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Self-assess your dialysis center against the Conditions for Coverage in 42 CFR Part 494 — the regulation every Medicare-certified ESRD facility must meet. Answer honestly, get a domain-by-domain alignment score, and a gap-closure roadmap for survey readiness.
CMS requires defined staff qualifications, an active medical director, and health screening for everyone who works in the facility — including contracted staff.
Does your facility have a designated medical director who is a licensed physician with training or experience in nephrology?
The medical director must be a physician who meets CMS qualification requirements and is responsible for the quality of medical care. [494.20(a)]
Are patient care and dialysis staff licensed/certified per state requirements, with documented qualifications on file?
RNs, LPNs, technicians, and dietitians each have defined qualification requirements; documentation must be current and verifiable. [494.20(b)-(c)]
Does every staff member have documented pre-employment and annual health screening (TB, hepatitis B status, immunizations)?
CMS requires baseline health screening, TB testing, and hepatitis B screening/immunization records for all staff. [494.30(a)-(c)]
Is there a documented staffing plan that accounts for patient acuity and is reviewed regularly?
Staffing must be sufficient for patient care at all times; CMS surveys evaluate staffing against patient census and acuity. [494.40(b)(2), 494.70(c)]
Written policies govern every aspect of dialysis care — from the plan of care to medication administration. CMS surveys read your policies first.
Do you have current, written patient care policies covering medical supervision, emergency care, medications, and infection control that staff can access?
Policies must cover all required areas, be dated and reviewed, and be available to all staff at all times. [494.40(a)]
Does each patient have an individualized, documented plan of care reviewed by the interdisciplinary team within 30 days of admission?
The interdisciplinary plan of care must address dialysis adequacy, anemia, nutrition, bone disease, vascular access, and patient education. [494.80(b)]
Are dialysis orders (dialyzer, blood/dialysate flow, ultrafiltration, medications) documented and updated after each assessment?
Prescription changes must be timed to the patient's assessment cycle; orders must be legible, dated, and signed. [494.60(c), 494.70(d)]
Is there a documented process for responding to and reporting adverse events (hypotension, access complications, medication errors)?
QAPI must capture adverse events, analyze them, and implement corrective actions — the survey will look for the loop, not just the log. [494.70(e), 494.170(a)(3)]
CMS mandates specific patient rights, advance directives, and transplant education — including documentation that each right was offered.
Are written patient rights (dignity, privacy, confidentiality, participation in care decisions) provided to every patient at admission?
Rights must be posted and given in writing; documentation must show the patient received them. [494.50(a)]
Do you provide advance directive information and document patient preferences?
Patients must receive written information about advance directives; documentation must record whether they completed one. [494.50(a)(8)]
Are patients offered transplant education and informed about living donation options, with documentation?
CMS requires transplant referral/education for all appropriate patients, with documentation of the discussion — a common survey finding. [494.62(a)]
Is there a documented process for patients to voice complaints, with investigation and response tracked?
Complaint procedures must be documented, and complaints must be investigated and resolved with evidence of follow-through. [494.50(a)(10)-(11)]
The core conditions: timely patient assessment, adequate dialysis delivered per prescription, and documented adequacy measurement.
Is every patient assessed by a physician within 30 days of admission, then at least monthly?
Physician assessment frequency is a hard CMS requirement; missed monthly assessments are a common deficiency. [494.60(b)]
Is dialysis adequacy (Kt/V or URR) measured and documented monthly for hemodialysis patients and at least quarterly for PD?
Adequacy must be measured and documented on a defined schedule, with interventions when targets are missed. [494.70(d)(2)]
Are water quality testing results (cultures, endotoxin, chloramines, total chlorine) documented per AAMI standards and your facility schedule?
Water treatment logs must show culture, endotoxin, and chemical testing at the required intervals — a top survey focus. [494.70(d)(3), 494.100(c)]
Is there a documented process for assessing vascular access and monitoring access outcomes (infection, thrombosis, catheter use)?
Access monitoring should connect to the CMS access quality measures: fistula/graft prevalence and catheter reduction. [494.70(d)(1), 494.80(c)]
The facility must be clean, safe, and suitable — fire safety, emergency power for dialysis machines, and equipment maintenance all fall here.
