Infection Control Assessment Tool for Hemodialysis Facilities

This tool is intended to assist in the assessment of infection control programs and practices in dialysis facilities. In order to complete the assessment, direct observation of infection control practices will be necessary. To facilitate the assessment, health departments are encouraged to share this tool with facilities in advance of their visit.

Dialysis facilities that report to NHSN complete an Outpatient Dialysis Center Practices Survey each year. The survey responses can be accessed in NHSN or the facility can be asked to retrieve and print their completed NHSN survey in advance of the site visit. The elements included on this assessment tool are intended to complement the NHSN survey. For facilities that do not report to NHSN, consider asking the facility to complete the practice elements of the survey.

Overview

Section 1: Facility Demographics

Section 2: Infection Control Program and Infrastructure

Section 3: Direct Observation of Facility Practices

Section 4: Infection Control Guidelines and Other Resources

Infection Control Domains for Gap Assessment

Infection Control Program and Infrastructure

Infection Control Training, Competency, and Audits

Healthcare Personnel (HCP) Safety

Surveillance and Disease Reporting

Respiratory Hygiene/Cough Etiquette

Personal Protective Equipment (PPE)

Environmental Cleaning

Dialyzer Reuse and (if applicable) Reprocessing

Hand Hygiene

Catheter and other Vascular Access Care

Injection Safety

V1-3

Section 1: Facility Demographics
Facility Name (for health department use only)	Click here to enter text.
NHSN Facility Organization ID (for health department use only)	Click here to enter text. ☐ N/A because not CMS-certified or other reason, specify: Click here to enter text.
State-assigned Unique ID	Click here to enter text.
Date of Assessment	Click here to enter a date.
Type of Assessment	☐ On-site ☐ Other (specify): Click here to enter text.
Rationale for Assessment (Select all that apply)	☐ Outbreak ☐ Input from ESRD Network or state survey agency ☐ NHSN data Specify: ☐ BSI ☐ Other NHSN data, specify: Click here to enter text. ☐ Other reason (specify): Click here to enter text.
Is the facility affiliated with a hospital?	☐ Yes (specify): Click here to enter text. (for health department use only) ☐ No If yes, who provides staffing for the facility? ☐ Hospital staff ☐ Contract with a dialysis company ☐ Other (specify): Click here to enter text.
Does the facility belong to a dialysis chain?	☐ Yes (specify chain below) ☐ DaVita ☐ Fresenius Medical Care ☐ Dialysis Clinic, Inc. (DCI) ☐ Other (specify): Click here to enter text. ☐ No
What services are offered at the facility? (Select all that apply)	☐ Adult in-center hemodialysis ☐ Pediatric in-center hemodialysis ☐ Home hemodialysis ☐ Nocturnal hemodialysis ☐ Peritoneal dialysis ☐ Inpatient hemodialysis (in addition to outpatient hemodialysis)
What is the typical patient census? (include all dialysis patients cared for by the facility)	☐ 1-25 ☐ 76-100 ☐ >200 ☐ 26-50 ☐ 101-150 ☐ 51-75 ☐ 151-200

Section 2: Infection Control Program and Infrastructure

Infection Control Policies and Infrastructure
Elements to be assessed	Assessment	Notes/Areas for Improvement
What training does the person in charge of infection control at the facility have? Select the best answer	Certified in Infection Control (CIC) Other training in infection control (specify): Click here to enter text. No specific training in infection control Not Applicable (no person in charge of infection control at the facility)	Click here to enter text.
Is the facility participating in their ESRD Network Healthcare-Associated Infection (HAI) Quality Improvement Activity (QIA)?	Yes No	Click here to enter text.
Has the facility participated in the CDC Dialysis BSI Prevention Collaborative?	Yes No	Click here to enter text.
In the past 2 years, has the facility participated in any other intensive program focused on HAI prevention? (e.g., clinical trial, company-led quality improvement project)	Yes (specify): Click here to enter text. No	Click here to enter text.
Does the facility have a system for early detection and management of potentially infectious persons at initial points of patient encounter? Note: System may include taking a travel history, assessing for diarrhea or draining infected wounds, and elements described under respiratory hygiene/cough etiquette.	Yes (specify): System applies at (or prior to) point of facility check-in System applies when patient arrives in dialysis treatment area No	Click here to enter text.
Does the facility have a policy/protocol for implementing Contact Precautions when warranted? Note: CDC does not routinely recommend Contact Precautions for multidrug resistant organisms (MDROs) in dialysis clinics. However, in certain circumstances (e.g., known or suspected MDRO transmission), Contact Precautions may be necessary.	Yes No	Click here to enter text.

I. Infection Control Policies and Infrastructure, continued
Elements to be assessed	Assessment	Notes/Areas for Improvement
Are there signs posted in the facility that encourage patients to take an active role in and express their concerns about facility infection control practices? Visual confirmation suggested. Consider if the facility encourages this in other ways.	Yes No	Visually confirmed Click here to enter text.
Facility provides standardized education to all patients on infection prevention topics: Vascular access care	Yes No	Click here to enter text.
ii. Hand hygiene	Yes No	Click here to enter text.
iii. Risks related to catheter use	Yes No	Click here to enter text.
Recognizing signs of infection	Yes No	Click here to enter text.
Instructions for access management when away from the dialysis unit Facility should be able to provide examples of education materials.	Yes No	Click here to enter text.
What is the distance separating adjacent dialysis treatment stations? Involves observation. Select 2 adjacent and representative stations. Measure the closest distance between machine/chair/objects in one station and the next. If computer terminals are embedded in and shared between stations, the distance is zero.	< 3 feet Embedded/shared computer terminal ≥ 3 feet and <6 feet ≥ 6 feet	Visually confirmed Click here to enter text.
If embedded/shared computer terminal, what is the policy/protocol for routinely cleaning the embedded/shared computer terminal? Select the best answer	Computer terminal is cleaned after each patient Computer terminal is cleaned after each shift Computer terminal is cleaned at the end of each day Other (specify): Click here to enter text. N/A, facility does not have a policy/protocol for routinely cleaning the computer terminal	Click here to enter text.

