THE ACCESS — AN ATLAS OF THE U.S. DIALYSIS SYSTEMPLATE VIII — PROOF STATE — 07|2026

The Two Ladders

A GENERATED VIEW · ONE NUMBER, THREE READINGS

Is this number a floor or a target — and for whom? The same adequacy value is read three ways on one scale: the regulatory floor a surveyor scores against the whole cohort, the best-practice target the guidelines set for the cohort, and the individualized goal the plan of care sets for one person. The peritoneal-dialysis panel is the argument: the regulator still holds a rung the best-practice guideline dissolved into the patient — and one lawful goal sits below the floor, because the regulation wrote its own escape hatch.

HOW TO READ · THE VERTICAL SCALE IS THE ADEQUACY NUMBER · BLUE RAIL = THE REGULATORY FLOOR (COHORT, SCORED) · CARBON RAIL = THE BEST-PRACTICE TARGET (COHORT, ASPIRATIONAL) · RED RAIL = ONE PATIENT’S GOAL (PLAN OF CARE, ILLUSTRATIVE) · HATCHING = BELOW THE FLOOR · THE LEDGER BELOW CARRIES EVERY VALUE WITH ITS SOURCE
AN ATLAS OF THE U.S. DIALYSIS SYSTEMWIDE GRAMMAR — LADDERPLATE VIII
The Two LaddersPROOF STATE · ED. 001 · 07|2026
THE HD LADDER READ ON spKt/V PER SESSION (3x/WEEK) 1.0 1.1 1.2 1.3 1.4 1.5 1.6 REGULATORY FLOOR FLOOR 1.2 BELOW = CITED BEST PRACTICE TARGET MIN 1.2 TARGET 1.4 THIS PATIENT PLAN OF CARE GOAL 1.3 ILLUSTRATIVE THE PD LADDER READ ON WEEKLY Kt/V UREA (DIALYSIS + RKF) 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2.0 REGULATORY FLOOR FLOOR 1.7 BELOW = CITED BEST PRACTICE TARGET NO SINGLE NUMBER THE PERSON IS THE TARGET THIS PATIENT PLAN OF CARE GOAL 1.5 ILLUSTRATIVE
MARGIN — RESERVED FOR THE HAND
KEY
REGULATORY FLOOR — COHORT, QIP-SCORED
BEST-PRACTICE TARGET — COHORT, ASPIRATIONAL
ONE PATIENT’S GOAL — PLAN OF CARE (ILLUSTRATIVE)
THE DISSOLVED RUNG — NO SINGLE NUMBER (ISPD 2020)
THE LEDGER — EVERY VALUE, WITH ITS SOURCE · LAST VERIFIED 2026-07-10
MODALITYREADINGVALUESOURCESTATUS
HDRegulatory floor1.2MAT V629 (CfC/CMS CPM 4-2008) + V544; QIP PY2028 rosterverified
Best-practice minimum1.2KDOQI HD Adequacy 2015 Update (unchanged from 2006)verified
Best-practice target1.4KDOQI HD Adequacy 2015 Updateverified
This patient’s goal1.3set in the plan of care; between floor and target, justified by measured residual kidney function · 42 CFR 494.90 (individualized, measurable POC) + the KDOQI RKF allowanceillustrative
PDRegulatory floor1.742 CFR 494.90(b)(1) verbatim; MAT V629 + V544 (KDOQI PD 2006)verified
Best-practice targetno single numberISPD 2020 (Brown et al., Perit Dial Int 2020;40(3):244-253) + KDOQI 2020 US Commentary; CMS still surveys the 1.7 -- the two ladders disagree, and the chart must carry the reconciliationverified
This patient’s goal1.5BELOW the regulatory floor, lawfully: the documented alternative individualized adequacy strategy of 494.90(b)(1), anchored on RKF and clinical goals · 42 CFR 494.90(b)(1) + ISPD 2020 goal-directed frameillustrative
THE ACCESS · 07|2026
ED. 001 · GENERATED VIEW SRC: MAT (ESRD IG V1.1 2008) · 42 CFR 494.90 · KDOQI HD ADEQUACY 2015 · ISPD 2020 (BROWN ET AL.)
PLATE VIII · PROOF STATE · LAST VERIFIED 2026-07-10 GENERATED FROM THE ATLAS DATASET
AWAITING THE AUTHOR’S PASS PLATE IX