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State of California—Health and Human Services Agency
California Department of Public Health

AFL 07-23
August 16, 2007

Skilled Nusing Facility Administrators
DP/SNF Administrators
End Stage Renal Dialysis Clinic Administrators
Chronic Dialysis Clinic Administrators

Dialysis Services in Skilled Nursing Facilites

​This letter supersedes AFL 07-13 in the manner described in this memo.

Upon further review, the Department has determined that peritoneal and hemodialysis services may be provided in skilled nursing facilities. Delivery of these services will be provided as an optional service in skilled nursing facilities pursuant to title 22 CCR section 72401, and the service must be added to the facility’s license.

The purpose of this correspondence is to provide direction to skilled nursing facilities, chronic dialysis clinics, and end stage renal dialysis clinics on how these services may be provided in accordance with Title 22 CCR section 72401(d).

A skilled nursing facility (SNF) wishing to provide peritoneal or hemodialysis services must apply for approval of the optional service. This optional service will only be available to residents of the facility and not to the general public. Licensing and Certification will evaluate and approve such dialysis services on a case-by-case basis applying applicable provisions of the ESRD standards for federal certification for such services. If the SNF does not employ qualified persons to provide dialysis services, arrangements must be made through a written agreement with outside resources who will meet the standards for providing dialysis services. (See title 22 CCR section 72511). The affiliation agreements or contract must be filed in the facility’s administrative office and must be readily available for inspection and review by the Department. The agreement must contain a description of the services to be provided, financial arrangements, methods by which the services are to be provided, and the conditions upon which the agreement, contract, or written arrangement can be terminated.

The following conditions apply:

  1. Skilled nursing facilities allowing peritoneal or hemodialysis services prior to June 13, 2007, may continue to provide these services pending approval of their application of this service as long as their application has been filed by October 15, 2007. To apply, facilities must submit a completed HS 200 form requesting the addition of peritoneal and/or hemodialysis services.
  2. Each peritoneal and hemodialysis services unit shall have written policies and procedures for the management of the peritoneal and/or hemodialysis service and must be available to Licensing and Certification staff, along with any written agreements with outside resources, to complete the application approval process.
  3. If a hemodialysis technician is employed, he or she must work under the immediate supervision of a licensed registered nurse as required under California Business and Professions Code Section 1247.3.

We apologize for any confusion or disruption AFL 07-13 may have had on residents, family members and facility staff. We believe that this policy clarification will allow for the safe delivery of these services to a very vulnerable population.

For questions regarding this letter, please contact Scott Vivona, Chief Field Operations Branch, at (916) 440-7377.



Original Signed by Kathleen Billingsley, R.N.

Kathleen Billingsley, R.N.
Deputy Director
Center for Healthcare Quality

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