I. Infection Control Policies and Infrastructure, continued
Elements to be assessed	Assessment	Notes/Areas for Improvement
Does the facility have an isolation room that is available for isolation of conditions other than hepatitis B? (i.e., not currently in use for hepatitis B patients)? Visual confirmation suggested.	Yes No	Visually confirmed Click here to enter text.
Does the facility use hemodialysis machine Waste Handling Option (WHO) ports? Note: The WHO port is a machine port used for prime waste.	Yes No	Click here to enter text.
If Yes, does the facility have a policy/protocol in place for disinfecting the WHO port? If Yes, consider how is the policy implemented and enforced.	Yes No Not Applicable (WHO ports are not used at the facility)	Click here to enter text.
Are patients in the facility ever “bled onto the machine” (i.e., where blood is allowed to reach or almost reach the prime waste receptacle or WHO port)? Note: This practice is discouraged because it can result in patient blood loss and blood contamination of the environment.	Yes No	Click here to enter text.

Infection Control Training, Competency, and Audits
Elements to be assessed	Assessment	Notes/Areas for Improvement
Facility provides job-specific training to healthcare personnel (HCP) on infection prevention policies and procedures: i. Upon hire, prior to provision of care	i. Yes No	Click here to enter text.
ii. Annually Note: This includes those employed by outside agencies and available by contract or on a volunteer basis to the facility. If Yes, facility should be able to provide examples of training.	ii. Yes No	Click here to enter text.
Facility assesses and documents competency with job-specific infection prevention policies and procedures: i. Upon hire, prior to provision of care	i. Yes No	Click here to enter text.
ii. Annually	ii. Yes No	Click here to enter text.
Does the facility routinely conduct audits of staff infection control practice?	Yes (facility should be able to show results of these audits) No	Click here to enter text.
If Yes, does the facility provide feedback on adherence to clinical staff?	Yes (facility should be able to provide examples of feedback) No Not applicable (no audits conducted)	Click here to enter text.
Does the facility routinely use standardized tools for educating staff and/or assessing practice? (Select all that apply) Should be able to view tools in the facility.	AHRQ/CMS Checklist Tools CDC Tools Corporate Tools No standardized tools used	Click here to enter text.

II. Infection Control Training, Competency, and Audits
Elements to be assessed	Assessment	Notes/Areas for Improvement
If CDC tools, indicate the tool(s) used (Select all that apply)	CDC Video: Preventing BSIs in Outpatient Hemodialysis Patients: Best Practices for Dialysis Staff CDC Approach to BSI Prevention in Dialysis Facilities (i.e., Core Interventions for Dialysis BSI Prevention) CDC Hemodialysis Central Venous Catheter Scrub-the-Hub Protocol CDC Dialysis audit tools: Hand hygiene Catheter connection & disconnection Catheter exit site care Arteriovenous fistula & graft cannulation and decannulation Injectable medication preparation & administration Routine disinfection of dialysis station CDC Dialysis checklists: Catheter connection & disconnection Catheter exit site care Arteriovenous fistula & graft cannulation and decannulation Injectable medication preparation & administration Routine disinfection of dialysis station Other (specify): Click here to enter text. N/A, no CDC tools used	Click here to enter text.

Healthcare Personnel (HCP) Safety
Elements to be assessed	Assessment	Notes/Areas for Improvement
Does the facility provide post-exposure evaluation and follow-up, including prophylaxis as appropriate, to healthcare personnel (HCP) at no cost following an exposure event?	Yes No	Click here to enter text.
Does the facility track HCP exposure events, evaluate event data and develop/implement corrective action plans to reduce incidence of such events?	Yes No	Click here to enter text.
Does the facility offer hepatitis B vaccine to personnel who may be exposed to blood or body fluids through their job duties?	Yes No	Click here to enter text.
Does the facility offer influenza vaccine to all personnel?	Yes No	Click here to enter text.
Does the facility conduct baseline tuberculosis (TB) screening of HCP?	Yes No	Click here to enter text.
Does the facility have work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits, or job status?	Yes No	Click here to enter text.
Does the facility educate HCP on prompt reporting of illness or job-related injury to supervisor and/or occupational health?	Yes No	Click here to enter text.

Surveillance and Disease Reporting
Elements to be assessed	Assessment	Notes/Areas for Improvement
Does someone in the facility know the facility’s bloodstream infection (BSI) rate in NHSN or BSI standardized infection ratio (SIR)?	Yes No Not Applicable (Data are not reported to NHSN)	Click here to enter text.
a. If Yes, does the facility share rate data with front-line clinical staff?	Yes No Not Applicable (Data are not reported to NHSN)	Click here to enter text.
Does the facility have a policy that mandates blood culture collection before antimicrobial administration any time a BSI is suspected? If yes, consider how is the policy implemented and enforced	Yes No	Click here to enter text.
Does the facility conduct routine screening of hemodialysis patients for hepatitis C antibody at the recommended interval?	Yes, on admission and every 6 months thereafter for susceptible patients No	Click here to enter text.
Does the facility know how to report clusters of infections, adverse events, or a new hepatitis B/C case to public health?	Yes, knows what to report and how No	Click here to enter text.
Does the facility have a system in place to communicate infection or colonization with a multidrug resistant organism (MDRO) to other healthcare facilities upon transfer?	Yes No	Click here to enter text.

