Volume 2025 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
RENAL DIALYSIS
ACHC’s Renal Dialysis Accreditation Program covers in-center dialysis and home dialysis training and support. This report identifies 10 standards that were cited for noncompliance on at least 20% of the surveys conducted from June 1, 2024 to May 31, 2025. To achieve or maintain accreditation, each deficiency noted must be corrected. Some standards are perennially challenging; these are usually the ones with many required elements. Nonetheless, organizations should always strive to make sustainable corrections and to avoid repeat deficiencies on subsequent surveys.
RENAL DIALYSIS SERVICES Services In-Center Dialysis Home Dialysis Training & Support
Distinctions Telehealth
Certifications Long-Term Care Dialysis
The findings Using the 20% threshold, we can compare this year’s report to 2022, the last triennial survey cycle for this cohort of organizations. The overall count of standards was seven in 2022 and ten in 2025. Six standards were repeated this year: RD5-J, RD5-G, RD7-A, RD7-C, RD7-E, and RD7-J . These fall into two groups, section 5: Provision of Care/Record Management and section 7: Risk Management: Infection and Safety Control where maintaining cleanliness, water quality, and avoiding cross contamination for infection prevention are prevalent citations. Standards from section 5 focus on individualized assessments and care plans with robust and accurate documentation regarding the care delivered and the patient’s progress toward goals. Many of these standards require a high level of detail and the primary challenge is current, complete, authenticated documentation. Standards from section 7 focus on mitigating risk to patients, especially those associated with infection and safety hazards. Deficiencies clustered around lapses in infection prevention practice and observable issues in the environment of care, for example, inadequate separation of clean and contaminated equipment and supplies to avoid cross-contamination.
Safety risks related to emergency preparedness were also noted. While most organizations did have emergency plans, in many cases staff was inadequately trained to maintain consistent readiness. Observation of expired supplies and inaccessible equipment were prevalent findings for emergency preparedness. A number of deficiencies were identified across long-term care settings. For providers delivering dialysis services within LTC/SNF facilities, collaboration between the dialysis facility’s staff and the LTC/SNF staff is paramount to ensure continuity of care and maintain compliance with the standards. How can we help? The ACHC Renal Dialysis Accreditation team is passionate about safe, high-quality care for dialysis patients. Don’t hesitate to reach out with your questions. We’re here to support your success!
FREQUENT DEFICIENCIES FROM RENAL DIALYSIS SURVEYS
60%
50%
40%
30%
20%
Teresa Hoosier Associate Clinical Director
10%
0%
RD5-G
RD5-7
RD5-P.01
RD6-A
RD7-A
RD7-C
RD7-E
RD7-J
RD7-R
RD7-T
Provision of Care and Record Management
Quality Outcomes/ Performance Improvement
Risk Management: Infection and Safety Control
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