• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

1.0 Hemodialysis Catheter Connection

  • 1.1 Mask worn?

  • 1.2 Hand hygiene performed?

  • 1.3 Clean gloves applied?

  • 1.4 Catheter hub scrubbed with antiseptic?

  • 1.5 Aseptically connected catheter to blood lines?

  • 1.6 Gloves removed and hand hygiene performed?

2.0 Disconnection of Hemodialysis Catheter

  • 2.1 Mask worn?

  • 2.2 Hand hygiene performed?

  • 2.3 Clean gloves applied?

  • 2.4 Aseptically disconnected catheter from blood lines?

  • 2.5 Catheter hub scrubbed with antiseptic?

  • 2.6 Aseptically attached new caps?

  • 2.7 Gloves removed and hand hygiene performed?

3.0 Changing of Hemodialysis Dressing

  • 3.1 Dressing change performed aseptically?

  • 3.2 Mask worn?

  • 3.3 Hand hygiene performed and new gloves donned?

  • 3.4 Skin antiseptic applied and allowed to dry?

  • 3.5 Site not touched after antiseptic applied?

  • 3.6 Antimicrobial ointment applied per policy?

  • 3.7 Dressing applied aseptically?

  • 3.8 Gloves removed and hand hygiene performed?

4.0 Reverse Osmosis (RO) Water Room

  • 4.1 Chlorine checks are documented every four hours?

  • 4.2 Is wand off of floor for bicarbonate tank?

  • 4.3 There is a water alarm on the floor to alert staff of flooding?

  • 4.4 Each water system component is clearly labeled with name and function?

  • 4.5 Written policies and procedures for water treatment system operation are utilized and current?

  • 4.6 Logbooks include parameters for each components operation and the action taken when a component is not within set parameters?

5.0 Maintenance of Dialysis Machine

  • 5.1 Exterior of dialysis machines are wiped down at the end of each use with bleach?

  • 5.2 Machines are vinegar rinsed and heat disinfected daily, and the outside of the machine is wiped down with bleach?

  • 5.3 Machines have a weekly internal bleach clean documented?

  • 5.4 Dialysis personnel will culture dialysate from all machines on a monthly basis?

6.0 Bicarbonate Jugs

  • 6.1 Jugs are bleached weekly (soaked for 15 minutes, rinsed with RO water, and allowed to air dry)?

  • 6.2 Space for jug bleaching is adequate to allow dirty to clean flow?

  • 6.3 Wands for bicarbonate jugs are bleach cleaned weekly?

  • 6.4 Wands for bicarbonate are soaked in RO water daily?

7.0 Staff Competency

  • 7.2 Dialysis management annually verifies competency of staff to perform connection, disconnection, and aseptic dressing changes?

8.0 Water

  • 8.1 Water testing results are reported and reviewed at dialysis steering committee meetings?

  • 8.2 All water testing results are recorded in log sheets, reviewed, and corrective action indicated as applicable per policy?

9.0 Safety

  • 9.1 Eye wash stations are located in rooms where chemicals are used (within ten seconds of point of use)?

  • 9.2 PPE worn while within the splash zone (within four feet of dialyzer)


  • Surveyor Signature

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