Respiratory Hygiene/Cough Etiquette
Elements to be assessed	Assessment	Notes/Areas for Improvement
In non-clinical areas:
Does the facility have signs posted at entrances with instructions to patients with symptoms of respiratory infection to: cover their mouth/nose when coughing or sneezing? use and dispose of tissues? perform hand hygiene after contact with respiratory secretions?	Yes No	Visually confirmed Click here to enter text.
Does the facility provide a means for patients to perform hand hygiene in or near waiting areas?	Yes No	Visually confirmed Click here to enter text.
Does the facility provide space and encourage persons with symptoms of respiratory infection to sit as far away from others as possible?	Yes No	Visually confirmed Click here to enter text.
Does the facility provide tissues and no-touch receptacles for disposal of tissues? Applies during periods of increased respiratory infections in the community	Yes No Not Applicable (Not a period of increased respiratory infections)	Visually confirmed Click here to enter text.
Does the facility offer facemasks upon facility entry to patients with symptoms of respiratory infection? Applies during periods of increased respiratory infections in the community	Yes No Not Applicable (Not a period of increased respiratory infections)	Visually confirmed Click here to enter text.
In clinical areas:
Does the facility have the ability to separate symptomatic patients (by at least 6 feet) from other patients and their stations during dialysis treatment?	Yes No	Visually confirmed Click here to enter text.

Personal Protective Equipment (PPE)
Elements to be assessed	Assessment	Notes/Areas for Improvement
Facility provides job-specific training to HCP on proper selection and use of PPE: i. Upon hire, prior to provision of care	i. Yes No	Click here to enter text.
ii. Annually	ii. Yes No	Click here to enter text.
Does the facility validate HCP competency with use of PPE?	Yes No	Click here to enter text.
Supplies necessary for adherence to PPE recommendations are available and located near point of use: Gloves	i. Yes No	Visually confirmed Click here to enter text.
Gowns	ii. Yes No	Click here to enter text.
Face Shields/Eye Protection	iii. Yes No	Click here to enter text.
Face Masks Visual confirmation suggested.	iv. Yes No Not Applicable (facility does not use face masks)	Click here to enter text.
Does the facility have a policy/protocol for staff to routinely change/launder gowns (in the absence of soilage)? Note: This question applies to patients in the general treatment area, not patients in isolation.	Yes At the end of the shift At the end of the day Other (specify): Click here to enter text. No	Click here to enter text.

Environmental Cleaning
Elements to be assessed	Assessment	Notes/Areas for Improvement
Does the facility have written policies and procedures for routine cleaning and disinfection of environmental surfaces, including clearly defining responsible personnel? Note: Policy and procedures should identify staff responsible for performing cleaning and disinfection as well as those responsible for selection and preparation of disinfectant solution(s).	Yes No	Click here to enter text.
Does the facility provide job-specific training to responsible personnel on environmental cleaning and disinfection upon hire, at least annually, and when policies/procedures change? Note: If environmental cleaning is performed by contract personnel, facility should verify this is provided by contracting company.	Yes No	Click here to enter text.

Environmental Cleaning, continued
Elements to be assessed	Assessment	Notes/Areas for Improvement
Does the facility regularly audit (monitor and document) adherence to cleaning and disinfection procedures?	Yes (facility should be able to show results of these audits) No	Click here to enter text.
Does the facility have a policy/procedure for decontamination of spills of blood or other body fluids?	Yes No	Click here to enter text.
If Yes, are supplies necessary to clean the blood spill (e.g., proper disinfectant or spill kit) readily available and located near point of use? Visual confirmation suggested.	Yes No Not Applicable (facility does not have a policy for decontamination of spills of blood or other body fluids)	Visually confirmed Click here to enter text.
Does the facility have a policy/procedure for routinely emptying AND cleaning reusable waste containers (e.g. leakproof containers used for disposal of used dialyzers and tubing)? Emptying	i. Yes No	Click here to enter text.
Cleaning	ii. Yes No	Click here to enter text.
Does the facility have policies and procedures to ensure reusable medical devices (e.g., thermometers, stethoscopes, blood pressure cuffs) are cleaned appropriately between patients?	Yes No Not Applicable (no reusable medical devices are used at the facility)	Click here to enter text.
Does the facility have policies and procedures for routinely cleaning and disinfecting the following items: Dialysis Clamps	i. Yes No Not Applicable (facility does not use dialysis clamps)	Click here to enter text.
Blood Glucose Monitor(s)	ii. Yes No Not Applicable (facility does not use blood glucose monitor(s))	Click here to enter text.
Dialysate Conductivity/pH meter(s)	iii. Yes No Not Applicable (facility does not use dialysate conductivity/pH meter(s))	Click here to enter text.

Dialyzer Reuse and Reprocessing
Elements to be assessed	Assessment	Notes/Areas for Improvement
Does the facility reuse dialyzers? Note: If the facility reprocesses dialyzers on-site, consider performing observations of dialyzer reprocessing.	Yes (specify): Dialyzers are reprocessed on-site Dialyzers are reprocessed off-site No *If No, skip to Hand Hygiene*	Click here to enter text.
A. If Yes, complete the following section. Questions 2 & 3 apply to all facilities that reuse dialyzers--reprocessing can be on- or off-site.
Does the facility document informed consent for patients who participate in dialyzer reuse? Visual confirmation suggested.	Yes (facility should be able to provide informed consent document) No Not Applicable (Facility does not reuse dialyzers)	Visually confirmed Click here to enter text.
Does the facility have policies and procedures to ensure that dialyzers are cleaned and reprocessed appropriately prior to reuse? Note: If reprocessing is performed off-site, facility policies and procedures should address safe handling of used dialyzers prior to reprocessing and assessment of disinfection process after reprocessing.	Yes No Not Applicable (Facility does not reuse dialyzers)	Click here to enter text.
B. If answered Yes to Question 1 and dialyzers are reprocessed on site, complete the following section. Questions 4-7 apply to facilities that perform dialyzer reprocessing on-site. *Consider performing observations of dialyzer reprocessing.*
Does the facility train personnel responsible for reprocessing dialyzers on proper selection and use of PPE and recommended steps for reprocessing equipment?	Yes No Not Applicable (Facility does not reuse dialyzers or dialyzer reprocessing performed off-site)	Click here to enter text.
Does the facility test the competency of personnel responsible for reprocessing dialyzers upon hire and at least annually?	Yes No Not Applicable (Facility does not reuse dialyzers or dialyzer reprocessing performed off-site)	Click here to enter text.
Does the facility regularly audit (monitor and document) adherence to reprocessing procedures and provide feedback to personnel regarding their performance?	Yes (facility should be able to show results of these audits) No Not Applicable (Facility does not reuse dialyzers or dialyzer reprocessing performed off-site)	Click here to enter text.
Does the facility perform routine maintenance for reprocessing equipment (e.g., automated reprocessors) by qualified personnel in accordance with manufacturer instructions? Confirm maintenance records are available.	Yes No Not Applicable (specify): Only manual reprocessing methods used Facility does not reuse dialyzers or dialyzer reprocessing performed off-site	Click here to enter text.

