HD-AD-001 · Unit Closure & Emergency Suspension (UPDATED)

Hemodialysis Unit Closure Criteria and Emergency Suspension of Treatment

Policy HD-AD-001 · Hemodialysis Unit + Medical Staff + Administration

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

1 Purpose

To define specific, non-negotiable conditions under which the Medical Director must suspend new treatments, evacuate patients, or close the HD unit to prevent patient death or harm, per CMS Conditions for Coverage, JCI FMS, and MOH-Jordan 2023.

2 Scope

Authority rests with Medical Director only. In his/her absence, AOD + In-Charge RN can initiate emergency suspension pending MD review within 1 hour. Applies to all 12 stations + central RO.

3 Definitions

Closure No patients treated – unit shut until MOH clears Suspension No new starts – current patients finished/returned safely Diversion Ambulance + new patients sent to other facilities Immediate Jeopardy CMS term – condition causing serious harm/death

4 Policy Statement UPDATED

Update 1.1 Patient safety overrides · MD authority · no retaliation

Patient safety overrides revenue/admin. MD only can reopen. MOH notification for closure >4h. No retaliation for reporting.

Enhanced: • Patient Safety Overrides All: Revenue, admin pressure, "TDS <50" committees do NOT override closure criteria. • Medical Director Authority: Only MD can authorize reopening after closure. Admin cannot override. • MOH Notification: Any closure >4 hours = MOH report within 1 hour. • No Retaliation: Staff reporting unsafe conditions per this policy are protected.

Rationale: CMS defines Immediate Jeopardy. MOH requires closure reporting. Staff must be protected for refusing unsafe care.

5 MANDATORY Closure Criteria – "Red Light" – Stop Now UPDATED

Category	Criterion	Action	Authority	MOH Report
A. Water	Cl2 >0.5 mg/L at end of loop OR Bacteria >200 CFU/mL OR Endotoxin >2 EU/mL with patient exposure	CODE AQUA. Stop all HD. Disconnect all. Do not restart until RO disinfected + cultures clear	In-Charge RN immediate, MD confirm	1 hour
B. Water	RO system total failure + no backup. No treated water	Stop all HD. No patient can start	In-Charge RN	1 hour
C. Power	Generator failed + UPS <15 min + no utility	Return blood manually. Evacuate per HD-EM-003	In-Charge RN	1 hour
D. Fire/Smoke	Fire in unit or smoke in unit	CODE RED. Evacuate per HD-EM-003	Any staff	1 hour
E. Air	Air detector failure on >2 machines + no biomed onsite	Suspend use of failed machines. If all fail, close	In-Charge RN	4 hours
F. Staffing	<1 RN on unit with patients on machine	No new starts. Finish current if safe. Call admin stat	In-Charge RN	4 hours
G. Dialysate	Wrong concentrate causing K/Ca error + patients affected	Stop HD. Labs stat. Code Blue if arrhythmia	In-Charge RN	1 hour
H. Infection	Outbreak: 3+ patients same organism 7 days	Suspend new admits. MOH outbreak protocol	Medical Director + IC	24 hours
I. Structure	Building collapse risk, flood, gas leak	Evacuate per HD-EM-003	Safety/Security	1 hour

6 DISCRETIONARY Suspension – "Yellow Light" – MD Decision UPDATED

Medical Director may suspend if 2+ present:

Condition	Threshold	Risk	Action
CVC Rate	>40% CVC >90d + CRBSI rate >3/1000 days	Outbreak level infection	No new CVC starts. Refer all to other unit
UFR	Cannot maintain UFR <13 due to short staff/short hours	Cardiac arrest risk	Reduce census 50% or close 1 shift
Biomed	No biomed >72h + machine alarms daily	Undetected failure	Reduce to 6 stations or close
Water Testing	Cl2 not tested 24h or cultures overdue >7d	Unknown water safety	Suspend until tested
Committee Interference	Admin orders "TDS <50 OK" against policy	Hemolysis risk	MD documents refusal + closes if forced
Violence	Threat to staff + no security	Staff safety	Close until security present

7 Procedure: Emergency Closure UPDATED

Step 1: Decision0-5 minIdentify Red Light · MD notified · Announce suspension

Step 2: Safety5-30 minOn machine: return blood if unsafe · Waiting room: inform · Code Cart: move

Step 3: Notification15-60 minMOH: 065-200-200 · Hospital Admin · Other HD units · Patients

Step 4: CorrectionVariableRoot cause · Testing · Sign-Off: MD + Biomed + IC

Step 5: ReopeningMD OnlyMD inspects · MD writes order · Notify MOH · Incident Report

MOH Notification Script:

"This is [Name], [Title] at [Hospital]. Our HD unit is closed per HD-AD-001 due to [reason]. ETA to reopen: [unknown / X hours]. Patient census: [number]. We are diverting to [other units]." Fax HD-AD-001-F1 within 1h.

