141 the responsibilities of the chief executive officer include but are not limited to: “(viii) ensuring that the facility employs the number of qualified personnel needed.” The nurse must assure that patients are provided safe and effective treatment.

In addition, the MBON’s Regulations Governing Standards of Practice for the Registered Nurse COMAR 10.27.09 Section (.03) (J) and the Regulations Governing Code of Ethics COMAR 10.27.19. COMAR describes the actions of a RN in accepting a patient assignment. Accepting a patient assignment may include the RN arriving on duty, and assuming responsibility for patient care based on the nurse’s reasonable, prudent professional judgment and the standards of nursing practice. Therefore, the RN charge nurse must determine that given the number of patients, the clinical status of the patients, the number of CNA-DTs and the skill level of the CNA-DTs, etc. that dialysis can be safely performed or whether more staff are needed or whether adjustments to the patients daily schedule must be made. 

The Regulations Governing the Standards of Practice for Registered Nurses, COMAR provide guidance on the RN’s right and responsibility in refusing an assignment. In addition, the MBON web page also contains a document entitled, “Giving, Accepting, and Rejecting a Work Assignment: A Guide for Nurses” which may also provide assistance.

5. Is it appropriate for a RN to be assigned to monitor up to 3 patients and be the nurse responsible for patient care (assessments, meds, etc.) for up to 6 patients including 3 patients he/she is monitoring?

Whether it is appropriate and safe depends upon a number of variables which may include but are not limited to: the clinical status of the patient; the skill level and experience of the CNA-DT assigned to the patient; the knowledge, skill and experience of the primary RN assigned to the patient; and the knowledge, skill set and experience of other licensed nurses present during the dialysis procedure.

6. Is the charge nurse allowed to run 3 patients on the floor at the same time as being charge?

Please refer to question 5. In addition to the above, The RN charge nurse must also examine additional variables which may include but are not limited to the question-would any other reasonable prudent nurse be able to effectively: delegate to and supervise the number of CNA-DTs present performing dialysis; assess and monitor all of the patients receiving dialysis; provide direction and supervision to other licensed nursing staff; and perform all other charge nurse responsibilities. 

7. Are CNA-DTs allowed to place oxygen on a patient under direct RN supervision?

Yes, please refer to the CNA-DT Training program curriculum – the component 
on Treatments.

8. Are CNA-DTs allowed to turn on oxygen for patients on maintenance oxygen? 

Yes, under the direction of the RN, charge nurse

9. Are CNA-DTs allowed to administer oxygen in emergency situations?

Yes, under the direction of the RN, charge nurse

10. Dialysis Assistant (DA) - Can they monitor and record treatments including vital signs? This is a different job than CNA – DT

The dialysis assistant is an unlicensed person. The dialysis assistant may not perform any patient care activities including any monitoring, recording of any treatment or taking vital signs.

11. Does the MBON have the primary authority and responsibility for interpreting and enforcing MBON regulations? 

Yes, the MBON has authority to regulate nursing education, licensure and Practice and interpret those regulations and laws.

12. Can current CNA-DTs precept new CNAs in the dialysis center?

Until the student completes the CNA-DT Training Program, the individual is a student not a “monitoring individual” as referenced in COMAR and COMAR The currently employed CNA-DT may not precept a CNA-DT student. Once the student has successfully completed the Board approved training, submitted an application to be certified as a CNA-DT and is an employee (no longer a student), the facility may partner a current CNA-DT with a new employee CNA-DT.

13. For the survey period 11/22/06 to 5/22/07 the statistics represent how many completed surveys by OHCQ?

There were eight surveys during this period.

14. May a RN call in a prescription for a patient if she has a written prescription from the physician?

It is up to the pharmacist to determine if the pharmacist will accept a new order or a medication refill from an RN rather than the prescribing physician. The MBON considers this question to be a physician precriber-pharmacist dispensing issue, not a nursing issue. 

15. In regards to computerized systems, can the CNA-DT enter the pre and post patient data collection elements into the computer and can the RN initial the hard copy of the treatment record?

The CNA-DT may collect selected data elements and the CNA-DT may record these data elements on the patient record (electronic or hard copy record). However, the pre and post assessment must be performed by the RN and entered into the patient record by the RN. The RN may not delegate performance of or documentation of the patient assessment.