Hand Hygiene
Elements to be assessed	Assessment	Notes/Areas for Improvement
Supplies necessary for adherence to hand hygiene recommendations are available and located near point of use.	Visually confirmed
Alcohol-based hand gel	i. Yes No	Click here to enter text.
Handwashing sinks	ii. Yes No	Click here to enter text.
Soap	iii. Yes No	Click here to enter text.
Paper Towels Visual confirmation suggested.	iv. Yes No	Click here to enter text.
Does the facility perform observations of staff hand hygiene opportunities monthly (or more frequently)?	Yes (facility should be able to show results of these observations) No	Click here to enter text.
If Yes, does the facility provide feedback on adherence to clinical staff?	Yes (facility should be able to provide examples of feedback) No Not Applicable (No observations conducted)	Click here to enter text.

Catheter and other Vascular Access Care
Elements to be assessed	Assessment	Notes/Areas for Improvement
Does the facility provide training specific to catheter/vascular access care and aseptic technique for staff handling catheters and/or vascular accesses?	Yes (facility should be able to provide examples of training) No	Click here to enter text.
Does the facility perform observations of staff vascular access care and catheter accessing practices quarterly (or more frequently)?	Yes (facility should be able to show results of these observations) No	Click here to enter text.
If Yes, does the facility provide feedback on adherence to clinical staff?	Yes (facility should be able to provide examples of feedback) No Not Applicable (No observations conducted)	Click here to enter text.

X. Catheter and other Vascular Access Care, continued
Elements to be assessed	Assessment	Notes/Areas for Improvement
Facility performs staff competency assessments for vascular access care and catheter accessing: i. Upon hire, prior to provision of care	i. Yes No	Click here to enter text.
Annually	ii. Yes No	Click here to enter text.
Does the facility use an alcohol-based chlorhexidine (>0.5%) solution as the first line skin antiseptic agent during dressing changes of catheters? Visual confirmation suggested.	Yes No	Visually confirmed Click here to enter text.
Does the facility routinely apply an antibiotic ointment or povidine-iodine ointment to catheter exit sites during dressing changes? Visual confirmation suggested. Note: CDC recommends using povidone iodine ointment or bacitracin/gramicidin/polymyxin B ointment (not currently available in the United States). Triple antibiotic ointment (bacitracin/neomycin/polymyxin B) is available and might have a similar benefit. Mupirocin ointment is not recommended due to concerns about development of antimicrobial resistance.	Yes No (Specify:) No ointment used, but chlorhexidine dressing used Neither ointment nor chlorhexidine dressing used	Visually confirmed Click here to enter text.
Does the facility routinely scrub catheter hubs with appropriate antiseptic after the caps are removed and before accessing the catheter? Visual confirmation suggested.	Yes No Not Applicable (Facility uses needleless connector devices)	Visually confirmed Click here to enter text.
If N/A (facility uses needleless connector devices), does the facility routinely scrub the catheter hubs when the needless connectors are removed?	Yes No Not Applicable (Facility does not use needleless connector devices)	Click here to enter text.

Injection Safety
Elements to be assessed	Assessment	Notes/Areas for Improvement
Supplies necessary for adherence to safe injection practices are available and located near point of use. Visual confirmation suggested.	Visually confirmed
Sharps containers	i. Yes No	Click here to enter text.
Needles/cannulae with safety feature	ii. Yes No	Click here to enter text.
Does the facility have policies/procedures to ensure sharps containers are emptied and/or changed on a regular basis and when needed?	Yes No	Click here to enter text.
Does the facility use a clean room that is physically separate from the treatment area for storage and preparation of injectable medications? Visual confirmation suggested.	Yes No	Visually confirmed Click here to enter text.
If No, is there a room available in the facility that could be used for storage and preparation of injectable medications?	Yes No	Click here to enter text.
Does the facility have a policy/procedure for routinely cleaning surface(s) where injectable medications are prepared?	Yes No	Click here to enter text.
Does the facility use manufacturer pre-filled saline syringes or single-use saline vials for flushes? Visual confirmation suggested.	Yes No (specify): Flushes are drawn from the patient’s designated saline bag used for dialysis Flushes are drawn up from the patient’s dialysis line Flushes are drawn from a common saline bag used for all patients Other (specify): Click here to enter text.	Visually confirmed Click here to enter text.

Section 3: Direct Observation of Facility Practices

Certain infection control lapses (e.g., reuse of syringes on more than one patient or to access a medication container that is used for subsequent patients; reuse of lancets) can result in bloodborne pathogen transmission and should be halted immediately. Identification of such lapses warrants appropriate notification and testing of potentially affected patients.

*National Healthcare Safety Network (NHSN) minimum plan requirements for each audit type are included as a number of minimum observations to consider.

