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Dialysis / ESRD Facility Conditions for Coverage Audit

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Survey-readiness checklist for end-stage renal disease facilities covering infection control, water treatment, patient assessment, and reuse under the ESRD Conditions for Coverage.

CMS 42 CFR 494AAMI Water StandardsSOM Appendix H

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Infection Control

  • Are standard and dialysis-specific infection control precautions followed at each station? *
  • Are patients screened and vaccinated for Hepatitis B, with HBsAg-positive patients dialyzed in a separate room? *
  • Are surfaces and machines cleaned and disinfected between patient treatments? *

Water & Dialysate Quality

  • Does the water treatment system meet AAMI standards for chemical and microbial quality? *
  • Are chlorine/chloramine levels tested before each treatment day (and at required intervals)? *
  • Are bacterial and endotoxin levels in water and dialysate cultured and within action limits? *

Patient Assessment & Plan of Care

  • Is a comprehensive interdisciplinary assessment completed for each patient? *
  • Is an individualized plan of care developed and periodically reviewed by the interdisciplinary team? *
  • Is dialysis adequacy (Kt/V or URR) measured and documented at required intervals? *

Reuse & Quality

  • If dialyzers are reused, is the reprocessing program compliant with AAMI standards and labeling verified?
  • Is a data-driven quality assessment and performance improvement (QAPI) program in place? *
  • Are patient adverse events and involuntary discharges tracked and reviewed? *

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