16. When will the renewal of the CNA-DT be available online?

The CNA-DT can renew online including the additional certification of DT. If the individual renews online, checks DT and does not receive this status, please contact the MBON-CNA Department, Ethel Stanley, Administrator of the CNA Program at 410-585-1934 or electronically at estanley@dhmh.state.md.us

17. Can RNs obtain the first initial informed consent/authorization for dialysis treatment from the patient?

The RN may obtain patient’s informed consent or may witness the patient giving informed consent for the dialysis treatment per Declaratory Ruling 2006-2 Re: Licensed nurse (RN and LPN) Obtaining the Patient’s Informed Consent; or Witnessing the Patient Giving Informed Consent for an Operative or Invasive Procedure or Treatment or Diagnostic Treatment; or Obtaining a Patient’s Consent to Participate in a Research Study.

18. I have a RN that has re-applied after having an expired RN license. He received a paper stating he has a license, but it is not online, but he is on the telephone verification system.

If the MBON has sent a notice that the applicant now has a current licensure status but it does not show online, then contact the MBON 410-585-1900 for assistance.

19. What can LPNs actually do in the clinic environment independently? Please be specific.

The LPN performs under the supervision of the RN charge nurse. The LPN is not an independent nursing care provider. The LPN can perform several activities relative to IV access devices and IV medication administration (see COMAR In addition, the LPN may assist in assessing and monitoring the patient during the dialysis treatment. The LPN assessment does not replace the RN initial assessment (prior to beginning dialysis that day) or the RN post dialysis assessment (following the dialysis treatment that same day). The LPN may augment the RN’s teaching of the dialysis patient. 

20. Can a CNA-DT collect pre-assessment data elements such as vital signs, check for edema; and report any abnormality to the RN and then start the patient’s treatment before the nurse does the assessment?

The CNA-DT can gather selected data elements which are part of the pre-assessment, such as vital signs. However, determining degree of edema present and determining whether dialysis may begin or not, can not be decided by the CNA-DT. These decisions rest with the RN. 

21. Do you think there is an overwhelming amount of responsibilities for a RN (charge nurse) for an ongoing understaffed dialysis setting? Do you think there should be a definite nurse: patient ratio in any dialysis clinic?

Please refer to previous questions 2, 4, 5, and 6 for a discussion of the reasonable prudent nurse and assigned responsibilities.

22. Can RNs review the CPR preference with the patient and have the physician co-sign?

The physician must write a prescriptive order addressing a “do not resuscitate” or other CPR preferences. Following the physician order, the RN may review the CPR preference with the patient.

23. Will there be a time when a CNA-DT could be trained as a medication technician to free up the RN for assessments in the dialysis facility?

The CNA-DT is already authorized to administer selected medications in the dialysis setting. The specific medications and under what conditions these medications may be administered are specified in the CNA-DT Board approved training program. The Board is not considering adding additional medications at this time.

24. Our nurses are paid for all the time-no lunch time deducted, are they considered on-duty the entire day? Therefore – one nurse in the facility meets the V432-Federal requirement. Is thus a correct statement?

No, this is not a correct statement. COMAR (B) and COMAR requires the RN charge nurse to be on the unit during dialysis. The requirement is that the RN must be physically present on the unit during clinical care, (dialysis).

25. In units with one nurse covering, can the RN leave the unit to take a break in the break room and still be considered physically present and available to the patients?

The RN must be physically present on the unit when dialysis is occurring. If the break room provides a clear view of the dialysis treatment area the RN may go to the break room. If the break room which is physically adjacent to the treatment room, has a loud audible alarm that permits the RN to respond as in an emergency situation, then the RN may go to the break room. For specific questions about your physical plant please contact OHCQ and the Commission on Kidney Disease.

26. There is great concern about requiring each dialysis center to provide Hepatitis B isolation. Hopefully centers will not have many of these patients and ideally isolation areas will be used for only those patients with Hepatitis B. However, if the center is full and has only one Hepatitis B patient they will be more likely to put non-Hepatitis B patients in that area to obtain full utilization of available chairs. This can increase the risk of a patient being infected with Hepatitis B if the patient loses or does not have Hepatitis B antibodies. From a process and organization standpoint it make much more sense for a group of centers who are geographically close to designate one or more centers to care for these patients; That way staff always know that the Hepatitis B area has specific procedures and its use doesn’t “change” based on the patients status. This also is much more practical and safe from an infection control standpoint and promotes optimal use of existing chairs and staff. Could you give cohorting of patients careful consideration?