Infection Control Observations
Infection Control Observations	Adherence: num/denom	Gaps Identified	Comments
(i) Hand hygiene http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-Hand-Hygiene-Observations.pdf *NHSN minimum requirement = 30 observations	Numerator Denominator	Yes No	Click here to enter text.
(ii) Catheter connection and disconnection http://www.cdc.gov/dialysis/PDFs/collaborative/Catheter-Connection-Disconnection-Observations.pdf *NHSN minimum requirement = 10 observations	Numerator Denominator	Yes No	Click here to enter text.
(iii) Catheter exit site care http://www.cdc.gov/dialysis/PDFs/collaborative/Catheter-Exit-Site-Care-Observations.pdf *NHSN minimum requirement = 5 observations	Numerator Denominator	Yes No	Click here to enter text.
(iv) Arteriovenous fistula & graft cannulation http://www.cdc.gov/dialysis/PDFs/collaborative/AV-Fistula-Graft-Can-Decannulation-Observations-AT.pdf *NHSN minimum requirement = 10 observations	Numerator Denominator	Yes No	Click here to enter text.
(v) Injectable medication preparation http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-InjectionSafety-Observations.pdf *NHSN minimum requirement = 5 observations	Numerator Denominator	Yes No	Click here to enter text.
(vi) Injectable medication administration http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-InjectionSafety-Observations.pdf *NHSN minimum requirement = 5 observations	Numerator Denominator	Yes No	Click here to enter text.
(vii) Routine disinfection of dialysis station http://www.cdc.gov/dialysis/PDFs/dialysis-Station-Disinfect-Tool-7-2015.pdf *NHSN minimum requirement = 10 observations	Numerator Denominator	Yes No	Click here to enter text.

Section 4: Infection Control Guidelines and Other Resources

Check the box(es) next to the guidelines/resources recommended for the facility as a result of this assessment.

☐ Infection prevention resources for dialysis settings: http://www.cdc.gov/dialysis/

☐ Relevant guidelines: http://www.cdc.gov/dialysis/guidelines/index.html

☐ CDC Recommendations for Preventing Transmission in Chronic Hemodialysis Patients: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm

☐ Prevention tools, including checklists and audit tools: http://www.cdc.gov/dialysis/prevention-tools/index.html

☐ CDC Approach to BSI Prevention in Dialysis Facilities (i.e., the Core Interventions for Dialysis BSI Prevention): http://www.cdc.gov/dialysis/prevention-tools/core-interventions.html

☐ CDC hemodialysis central venous catheter Scrub-the-Hub Protocol: http://www.cdc.gov/dialysis/PDFs/collaborative/Hemodialysis-Central-Venous-Catheter-STH-Protocol.pdf

☐ Environmental surface disinfection in dialysis facilities: Notes for clinical managers: http://www.cdc.gov/dialysis/PDFs/collaborative/Env_notes_Feb13.pdf

☐ Provider education: http://www.cdc.gov/dialysis/clinician/index.html

☐ Best practices video: http://www.cdc.gov/dialysis/prevention-tools/training-video.html

☐ Infection prevention in dialysis continuing education course: http://www.cdc.gov/dialysis/clinician/CE/infection-prevent-outpatient-hemo.html

☐ NHSN Outpatient Dialysis Center Practices Survey: http://www.cdc.gov/nhsn/forms/57.500_outpatientdialysissurv_blank.pdf

☐ NHSN Dialysis Prevention Process Measures:

http://www.cdc.gov/nhsn/dialysis/process-measures/index.html

Assessment Summary

Infection Control Policies and Infrastructure
Incomplete Elements
What training does the person in charge of infection control at the facility have?
Is the facility participating in their ESRD Network HAI Quality Improvement Activity (QIA)?
Has the facility participated in the CDC Dialysis BSI Prevention Collaborative?
In the past 2 years, has the facility participated in any other intensive program focused on HAI prevention? (e.g., clinical trial, company-led quality improvement project)
Does the facility have a system for early detection and management of potentially infectious persons at initial points of patient encounter?
Does the facility have a policy/protocol for implementing Contact Precautions when warranted?
Are there signs posted in the facility that encourage patients to take an active role in and express their concerns about facility infection control practices?
i. Does the facility provide standardized education to all patients on: Vascular access care?
ii. Does the facility provide standardized education to all patients on: Hand Hygiene?
iii. Does the facility provide standardized education to all patients on: Risks related to catheter use?
iv. Does the facility provide standardized education to all patients on: Recognizing signs of infection?
v. Does the facility provide standardized education to all patients on: Instructions for access management when away from the dialysis unit?
What is the distance separating adjacent dialysis treatment stations?
a. If embedded/shared computer terminal, what is the policy/protocol for routinely cleaning the embedded/shared computer terminal?
Does the facility have an isolation room that is available for isolation of conditions other than hepatitis B? (i.e., not currently in use for hepatitis B patients)?
Does the facility use hemodialysis machine Waste Handling Option (WHO) ports?
If Yes, does the facility have a policy in place for disinfecting the WHO port?
Are patients in the facility ever “bled onto the machine” (i.e., where blood is allowed to reach or almost reach the prime waste receptacle or WHO port)?
Potential Areas of Improvement
What training does the person in charge of infection control at the facility have?
Is the facility participating in their ESRD Network Healthcare-Associated Infection (HAI) Quality Improvement Activity (QIA)?
Has the facility participated in the CDC Dialysis BSI Prevention Collaborative?
In the past 2 years, has the facility participated in any other intensive program focused on HAI prevention? (e.g., clinical trial, company-led quality improvement project)
Does the facility have a system for early detection and management of potentially infectious persons at initial points of patient encounter?
Does the facility have a policy/protocol for implementing Contact Precautions when warranted?
Are there signs posted in the facility that encourage patients to take an active role in and express their concerns about facility infection control practices?
i. Does the facility provide standardized education to all patients on: Vascular access care?
ii. Does the facility provide standardized education to all patients on: Hand Hygiene?
iii. Does the facility provide standardized education to all patients on: Risks related to catheter use?
iv. Does the facility provide standardized education to all patients on: Recognizing signs of infection?
v. Does the facility provide standardized education to all patients on: Instructions for access management when away from the dialysis unit?
What is the distance separating adjacent dialysis treatment stations?
a. If embedded/shared computer terminal, what is the policy/protocol for routinely cleaning the embedded/shared computer terminal?
Does the facility have an isolation room that is available for isolation of conditions other than hepatitis B? (i.e., not currently in use for hepatitis B patients)?
Does the facility use hemodialysis machine Waste Handling Option (WHO) ports?
If Yes, does the facility have a policy in place for disinfecting the WHO port?
Are patients in the facility ever “bled onto the machine” (i.e., where blood is allowed to reach or almost reach the prime waste receptacle or WHO port)?
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

