About Hospital Safety Center  
Career Center  
Contact Us
       Free Resources
Hospital Safety Insider

Mac's Safety Space  
        News & Analysis
Healthcare Safety Leader  
Environment of Care Leader  
Forms and Checklists Library  




Surveyor gaze is on dialysis compliance


November 1, 2018

Surveyors from CMS and The Joint Commission are taking an interest in dialysis compliance. That means you should too. Dialysis is one of the three main topics that have come up repeatedly at Joint Commission presentations, along with sterile compounding and pain standards. And there’s been a corresponding uptick in scoring for all of these areas in 2018.

“When The Joint Commission indicated that dialysis is going to be a focus area, the field should be prepared for more detailed surveys than we have seen in the past,” says Jennifer Cowel, RN, MHSA, president of Patton Healthcare Consulting in Naperville, Illinois. “Take this as a heads-up notice. We have seen an uptick in dialysis scoring; in fact, we have seen scoring in dialysis in more than half of the survey reports we have seen in recent months.”

“Note that hospitals that are providing inpatient hemodialysis or contracting for the service need to pay attention to the room where dialysis is being provided, particularly if [it’s] not in the patient’s room,” adds Kathleen Good, MSN, RN, an associate of Patton Healthcare Consulting.

“I have seen rusty air conditioning units, soil around the unit, blood spots on the floor, tiles missing behind the dialysis machine, wet towels on the floor, [and] sinks designated solely for hand hygiene being used for emptying bottles of concentrate that were used for patient dialysis,” Good says. 

With the appointment of Sylvia Garcia-Houchins, MBA, RN, CIC as The Joint Commission’s infection prevention and control director, a focus on dialysis is more likely, say Cowel and Good. Garcia-Houchins has over 30 years of experience in the infection prevention and control field and is a specialist in dialysis infection control. 

Yellow and orange findings 

Each year, 468,000 patients receive dialysis as treatment for end-stage renal disease (ESRD). A single procedure takes about four hours, during which a patient’s blood is filtered and cleaned inside the patient’s body (peritoneal dialysis) or outside of it (hemodialysis). There are many possible points of failure in a dialysis treatment, and infections are a major risk. That’s why surveyors are being extra stringent about compliance. 

Cowel and Good have seen numerous findings in dialysis in recent months, including the calibration of the pH/conductivity meter not being tested per the manufacturer instructions for use (IFU). Other issues cited include:

  • Not having an eyewash station when bleaching of a portable dialysis machine is done in a patient room
  • Not conducting a special check of a patient’s catheter that was locked with high-concentration anticoagulant, in clear violation of the hospital’s policy on high-risk medications
  • Improper management of medicines administered during or before dialysis treatment (for example, a dialysis nurse transporting multi-dose vials of heparin instead of single-dose vials) 
  • Not documenting vascular site assessment (e.g., redness, warmth, tenderness, swelling) before and after dialysis, per hospital policy 
  • Not recording that consent was received from a new dialysis patient or that a conversation about risks and benefits occurred 
  • Not verifying that the amount of fluids or medications administered to a patient match the medical order (for example, a nurse administering 100 cc normal saline (NS) instead of 200 cc NS per the protocol order set for hypotension during dialysis) 

Most of these findings have fallen in the yellow and orange levels of the SAFER Matrix, they note. The matrix is a color-coded tool used by Joint Commission surveyors to measure the risk and scale of a problem. 

“We aren’t seeing red, or high risk, scored for the dialysis findings,” says Cowel. “In recent months, The Joint Commission seems to be carefully limiting those issues that land in the high-risk category.”

Still, they warn, don’t minimize the impact of those yellow and orange findings. There have been a few hospitals that have received red findings because of some particularly egregious problem and adverse outcomes.  

“The few high-risk findings noted are related to patient safety where the patient’s graft, fistula, or dialysis site is not openly visible during the treatment, and infection control where poor PPE or no PPE is worn as required, as well as not following isolation practices when required,” says Cowel. 

Good notes that any time a staff member is using a new dialysis monitor (or other device) that he or she hasn’t been trained or tested on, that will definitely be scored as high risk on the matrix.


When it comes to preventing dialysis deficiencies, Cowel recommends reviewing the CMS requirements for ESRD. Most, though not all, of the requirements pertain to inpatient dialysis.  

You should also have a knowledgeable team conduct observational audits in the dialysis unit, she says. The team should include an infection preventionist, a facilities/bio-med person, and someone with dialysis skills.

“[The team] needs to review the environment, the orders, the water testing, dialysate and water cultures, the [practice management], and cleaning of the machines,” she says. “They need to review the IFU for each and every piece of equipment used in dialysis and compare the procedures and documentation in place to the detailed IFU.”

Often the IFU is missing or doesn’t match the unit’s procedures. Sometimes the documentation is not clear or complete. To help the audit team, you want to borrow and adapt a tracer tool for this unit. 

“There are some tracer tools available if you do an internet search,” says Cowel. “This is particularly helpful if your dialysis staff is contracted and you don’t have internal expertise in dialysis.”

Compliance obligations for contracted services

Some facilities contract out their dialysis treatments to a third party. However, giving a job to someone else doesn’t negate all your compliance responsibilities. 

“If the contracted company is not certified by The Joint Commission, everything is fair game to [the] surveyor,” says Good. “[However] if the contracted hemodialysis company is certified by The Joint Commission, the surveyor shouldn’t be asking for HR files, etc. Their focus should be on communication, collaboration of care, handoff, who documents what, orders, etc.”

The dialysis contract will specify what the contractor is responsible for, she says. Every contract is different, so you should double-check your obligations. For example, either your bio-med staff or the contractor could be responsible for the dialysis equipment. If it falls to your staff, the responsible person needs to have competencies in place to validate his or her skills.

Sometimes surveyors don’t realize that doing a full survey of a Joint Commission–certified dialysis company is duplication of efforts, she adds. Instead, they just dive in and look at things that the certification person has already looked at. 

“If you are unsure if your contractor is meeting expectations, you can do internal clinical and EC/LS tracers in this area,” Good says. “You may want to have outside experts come in to review your program.”

Cowel says clinical managers are often made responsible for inpatient dialysis, despite not having a clinical background in dialysis. In these cases, it’s common for people to worry that they don’t know what they don’t know. 

“A hospital should have a detailed contract that spells out the obligations of the contractor,” Cowel says. “There should be detailed quality expectations in the contract. At a minimum, the leadership standards that require an annual evaluation of contracted services will be in play here.”

“The hospital manager can verify the quality expectations in the contract,” she continues. “They can validate that the staff have the training, education, and competencies required in the contract. The infection control committee should share the responsibility in review of the dialysis water and culture reports. This is a necessary oversight and safeguard.”

Subscribe Now!
Sign up for our free e-newsletter
About Us | Terms of Use | Privacy Statement | Contact Us
Copyright © 2019. Hospital Safety Center.