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
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.