The CDC recommendations and COMAR require staff members who are caring for HbsAg+ patient(s) should not care for susceptible patients at the 
same time, including during the period when dialysis is terminated on one patient 
and initiated on another. COMAR 10.30.02 states “An end stage renal disease patient with viral hepatitis or acquired immunodeficiency syndrome (AIDS), or both, may not be denied dialysis or transplantation by a certified Maryland dialysis or transplantation facility solely because of the potential for transmission of hepatitis B virus or human immunodeficiency virus (HIV), or both, to other patients of treatment personnel.” 

27. The proposed revisions to the Federal Conditions for Coverage include radical changes to the nursing assessment and other assessment processes. What is being done by the State to ensure that the state regulations do not contradict the revised Federal regs (when they are released)?

The federal regulations for the Long Term Plan (LTP) and Patient Care Plan (PCP) will be replaced by a condition for patient assessment. Once the new federal regulations are implemented, the facilities have a 90 day period, to come into compliance with the new regulations. The state regulations for the LTP and PCP have not changed. The licensing requirements will still require LTPs and PCPs to be completed as per COMAR and (.08). Regardless of the changes to the federal regulations, the most stringent regulations will be applied.

28. Are there guidelines for how to treat or handle psychiatric or behavior problem patients, so that a facility is not cited for not doing particular procedures for that patient? Especially after the facility documents, and holds meetings. The patient can be competent and slightly demented, and also be manipulative.

These patients should be quickly identified and treatment plans including specific behavior contracts and appropriate outside referrals should be implemented and documented by the interdisciplinary team to address the patient’s issues. According to COMAR facilities must have policies and procedures addressing the management of abusive and dangerous patients.

29. In some jobs, time management studies are performed i.e. how long does it take to do what. No time management studies have been done in the medical field. Why isn’t time management studied in the medical field?

The Commission on Kidney Disease, The Office of Health Care Quality and the Maryland Board of Nursing are regulatory agencies. It is not within their legislative authority to perform time management research.

30. Doesn’t every business book on management/leadership state that an individual should only work for one person? Why is it in the medical field most RNs work for 2 people? Doesn’t this lead to many communication problems?

Registered nurse practice is regulated by the Maryland Board of Nursing, just as the pharmacist practice is regulated by the Pharmacy Board and the physician practice is regulated by the Physician Board. The practice setting itself is regulated by another entity usually another state agency. This leads to at least two regulatory agencies being involved in the care of patients. The purpose of licensure and regulation is public protection. The RN, physician or pharmacist who practices in a hospital, nursing home, home health setting or assisted living setting etc are faced with a similar situation as the nurse in the dialysis setting.

31. Why are surveyors for the CKD and OHCQ now enforcing compliance with the same regulations in a manner that is inconsistent with prior survey practices and historic interpretations?

Currently, the surveyors from both OHCQ and CKD apply the same federal regulations. In addition the surveyors meet periodically in order to develop consistency between and among all surveyors in application and interpretation of the regulations. If there were inconsistency in the past, it is the goal of these state agencies to assure that history is not repeated now or in the future.

32. How many of the 60,000 RNs are providing clinical care? If the treatment requires RNs and there aren’t enough, how will care be rationed?

The RN renewal application does not require the applicant to reveal whether or not the applicant is practicing nursing at the bedside – therefore not all RNs respond to this question. Nursing, as is every other health profession, is continuing to evolve. This includes the utilization of others such as the CNA-DT to assist in providing care. Work is being done by a number of groups to deal with the nursing shortage and increase the number of licensed nurses. 

33. It seems 50% of nurses leave a position because of “other” than strictly job specific tasks i.e. attitudes etc. Some CKD or MBON rules alienate the RN. e.g. letting a CNA-DT cannulate patients all day long and then telling the CNA-DT he/she can not start oxygen on a patient. Why is it that no one understands how these rules puts the nurse in an awkward position and usually make the CNA-DT resent the RN?