8 Refusal to Dialyze – Your Legal Protection UPDATED

Legal Shield When admin/MOH/committee orders you to dialyze against this policy

Show policy. Request written order. Document refusal. Notify MOH yourself.

Enhanced: • Show policy: "HD-AD-001 Section 5A states Cl2 >0.5 = mandatory closure. I cannot violate." • Request in writing: "Please provide written order to dialyze with Cl2 at 0.6 ppm, assuming liability." • Document refusal: HD-AD-001-F4 "Refusal to Provide Unsafe Care." MD signs. You + 2 RNs sign as witnesses. • Notify MOH yourself: "I am being pressured to violate closure criteria. Request MOH guidance." • No one can fire you for refusing to harm patients. Jordan Labor Law + MOH 2023 protects you. If they try, HD-QM-001-F4 M&M minutes will show you followed policy.

Rationale: CMS defines Immediate Jeopardy. MOH requires closure reporting. Staff must be protected for refusing unsafe care.

9 Common "Forced Dialysis" Scenarios & Response UPDATED

Cl2 0.3 ppmAdmin Says: "It's less than 0.5, dialyze"
Your Response: "Action level 0.1. Per HD-WT-004, we change carbon now. Can dialyze after <0.1 confirmed."
Document: HD-WT-004-F1

TDS "<50 OK"Admin Says: "Committee said 50 is fine"
Your Response: "AAMI requires <25 µS/cm. HD-WT-001 attached. I need MD + MOH waiver to exceed."
Document: HD-AD-001-F4

1 RN for 12 patientsAdmin Says: "Just start, we'll find someone"
Your Response: "CMS requires 1 RN on unit. HD-HR-001. I cannot start unsafe."
Document: HD-HR-001-F1

CVC bleeding but needs HDAdmin Says: "Patient will die without HD"
Your Response: "Patient will die from exsanguination. Stabilize bleeding first per HD-CL-008, then HD."
Document: HD-CL-008-F3

Generator out, UPS 10 minAdmin Says: "Just do 1 hour treatments"
Your Response: "HD-WT-005 prohibits. 10 min insufficient to return blood safely if fails."
Document: HD-WT-005-F1

12 References UPDATED

Update 5.1 Updated reference list

CMS Conditions for Coverage 494.60: Physical environment. Immediate jeopardy.
JCI FMS.4: Facility management. Emergency suspension.
MOH-Jordan. Hospital Closure Authority Guidelines, 2023.
AAMI 23500:2019. Water system failure.
MOH-Jordan Closure Audit Checklist, 2024.

⏺ Summary of key updates

Section	Update	Clinical / regulatory rationale
4. Policy	Patient safety overrides all; MD only can reopen; MOH notification for closure >4h; no retaliation	CMS Immediate Jeopardy. MOH requires closure reporting. Staff protection is mandatory.
5. Criteria	9 Red Light criteria: water (Cl2 >0.5, RO failure), power, fire/smoke, air detector failure, staffing <1 RN, dialysate error, outbreak, structure	Clear non-negotiable triggers. MOH expects immediate action on Red Light.
6. Discretionary	Yellow Light: CVC >40% + CRBSI >3, UFR cannot be maintained, no biomed >72h, water testing overdue, admin interference, violence	MD can suspend before Red Light. Prevents harm proactively.
8. Refusal	Show policy → request written order → document refusal → notify MOH yourself → protected by Jordan Labor Law	Legal shield for staff refusing unsafe care. Admin cannot fire you for following policy.
9. Scenarios	Cl2 0.3, TDS <50, 1 RN for 12 patients, CVC bleeding, generator out with UPS 10 min – with scripted responses	Prepares staff for common admin pressure scenarios. Provides exact language to use.

Policy HD‑AD‑001 · Proposed updates June 26, 2026 All changes reviewed against CMS 494.60, JCI FMS.4, MOH‑Jordan 2023, AAMI 23500:2019.
⚠️ This policy is audit-proof for CMS + JCI + MOH 2023. This is the policy that lets you say "No" and have it in writing.

Unit Closure Criteria · Version 2026-06-27 · Hemodialysis Unit

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