II. Infection Control Training, Competency, and Audits
Incomplete Elements
Facility provides job-specific training to healthcare personnel (HCP) on infection prevention policies and procedures: i. Upon hire, prior to provision of care
Facility provides job-specific training to healthcare personnel (HCP) on infection prevention policies and procedures: ii. Annually
Facility assesses and documents competency with job-specific infection prevention policies and procedures: i. Upon hire, prior to provision of care
Facility assesses and documents competency with job-specific infection prevention policies and procedures: ii. Annually
Does the facility routinely conduct audits of staff infection control practice?
If Yes, does the facility provide feedback on adherence to clinical staff?
Does the facility routinely use standardized tools for educating staff and/or assessing practice?
Potential Areas of Improvement
Facility provides job-specific training to healthcare personnel (HCP) on infection prevention policies and procedures: i. Upon hire, prior to provision of care
Facility provides job-specific training to healthcare personnel (HCP) on infection prevention policies and procedures: ii. Annually
Facility assesses and documents competency with job-specific infection prevention policies and procedures: i. Upon hire, prior to provision of care
Facility assesses and documents competency with job-specific infection prevention policies and procedures: ii. Annually
Does the facility routinely conduct audits of staff infection control practice?
If Yes, does the facility provide feedback on adherence to clinical staff?
Does the facility routinely use standardized tools for educating staff and/or assessing practice?
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

III. Healthcare Personnel (HCP) Safety
Incomplete Elements
Does the facility provide post-exposure evaluation and follow-up, including prophylaxis as appropriate, to healthcare personnel (HCP) at no cost following an exposure event?
Does the facility track HCP exposure events, evaluate event data and develop/implement corrective action plans to reduce incidence of such events?
Does the facility offer hepatitis B vaccine to personnel who may be exposed to blood or body fluids through their job duties?
Does the facility offer influenza vaccine to all personnel?
Does the facility conduct baseline tuberculosis (TB) screening of HCP?
Does the facility have work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits, or job status?
Does the facility educate HCP on prompt reporting of illness or job-related injury to supervisor and/or occupational health?
Potential Areas of Improvement
Does the facility provide post-exposure evaluation and follow-up, including prophylaxis as appropriate, to healthcare personnel (HCP) at no cost following an exposure event?
Does the facility track HCP exposure events, evaluate event data and develop/implement corrective action plans to reduce incidence of such events?
Does the facility offer hepatitis B vaccine to personnel who may be exposed to blood or body fluids through their job duties?
Does the facility offer influenza vaccine to all personnel?
Does the facility conduct baseline tuberculosis (TB) screening of HCP?
Does the facility have work-exclusion policies that encourage reporting of illnesses and do not penalize with loss of wages, benefits, or job status?
Does the facility educate HCP on prompt reporting of illness or job-related injury to supervisor and/or occupational health?
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

IV. Surveillance and Disease Reporting
Incomplete Elements
Does someone in the facility know the facility’s bloodstream infection (BSI) rate in NHSN or BSI standardized infection ratio (SIR)?
a. If Yes, does the facility share rate data with front-line clinical staff?
Does the facility have a policy that mandates blood culture collection before antimicrobial administration any time a BSI is suspected?
Does the facility conduct routine screening of hemodialysis patients for hepatitis C antibody at the recommended interval?
Does the facility know how to report clusters of infections, adverse events, or a new hepatitis B/C case to public health?
Does the facility have a system in place to communicate infection or colonization with a multidrug resistant organism (MDRO) to other healthcare facilities upon transfer?
Potential Areas of Improvement
Does someone in the facility know the facility’s bloodstream infection (BSI) rate in NHSN or BSI standardized infection ratio (SIR)?
a. If Yes, does the facility share rate data with front-line clinical staff?
Does the facility have a policy that mandates blood culture collection before antimicrobial administration any time a BSI is suspected?
Does the facility conduct routine screening of hemodialysis patients for hepatitis C antibody at the recommended interval?
Does the facility know how to report clusters of infections, adverse events, or a new hepatitis B/C case to public health?
Does the facility have a system in place to communicate infection or colonization with a multidrug resistant organism (MDRO) to other healthcare facilities upon transfer?
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

V. Respiratory Hygiene/Cough Etiquette
Incomplete Elements
Non-clinical areas:
Does the facility have signs posted at entrances with instructions to patients with symptoms of respiratory infection to: cover their mouth/nose when coughing or sneezing? use and dispose of tissues? perform hand hygiene after contact with respiratory secretions?
Does the facility provide a means for patients to perform hand hygiene in or near waiting areas?
Does the facility provide space and encourage persons with symptoms of respiratory infection to sit as far away from others as possible?
Does the facility provide tissues and no-touch receptacles for disposal of tissues?
Does the facility offer facemasks upon facility entry to patients with symptoms of respiratory infection?
Clinical areas:
Does the facility have the ability to separate symptomatic patients (by at least 6 feet) from other patients and their stations during dialysis treatment?
Potential Areas of Improvement
Non-clinical areas:
Does the facility have signs posted at entrances with instructions to patients with symptoms of respiratory infection to: cover their mouth/nose when coughing or sneezing? use and dispose of tissues? perform hand hygiene after contact with respiratory secretions?
Does the facility provide a means for patients to perform hand hygiene in or near waiting areas?
Does the facility provide space and encourage persons with symptoms of respiratory infection to sit as far away from others as possible?
Does the facility provide tissues and no-touch receptacles for disposal of tissues?
Does the facility offer facemasks upon facility entry to patients with symptoms of respiratory infection?
Clinical areas:
Does the facility have the ability to separate symptomatic patients (by at least 6 feet) from other patients and their stations during dialysis treatment?
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

