Skip Navigation LinksAFL-22-32

State of Cal Logo

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

AFL 22-32
December 12, 2022

Skilled Nursing Facilities (SNFs)
Chronic Dialysis Clinics (CDCs)
End Stage Renal Disease Dialysis Facilities (ESRDs)

Guidelines for Dialysis Care

​AUTHORITY:     Health and Safety Code (HSC) section 1276.65

                                Title 22 California Code of Regulations (CCR) section 51215.5

​All Facilities Letter (AFL) Summary

  • This AFL reminds SNFs and CDCs/ESRDs of the guidance put forward from the Centers for Medicare and Medicaid Services (CMS) regarding the provision of dialysis services.
  • This AFL also clarifies the 3.5 Direct Care Service Hours Per Patient Day (DHPPD) requirements, of which a minimum of 2.4 DHPPD must be performed by certified nurse assistants (CNAs). 


In recent years, CMS has released updated guidance through memoranda and revisions to the State Operations Manual (SOM) to allow a dialysis facility meeting federal standards and approved for a home dialysis training and support modality to provide dialysis services to SNF residents in the SNF "home" setting. SOM Chapter 2, section 2271 (PDF) issues specific requirements for dialysis facilities and SNFs for the administration of dialysis care to SNF residents. This guidance provides detailed information on the requirements for this service including:

  • Dialysis Supervision and Administration
  • Hemodialysis Treatment Supervision

Dialysis Supervision and Administration

The CDC/ERSD facility providing services to a resident in a SNF must ensure:

  • Onsite supervision of dialysis by a trained registered nurse (RN) (who has completed a training course approved by the ESRD facility) whenever a resident is receiving hemodialysis (HD) in the SNF, and by a trained RN or licensed vocational nurse (who has completed a training course approved by the ESRD facility) when a resident is receiving peritoneal dialysis treatment in the SNF;
  • Qualified/trained dialysis administering personnel must be present in the room and maintain direct visual contact with the resident receiving HD throughout the entire duration of the treatment (the supervising nurse may also be the dialysis administering personnel); and
  • Although CMS guidance may allow SNF nurses to provide dialysis treatments, this is not permitted in California. Dialysis services must be provided by staff from the CDC/ESRD.

Hemodialysis Treatment Supervision

The CDC/ESRD facility must ensure that a trained supervising RN is constantly present on-site at the SNF and immediately available to respond to concerns or emergencies that may occur during a resident's hemodialysis treatment. The supervising nurse must be present in the general area where the resident(s) are receiving dialysis and readily available. The supervising nurse should not have other duties that may hinder or negatively affect their ability to respond immediately to the needs of the dialysis patient(s).

SNF DHPPD Standards

In accordance with HSC section 1276.65(c)(B), SNFs must have a minimum number of direct care service hours of 3.5 per patient day. Only direct caregivers shall count toward the 3.5 and 2.4 DHPPD staffing standards. For purposes of determining compliance with the minimum 3.5 and/or 2.4 DHPPD requirements, CDPH shall not count direct care service hours provided in subacute care units approved by the Department of Health Care Services and subject to the staffing requirements set forth in Title 22 CCR section 51215.5. Additionally, a nurse supervising or participating in the provision of dialysis treatments is not counted in the 3.5 DHPPD.

If you have any questions about this AFL, please contact your local district office.



Original signed by Cassie Dunham

Cassie Dunham

Deputy Director



Page Last Updated :