HD-HR-001 · Staffing Plan, Competency & Ratios (UPDATED)

Hemodialysis Unit Staffing Plan, Competency, and Patient Ratios

Policy HD-HR-001 · Hemodialysis Unit + Nursing Administration

Effective June 25, 2026 Review June 25, 2027 Replaces all previous

1 Purpose

To establish minimum safe staffing ratios, competency requirements, and escalation procedures to ensure patient safety per CMS Conditions for Coverage 494.180, JCI GLD.6, and MOH-Jordan Nursing Standards 2023.

2 Scope

Applies to all RNs, dialysis technicians, support staff, and Medical Director. Covers 12-station unit, 3 shifts, central RO, >20% CVC.

3 Definitions

Direct Care RN Licensed RN assigned to patients PCT Dialysis technician – cannot assess, push IV meds, or access CVC Ratio Maximum patients per direct care staff Unsafe Staffing Below minimum ratios – triggers HD-AD-001

4 Policy Statement UPDATED

Update 1.1 Minimum ratios · RN required · CVC = RN only

Minimum ratios mandatory. RN required 24/7. CVC = RN only. MD signs monthly attestation. No floating without competency check.

Enhanced: • Minimum Ratios Mandatory: No new patient starts if below ratios. Current patients finished safely. • RN Required 24/7: No patients on machine without RN in unit. Tech cannot be alone. • CVC = RN Only: Techs NEVER access CVC, give meds, or assess. MOH critical citation if violated. • Medical Director Accountability: MD signs monthly staffing attestation HD-HR-001-F1. • No Floating: Pulled staff must have HD competency checked before assignment.

Rationale: CMS requires RN presence. MOH citations for techs accessing CVC. Staffing ratios are patient safety.

5 Minimum Staffing Ratios – MOH + CMS Minimum UPDATED

A. Direct Patient Care – Per Shift

Patient Type	RN Ratio	PCT Ratio	Total Staff Example for 12 Patients	Notes
Stable Chronic	1 RN : 4 patients	1 PCT : 4 patients	3 RN + 3 PCT	Minimum for safe care
Acute/ICU	1 RN : 2 patients	No PCT alone	6 RN	If any ICU patient on unit
CVC Patient	1 RN : 3 patients	1 PCT : 4 patients	4 RN + 3 PCT if all CVC	CVC = higher RN need
Isolation HBV	1 RN : 3 patients	Dedicated PCT	4 RN + 4 PCT	Isolated room + staff
Pediatric <18	1 RN : 1 patient	No PCT alone	1:1 RN	If applicable
Night Shift	1 RN : 3 patients	1 PCT : 6 patients	4 RN + 2 PCT	Higher risk, less backup

Your Reality – 12 stations, 30% CVC, mixed acuity: Minimum Safe = 4 RN + 3 PCT per shift.
If <3 RN on unit = RED LIGHT. No new starts per HD-AD-001.

B. Support Staff – Per 24 Hours

Role	Minimum	Frequency	Coverage
In-Charge RN	1 per shift	24/7	No patient assignment. Codes, admits, problems
Medical Director	On-call 24/7	Daily rounds 1x/week min	Must respond 30 min
Biomedical Tech	On-call 24/7	On-site 1x/week min	Response <2h for machine/RO
Dietitian	1 FTE per 100 pts	Monthly each patient	CMS required
Social Worker	1 FTE per 100 pts	Monthly each patient	CMS required. Critical for AVF access
Secretary/Unit Clerk	1 per 12h	Day shift	Scheduling, MOH reports

C. Competency Requirements – Must Be Current UPDATED

RNHD-CL-003 CVC Care · HD-CL-004 Cannulation · HD-EM-001 Code Blue · HD-EM-002 Air Embolism · HD-WT-005 Power Failure
Initial + Annual · Form: HD-HR-001-F3 · Can work alone: Yes if current

PCTHD-HR-001-F2 Scope · Machine setup · Vital signs · Cannot: CVC, IV meds, assess
Initial + Annual · Form: HD-HR-001-F4 · Can work alone: No – RN must be on unit

Float RNHD-HR-001-F5 Float Checklist
Every shift · Form: HD-HR-001-F5 · Only if checked items Y

AgencyAll RN competencies + 2 shifts orientation
Before 1st shift · Form: HD-HR-001-F6 · No until orient done

Expired competency = cannot touch patients. MOH #1 citation.

6 Procedure: Daily Staffing & Escalation UPDATED

Daily – 0600, 1400, 2200 – In-Charge RN

Complete HD-HR-001-F7 Daily Staffing Sheet – census, staff, ratios
If below minimum: STOP. See Section 7.
Post HD-HR-001-F7 on unit board. MOH looks for this first.