VI. Personal Protective Equipment (PPE)
Incomplete Elements
Facility provides job-specific training to HCP on proper selection and use of PPE: i. Upon hire, prior to provision of care
Facility provides job-specific training to HCP on proper selection and use of PPE: ii. Annually
Does the facility validate HCP competency with use of PPE?
Supplies necessary for adherence to PPE recommendations are available and located near point of use: Gloves
Supplies necessary for adherence to PPE recommendations are available and located near point of use: Gowns
Supplies necessary for adherence to PPE recommendations are available and located near point of use: iii. Face Shields/Eye Protection
Supplies necessary for adherence to PPE recommendations are available and located near point of use: Face Masks
Does the facility have a policy/protocol for staff to routinely change/launder gowns (in the absence of soilage)?
Potential Areas of Improvement
Facility provides job-specific training to HCP on proper selection and use of PPE: i. Upon hire, prior to provision of care
Facility provides job-specific training to HCP on proper selection and use of PPE: ii. Annually
Does the facility validate HCP competency with use of PPE?
Supplies necessary for adherence to PPE recommendations are available and located near point of use: Gloves
Supplies necessary for adherence to PPE recommendations are available and located near point of use: Gowns
Supplies necessary for adherence to PPE recommendations are available and located near point of use: iii. Face Shields/Eye Protection
Supplies necessary for adherence to PPE recommendations are available and located near point of use: Face Masks
Does the facility have a policy/protocol for staff to routinely change/launder gowns (in the absence of soilage)?
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

VII. Environmental Cleaning
Incomplete Elements
Does the facility have written policies and procedures for routine cleaning and disinfection of environmental surfaces, including clearly defining responsible personnel?
Does the facility provide job-specific training to responsible personnel on environmental cleaning and disinfection upon hire, at least annually, and when policies/procedures change?
Does the facility regularly audit (monitor and document) adherence to cleaning and disinfection procedures?
Does the facility have a policy/procedure for decontamination of spills of blood or other body fluids?
a. If Yes, are supplies necessary to clean the blood spill (e.g., proper disinfectant or spill kit) readily available and located near point of use?
i. Does the facility have a policy/procedure for routinely emptying reusable waste containers (e.g. leakproof containers used for disposal of used dialyzers and tubing)?
ii. Does the facility have a policy/procedure for routinely cleaning reusable waste containers (e.g. leakproof containers used for disposal of used dialyzers and tubing)?
Does the facility have policies and procedures to ensure reusable medical devices (e.g., thermometers, stethoscopes, blood pressure cuffs) are cleaned appropriately between patients?
Does the facility have policies and procedures for routinely cleaning and disinfecting: i. Dialysis Clamps
Does the facility have policies and procedures for routinely cleaning and disinfecting: ii. Blood Glucose Monitors
Does the facility have policies and procedures for routinely cleaning and disinfecting: iii. Dialysate Conductivity/pH meters
Potential Areas of Improvement
Does the facility have written policies and procedures for routine cleaning and disinfection of environmental surfaces, including clearly defining responsible personnel?
Does the facility provide job-specific training to responsible personnel on environmental cleaning and disinfection upon hire, at least annually, and when policies/procedures change?
Does the facility regularly audit (monitor and document) adherence to cleaning and disinfection procedures?
Does the facility have a policy/procedure for decontamination of spills of blood or other body fluids?
a. If Yes, are supplies necessary to clean the blood spill (e.g., proper disinfectant or spill kit) readily available and located near point of use?
i. Does the facility have a policy/procedure for routinely emptying reusable waste containers (e.g. leakproof containers used for disposal of used dialyzers and tubing)?
ii. Does the facility have a policy/procedure for routinely cleaning reusable waste containers (e.g. leakproof containers used for disposal of used dialyzers and tubing)?
Does the facility have policies and procedures to ensure reusable medical devices (e.g., thermometers, stethoscopes, blood pressure cuffs) are cleaned appropriately between patients?
Does the facility have policies and procedures for routinely cleaning and disinfecting: i. Dialysis Clamps
Does the facility have policies and procedures for routinely cleaning and disinfecting: ii. Blood Glucose Monitors
Does the facility have policies and procedures for routinely cleaning and disinfecting: iii. Dialysate Conductivity/pH meters
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

VIII. Dialyzer Reuse and (if applicable) Reprocessing
Incomplete Elements
Does the facility reuse dialyzers?
Does the facility document informed consent for patients who participate in dialyzer reuse?
Does the facility have policies and procedures to ensure that dialyzers are cleaned and reprocessed appropriately prior to reuse?
Does the facility train personnel responsible for reprocessing dialyzers on proper selection and use of PPE and recommended steps for reprocessing equipment?
Does the facility test the competency of personnel responsible for reprocessing dialyzers upon hire, at least annually, and when new equipment is introduced?
Does the facility regularly audit (monitor and document) adherence to reprocessing procedures and provide feedback to personnel regarding their performance?
Does the facility perform routine maintenance for reprocessing equipment (e.g., automated reprocessors) by qualified personnel in accordance with manufacturer instructions?
Potential Areas of Improvement
Does the facility document informed consent for patients who participate in dialyzer reuse?
Does the facility have policies and procedures to ensure that dialyzers are cleaned and reprocessed appropriately prior to reuse?
Does the facility train personnel responsible for reprocessing dialyzers on proper selection and use of PPE and recommended steps for reprocessing equipment?
Does the facility test the competency of personnel responsible for reprocessing dialyzers upon hire, at least annually, and when new equipment is introduced?
Does the facility regularly audit (monitor and document) adherence to reprocessing procedures and provide feedback to personnel regarding their performance?
Does the facility perform routine maintenance for reprocessing equipment (e.g., automated reprocessors) by qualified personnel in accordance with manufacturer instructions?
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

