Dialysis Infection Control Policies Required for CMS Compliance

Introduction

Infection control is one of the most heavily reviewed areas during CMS dialysis surveys—and one of the most common reasons facilities receive deficiencies.

Dialysis providers must maintain clear infection control policies that protect patients, reduce transmission risks, and ensure compliance with CMS Conditions for Coverage.

Facilities with outdated or incomplete infection control documentation often face citations, operational disruptions, and increased compliance risk.

Many providers strengthen their compliance systems by reviewing updated dialysis policies for purchase and comparing them against their current manuals. If your facility needs updated documentation, you can also view our dialysis policies for sale here. 

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Why Infection Control Is Critical in Dialysis Facilities

Dialysis patients often have weakened immune systems and require frequent treatments, making infection prevention especially important.

CMS surveyors closely review whether facilities have structured infection control systems in place to protect patients and staff.

They often evaluate:

• sanitation procedures

• PPE protocols

• bloodborne pathogen prevention

• catheter care procedures

• equipment disinfection

• documentation processes

Failures in these areas can quickly result in deficiencies.

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How Often Should Policies Be Reviewed?

At minimum, dialysis policies should be formally reviewed annually.

Many facilities also review policies when:

• preparing for CMS surveys

• launching new dialysis programs

• expanding home dialysis services

• responding to deficiencies

• implementing new equipment or technology

Annual review helps ensure policies stay aligned with current regulations.

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Infection Control Policies CMS Surveyors Expect to See

Infection Control Policies CMS Surveyors Expect to See

Hand Hygiene

Policies should define:

• hand washing requirements

• sanitizer usage

• patient contact protocols

• compliance monitoring

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Equipment Cleaning and Disinfection

Policies should address:

• machine disinfection

• surface cleaning

• reusable equipment handling

• documentation logs

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Bloodborne Pathogen Exposure

Facilities should maintain protocols for:

• exposure incidents

• reporting requirements

• follow-up care

• employee protection measures

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Catheter and Access Site Infection Prevention

Policies should outline:

• dressing changes

• sterile techniques

• monitoring procedures

• infection prevention standards

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Isolation Procedures

Facilities need policies for:

• infectious patients

• isolation stations

• staff protocols

• cleaning requirements

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Personal Protective Equipment (PPE)

Policies should address:

• PPE requirements

• proper usage

• disposal procedures

• supply management

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Documentation Requirements

CMS surveyors often review documentation showing that infection control policies are actively implemented.

This may include:

• cleaning logs

• incident reports

• training documentation

• competency records

• audit documentation

Even strong policies can create issues if implementation documentation is missing.

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Common Infection Control Mistakes

Many facilities receive deficiencies due to:

• outdated infection control manuals

• inconsistent staff compliance

• poor documentation

• missing logs

• weak staff training

Many of these same issues are covered in our guide on common dialysis compliance mistakes that trigger CMS deficiencies.

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How Infection Control Policies Support Survey Readiness

Strong infection control documentation helps facilities:

• reduce deficiencies

• improve patient safety

• standardize staff behavior

• strengthen survey readiness

Facilities preparing for upcoming inspections should also review our CMS dialysis survey checklist.

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Should You Build Infection Control Policies Internally?

Some facilities build policies internally.

However, this often leads to:

• missing regulatory requirements

• inconsistent documentation

• outdated protocols

Many providers choose dialysis policy manuals for sale because they include infection control policies already aligned with CMS requirements.

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Final Thoughts

Infection control policies are not optional—they are a core component of dialysis compliance.

Facilities that maintain strong infection prevention documentation are better positioned to protect patients and pass CMS surveys.

Need updated infection control policies?

👉 View our dialysis policies and procedures 

👉 Book a consultation