August 22, 2018
3 min read

CMS releases new rules on dialysis care in nursing homes

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A long-anticipated set of rules on how dialysis providers can provide treatments to patients living in skilled nursing facilities and nursing homes was released by CMS on Aug. 10 as part of an update to guidelines used by Medicare surveyors to inspect dialysis facilities.

Revisions to the State Operations Manual were released to state survey agencies by David Wright, the director of the Quality, Safety and Oversight Group at CMS, and are effective immediately with no further changes. In addition to the nursing home guidelines, the revisions cover basic requirements for operating a dialysis facility, including definitions of modality types, guidelines for establishing a home dialysis training center, addition of stations, expansion of services and temporary closures; infection control considerations; and rules regarding medical director waiver considerations.

Staffing requirements and supervision

The nursing home requirements set definitions along with education and training requirements for staff providing dialysis care and are “to ensure that an ESRD facility, providing home dialysis services to a nursing home resident under a written agreement with the resident’s nursing home, maintains direct responsibility for the dialysis related care and services provided to the nursing home resident(s) consistent with the ESRD Conditions for Coverage (CfC) requirements as well as the terms of an applicable agreement with the nursing home,” CMS wrote.

Of particular importance in the new rules is the training and supervision of staff performing the dialysis treatment in the nursing home facility. The dialysis provider must, according to the new rules, ensure that:

1. Onsite supervision of dialysis is provided by a trained registered nurse (RN) whenever a resident is receiving hemodialysis (HD) in the nursing home, and by a trained RN or licensed practical/vocational nurse (LPN/LVN) when PD treatment is provided;

2. Qualified/trained dialysis administering personnel are present in the room and maintain direct visual contact with the resident receiving HD throughout the entire duration of the treatment (the supervising nurse may also be the dialysis administering personnel); and

3. If a situation occurs in which the nursing home is unable to provide dialysis treatments due to reasons such as insufficient trained staff and/or supervision, the ESRD facility is notified and provides the dialysis treatments to avoid a delay or cancellation of treatment.

The ESRD facility providing the care “must ensure that a trained supervising RN is constantly present on-site at the nursing home and immediately available to respond to concerns or emergencies that may occur during a resident’s hemodialysis,” the policy states. “The supervising nurse must be present in the general area where the resident(s) are receiving dialysis and readily available. If the supervising nurse has other nursing duties in the nursing home, these other duties must not hinder or negatively affect his/her ability to respond immediately to the needs of the dialysis patient(s),” CMS wrote.


Nurses who supervise hemodialysis treatments in the nursing home must have successfully completed a training program approved by the dialysis facility medical director and governing body; administered under the direction of a home training nurse; and is equivalent to the ESRD facility training and competency verification for patients on home dialysis.

The personnel who initiate and discontinue dialysis treatments for HD and PD to nursing home residents must be a RN, LPN or LVN who meets the practice requirements in the state in which he or she is employed.

“A trained nursing home staff member such as a nurse aide or trained caregiver may monitor the patient for the duration of the patient’s treatment, but initiation and discontinuation of HD and PD must only be performed by the supervising nurse,” the policy states. To assure resident safety, the ESRD facility and nursing home must ensure that qualified dialysis administering personnel remain in the room with direct visual contact of the resident and their vascular access throughout the hemodialysis treatment.

If an existing ESRD facility home dialysis (PD or home HD) patient is admitted to a nursing home and that patient has a trained personal caregiver who administered the dialysis treatments at home, that caregiver may be approved by the ESRD facility and the nursing home to continue to administer the patient’s dialysis treatments in the nursing home, the policy states.

“The collaborative decision-making process for such situations must be addressed in the written agreement between the ESRD facility and nursing home. If the nursing home and ESRD facility determine that an existing home dialysis caregiver may continue to administer the dialysis in the nursing home, the ESRD facility must assure that the caregiver meets the training requirements and the verification of demonstrated competency,” CMS wrote.

Questions about the regulations can be sent to – by Mark Neumann