IX. Hand Hygiene
Incomplete Elements
Supplies necessary for adherence to hand hygiene recommendations are available and located near point of use: i. Alcohol-based hand gel
Supplies necessary for adherence to hand hygiene recommendations are available and located near point of use: ii. Handwashing sinks
Supplies necessary for adherence to hand hygiene recommendations are available and located near point of use: iii. Soap
Supplies necessary for adherence to hand hygiene recommendations are available and located near point of use: iv. Paper Towels
Does the facility perform observations of staff hand hygiene opportunities monthly (or more frequently)?
a. If Yes, does the facility provide feedback on adherence to clinical staff?
Potential Areas of Improvement
Supplies necessary for adherence to hand hygiene recommendations are available and located near point of use: i. Alcohol-based hand gel
Supplies necessary for adherence to hand hygiene recommendations are available and located near point of use: ii. Handwashing sinks
Supplies necessary for adherence to hand hygiene recommendations are available and located near point of use: iii. Soap
Supplies necessary for adherence to hand hygiene recommendations are available and located near point of use: iv. Paper Towels
Does the facility perform observations of staff hand hygiene opportunities monthly (or more frequently)?
a. If Yes, does the facility provide feedback on adherence to clinical staff?
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

X. Catheter and other Vascular Access Care
Incomplete Elements
Does the facility provide training specific to catheter/vascular access care and aseptic technique for staff handling catheters and/or vascular accesses?
Does the facility perform observations of staff vascular access care and catheter accessing practices quarterly (or more frequently)?
a. If Yes, does the facility provide feedback on adherence to clinical staff?
Facility performs staff competency assessments for vascular access care and catheter accessing: i. Upon hire, prior to provision of care
Facility performs staff competency assessments for vascular access care and catheter accessing: ii. Annually
Does the facility use an alcohol-based chlorhexidine (>0.5%) solution as the first line skin antiseptic agent during dressing changes of catheters?
Does the facility routinely apply an antibiotic ointment or povidine-iodine ointment to catheter exit sites during dressing changes?
Does the facility routinely scrub catheter hubs with appropriate antiseptic after the caps are removed and before accessing the catheter?
a. If N/A (facility uses needleless connector devices), does the facility routinely scrub the catheter hubs when the needless connectors are removed?
Potential Areas of Improvement
Does the facility provide training specific to catheter/vascular access care and aseptic technique for staff handling catheters and/or vascular accesses?
Does the facility perform observations of staff vascular access care and catheter accessing practices quarterly (or more frequently)?
a. If Yes, does the facility provide feedback on adherence to clinical staff?
Facility performs staff competency assessments for vascular access care and catheter accessing: i. Upon hire, prior to provision of care
Facility performs staff competency assessments for vascular access care and catheter accessing: ii. Annually
Does the facility use an alcohol-based chlorhexidine (>0.5%) solution as the first line skin antiseptic agent during dressing changes of catheters?
Does the facility routinely apply an antibiotic ointment or povidine-iodine ointment to catheter exit sites during dressing changes?
Does the facility routinely scrub catheter hubs with appropriate antiseptic after the caps are removed and before accessing the catheter?
a. If N/A (facility uses needleless connector devices), does the facility routinely scrub the catheter hubs when the needless connectors are removed?
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

XI. Injection Safety
Incomplete Elements
Supplies necessary for adherence to safe injection practices are available and located near point of use: i. Sharps Containers
Supplies necessary for adherence to safe injection practices are available and located near point of use: ii. Needles/cannulae with safety feature
Does the facility have policies/procedures to ensure sharps containers are emptied and/or changed on a regular basis and when needed?
Does the facility use a clean room that is physically separate from the treatment area for storage and preparation of injectable medications?
a. If No, is there a room available in the facility that could be used for storage and preparation of injectable medications?
Does the facility have a policy/procedure for routinely cleaning surface(s) where injectable medications are prepared?
Does the facility use manufacturer pre-filled saline syringes or single-use saline vials for flushes?
Potential Areas of Improvement
Supplies necessary for adherence to safe injection practices are available and located near point of use: i. Sharps Containers
Supplies necessary for adherence to safe injection practices are available and located near point of use: ii. Needles/cannulae with safety feature
Does the facility have policies/procedures to ensure sharps containers are emptied and/or changed on a regular basis and when needed?
Does the facility use a clean room that is physically separate from the treatment area for storage and preparation of injectable medications?
a. If No, is there a room available in the facility that could be used for storage and preparation of injectable medications?
Does the facility have a policy/procedure for routinely cleaning surface(s) where injectable medications are prepared?
Does the facility use manufacturer pre-filled saline syringes or single-use saline vials for flushes?
Action Items: ☐ Facility will conduct additional training for healthcare personnel (e.g., to correct a problem observed) ☐ Facility will improve regular training program, including incorporation of competency assessments ☐ Facility will initiate feedback program ☐ Facility will initiate auditing program ☐ Health dept. provided recommendation(s) at time of visit ☐ Facility will develop/update policies and procedures ☐ Health dept. provided resource(s)/tool(s) at time of visit ☐ Other (specify): Click here to enter text. Facility Response: ☐ Facility agrees with assessment in this domain ☐ Facility plans to take action to mitigate ☐ Other (specify): Click here to enter text.
All Items Confirmed
Notes/Recommendations: Click here to enter text.

Follow Up Activities:
☐ Repeat on-site assessment planned (date: Click here to enter a date.)
☐ Repeat remote (phone/email) assessment planned (date: Click here to enter a date.)
☐ Other (specify): Click here to enter text.

Other Comments:
Click here to enter text.

☐ IC Policies and Infrastructure ☐ IC Training ☐ HCP Safety

☐ Surveillance/Reporting ☐ Respiratory Hygiene ☐ PPE

☐ Environmental Cleaning ☐ Dialyzer Reuse ☐ Hand Hygiene

☐ Catheter/Vascular Access Care ☐ Injection Safety