Renal Dialysis Findings Offer Key Compliance Insights

By: Teresa Hoosier, RN, CDN, Associate Clinical Director 

Teresa Hoosier leads ACHC’s Renal Dialysis , Behavioral Health, and Assisted Living Accreditation programs. She also serves as a clinical review specialist based on more than 30 years’ experience in the treatment of end-stage renal disease.  

Teresa’s expertise encompasses clinical compliance, quality assurance, policy and procedure development, and clinical training and education. Her knowledge of interdisciplinary coordinated care makes her a great resource to organizations seeking a knowledgeable, practical partner in improving quality. 

Posted: December 5, 2025

Survey findings in the new Quality Review edition of Surveyor break down compliance gaps, delivering valuable insights to help your renal dialysis facility strengthen processes, elevate safety, and improve overall performance.

Data from recent ACHC Renal Dialysis Accreditation surveys identify 10 standards that were cited for noncompliance on at least 20% of surveys. Nine of these frequent deficiencies emerged from two critical areas, Sections 5 and 7, and directly impact patient quality of care and safety.

Common challenges

Many organizations struggled with maintaining current, complete, and authenticated patient records that accurately reflect the care delivered and progress toward established goals.

ACHC Surveyors also frequently cited breakdowns in infection prevention practices, including poor separation of clean and contaminated equipment and lapses in environmental cleanliness that increase the risk of cross-contamination and compromise patient safety.

Surveyor citations also extended to emergency preparedness. While emergency plans were generally in place, staff readiness was inconsistent. Findings such as expired or missing supplies, inaccessible equipment, and insufficient staff/patient training can be viewed as opportunities to strengthen operational preparedness.

New this year

Continuous improvement is woven into all we do at ACHC, including the annual Quality Review edition of Surveyor. In our recent issue, “tips for compliance” under each standard profile are enhanced to address varying levels of accreditation knowledge and experience across your agency. Explore our new Accreditation Nerd categories to see which is best for you. 

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