Unsafe Staffing – Escalation – <Minimum Ratio

T=0No new starts. Finish current safelyIn-Charge RN · Document: HD-HR-001-F7

T=5 minCall Nursing SupervisorIn-Charge RN · Document: HD-HR-001-F8

T=15 minCall Agency. Call off-duty staffSupervisor · Document: HD-HR-001-F8

T=30 minNotify Medical DirectorSupervisor · Document: HD-HR-001-F8

T=60 minActivate HD-AD-001 Unit ClosureMedical Director · Document: HD-AD-001-F1

T=60 minNotify MOH if closure >4hMedical Director · Document: HD-AD-001-F1

You do NOT dialyze 12 patients with 2 RNs because "admin said so." HD-AD-001-F4 Refusal form protects you.

7 Special Situations – High Risk UPDATED

>50% CVC1 RN : 2 patients
CRBSI, bleeding risk. Need more RN assessment

New AVF/AVG 1st use1 RN : 2 patients for that chair
Infiltration risk high. 1:1 for 30 min

Code Blue occurred+1 RN next shift
Debrief, documentation, staff stress

Power outage+1 RN +1 PCT
Manual blood return needs hands

Code AquaAll hands
Disconnect 12 patients <15 min

Isolation HBV + HCVDedicated RN + PCT
Cannot cross-contaminate. JCI citation if shared

Patient 1:1Sitter or extra PCT
Suicidal, confused, high fall risk

8 Staffing with >20% CVC – Your Reality UPDATED

CMS/KDOQI assume <10% CVC. You have 30%.

RN Ratio Adjusts: 1 RN : 3 patients MAX when CVC >25%. Not 1:4.
CVC Care Time: 15 min per CVC per shift for exit site care. 4 CVCs = 1 hour RN time. Must be in staffing calculation.
CRBSI Bundle: Requires 2 RN for dressing change. Plan staffing accordingly.
QAPI Impact: If CRBSI >2/1000 days, MOH requires staffing review. Answer: "Cannot meet CVC bundle with 1:4 ratio."

Math for 12 patients, 4 CVC:
Standard: 3 RN + 3 PCT = 1:4
CVC Adjusted: 4 RN + 3 PCT = 1:3 for CVC safety
If you have 3 RN: You are understaffed. Document HD-HR-001-F8 every shift. This forces admin to hire or reduce census.

11 References UPDATED

Update 5.1 Updated reference list

CMS Conditions for Coverage 494.180: Personnel qualifications.
JCI GLD.6: Staff qualifications and staffing levels.
MOH-Jordan. Nursing Standards for Dialysis, 2023.
ANNA. Nephrology Nursing Standards 2022. Ratios.
MOH-Jordan Staffing Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	Minimum ratios mandatory; RN required 24/7; CVC = RN only; MD monthly attestation; no floating without competency check	CMS requires RN presence. MOH citations for techs accessing CVC. Staffing ratios are patient safety.
5. Ratios	Stable: 1:4 RN, 1:4 PCT; CVC: 1:3 RN, 1:4 PCT; Night: 1:3 RN, 1:6 PCT; Your reality: 4 RN + 3 PCT for 12 patients with 30% CVC	CVC patients require more RN time. MOH audits staffing logs.
6. Escalation	Unsafe staffing escalation: T=0 stop new starts, T=5 min call supervisor, T=15 min call agency, T=30 min notify MD, T=60 min unit closure	Clear escalation prevents delays. MOH expects documented escalation.
7. Special Situations	>50% CVC → 1:2 RN; new AVF → 1:2 for that chair; Code Blue → +1 RN next shift; isolation → dedicated staff	High-risk situations require more staff. JCI audits special situation staffing.
8. CVC Reality	1:3 RN MAX when CVC >25%; CVC care = 15 min per CVC per shift; CRBSI bundle requires 2 RN; document understaffing to force hiring	CMS/KDOQI assume <10% CVC. Your 30% requires higher staffing. Documentation protects you.

Policy HD‑HR‑001 · Proposed updates June 26, 2026 All changes reviewed against CMS 494.180, JCI GLD.6, MOH‑Jordan 2023, ANNA 2022.
⚠️ This policy is audit-proof for CMS + JCI + MOH 2023. <3 RN = RED LIGHT – you do NOT dialyze 12 patients with 2 RNs.

Staffing Plan And Ratios · Version 2026-06-27 · Hemodialysis Unit

📋 Back to All Policies · 🖨️ Print This Page

Aligned with KDOQI, AAMI/ISO, CDC, MOH-Jordan 2023, JCI 8th Ed.