Does the facility meet fire and building safety codes, with documented fire drills and safety inspections?
Life safety code compliance includes documented drills, exits, alarms, and maintenance records. [494.100(b)]
Is emergency power available and tested that can sustain dialysis machines and critical systems during outages?
Emergency generators must be tested on a schedule and able to support machines through a power failure. [494.100(b)]
Is dialysis equipment (machines, water system, reprocessing) maintained on a documented preventive maintenance schedule?
Maintenance logs must be complete and current; equipment must be available and functional during survey. [494.100(c)]
Are housekeeping, ventilation, and infection-related environmental standards (handwashing stations, isolation capability) in place?
The environment must prevent cross-contamination — hand hygiene stations at stations, separation for hepatitis B patients, and clean housekeeping. [494.100(a)-(d)]
The highest-priority survey focus in dialysis: surveillance, isolation, hand hygiene, and the CMS infection measures.
Do you have a written infection control program with active surveillance for bloodstream infections, peritonitis, and access infections?
Surveillance must be systematic and use defined definitions (e.g., CDC dialysis event definitions) — not anecdote. [494.110(a)]
Are hepatitis B (HBsAg-positive) patients isolated in a separate room with dedicated machines and equipment?
Separation requirements for HBsAg-positive patients are specific and a frequently cited deficiency. [494.110(b)]
Is hand hygiene compliance monitored with feedback to staff?
CMS expects monitoring of hand hygiene practices with documented results and improvement actions. [494.110(a)(2)]
Are catheter care, cannulation, and dialysis station cleaning practices documented and observed for compliance?
The audit should verify both written protocols and observed practice — CMS observes during survey. [494.110(a)-(c)]
Complete, timely medical records and a working quality assessment and performance improvement program — the backbone of any successful survey.
Is a complete medical record maintained for each patient, with timely entries and secure storage?
Records must be complete, accurate, and timely — including dialysis records, assessments, consents, and lab results. [494.140(a)]
Do you have an active QAPI program with documented quality indicators, data review, and improvement projects?
CMS wants to see data-driven improvement: indicators chosen, data collected, analyzed, and acted upon. [494.170(a)]
Does QAPI review infection rates, hospitalizations, adequacy measures, and patient satisfaction on a defined schedule?
The required review areas are specified; documentation must show the review happened and what changed. [494.170(a)(3)]
Are lab results and CROWNWeb data submissions current and reconciled with facility records?
Data submission to CMS (CROWNWeb) must be complete and on time — it feeds your published quality measures. [494.180(a)]
Since 2016, every dialysis facility must have a documented emergency preparedness program: risk assessment, plan, training, and testing.
Do you have a written emergency preparedness plan based on a documented all-hazards risk assessment?
The plan must address the risks specific to your facility and region — power, water, weather, and patient evacuation. [494.160(a)-(b)]
Are staff trained on the emergency plan with documented annual drills (including one full-scale exercise)?
Training and exercises must be documented, and the plan reviewed after each exercise. [494.160(c)-(d)]
Is there a documented plan for coordinating with local emergency management and neighboring facilities for patient continuity?
CMS expects arrangements with community partners so dialysis continues during disruptions. [494.160(a)(4)]
42 CFR Part 494 sets the Conditions for Coverage for ESRD facilities: personnel qualifications (494.20), personnel health (494.30), patient care policies (494.40), patient rights (494.50), patient assessment (494.60), transplant referral (494.62), dialysis services (494.70), physical environment (494.100), infection control (494.110), medical records (494.140), QAPI (494.170), and emergency preparedness (494.160). CMS state surveyors verify these conditions through document review, observation, and staff interviews.
This self-assessment is an educational tool derived from the text of 42 CFR Part 494 (Conditions for Coverage for End-Stage Renal Disease Facilities, eCFR, retrieved August 2026). It is not a CMS survey, a substitute for regulatory counsel, or a guarantee of survey outcome. Section citations refer to the current CFR text — always verify against the official eCFR at ecfr.gov before acting.