Each individual regardless of his/her license or certification status must be educated to the scope of his or her license or certificate; and to the facility’s policies and procedures on what acts are permitted or prohibited at the specific employment site. Without this constant reinforcement and understanding of each care provider role and responsibility, it frequently becomes an individual issue between the RN, LPN or CNA-DT rather than a legal scope of practice and patient safety issue. 

34. When can the CNA-graduate of the DT training program practice after passing the test?

The new graduate of the dialysis training program must have the MBON 60 day 
permit in hand prior to practicing as a CNA-DT.

35. Recently in the Nurse Communicator the MBON stated that “readily available” in the chronic dialysis setting requires the RN to be “physically present” on the unit of care where the patient is receiving dialysis. As this statement has appeared in a nursing article, does the MBON intend to promulgate a regulation defining what constitutes “physically present on the unit” within the meaningful COMAR so that it has legal force and effect for nurses in all “structured settings”? If so, will the MBON allow a public comment period for nurses and providers in all “structured settings” to provide feedback to the MBON on the implications of such a new regulation?

The MBON’s existing regulations COMAR 10.27.11 Delegation of Nursing 
Functions which you are referencing already defines structured care settings and also includes the RN requirements of “physically present” on the unit. These regulations have been in place since 1994. Physically present on the unit is self-explanatory in that it requires the RN to be physically present on the patient unit, (e.g. not available by telephone or only in the facility). The MBON has no plans to modify this component of the regulations. 

36. Regarding to the CNA-DT on the certificate is there a possibility to fix the problem of the DT not showing up on the licenses?

When the CNA is displayed on the Board web page as a CNA-DT then he/she can renew online. If the CNA is not appearing online as a DT, then he/she can not renew online as a CNA-DT. If the applicant is online as a CNA-DT, renews online as CNA-DT and the renewed certificate does not show CNA-DT then please contact the MBON for assistance, (e.g. Ethel Stanley, Administrator, 410-585-1934 or estanley@dhmh.state.md.us​

37. Post data collection completed by the CNA-DT is different from the post assessment of a nurse. Is post data collection by the CNA-DT adequate for completion of dialysis treatment if the patient is stable?

The RN is the responsible party for determining when the dialysis treatment is complete. The CNA-DT data collection can not replace the RN post-assessment for completion of the treatment.

38. How can compact state RNs verify CNA-DTs online?

The MBON Information Technology Department is currently developing a software program which will allow compact nurses to log in and renew the CNA-DT. It is not competed as yet but is expected to be in place before 2008.

39. When you say the CNA-DT cannot calculate a medication dose, does that mean the CNA-DT cannot draw up the medications? These medications are in multi-dose vials.

The CNA-DT can draw up medication from a multidose vial (e.g. heparin) when the Medication Administration Record (MAR) specifies the number of CCs to be drawn up from the vial and when the medication concentrate is also specified (e.g administer 2000 units of Heparin- 2cc from a 1:1000 unit vial). 

40. Define an example of “process in place to verify correct dosage from correct vial prior to 
administration” of heparin.

The RN, Charge nurse would visually verify the vial from which the heparin is drawn and the syringe the heparin is in. The documentation can be checklist or MAR or nursing note entered by the RN. The methodology can be determined by the facility.

41. Regarding the review of the heparin administration (1,000 u per 1 ml) by the CNA-DT- does the nurse have to verify the bolus heparin administration?

Please refer to question 40

42. Please clarify: Can CNA-DTs administer heparin mid-treatment as a bolus instead of infusion?

Yes, the CNA-DT can administer heparin as a bolus during dialysis when it is a time interval basis per facility policy and is a commonly routinely prescribed dose.

43. Please clarify: Does the RN have to draw up the heparin bolus i.e. bolus is 5,000 units using a 1000u/ml = 5 cc, can the CNA-DT draw up the heparin?

The RN does not have to draw up the heparin.

44. To recertify the CNA-DT, is formal heparin, normal saline or lidocaine training required?

Yes, the required Clinical Update states the current medications including related precautions and interactions of the medications be included in the Clinical Update.

​45. What is required for employee files in regard to proof of experience? 

Proof of experience could be documented in a resume or job application but must be reflected in the initial orientation documentation.

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