Karunya Benevolent Fund

Karunya Benevolent Fund
Vrindravan Housing Scheme
Pattom PO., Trivandrum-695 004
Phone: 0471-2442363/2440325/2440328
e-mail-karunyabf@gmail.com
APPLICATION FOR ACCREDITATION OF DIALYSIS CENTRES
Hospital:
_______________________________________________________
Address:
_______________________________________________________
Chief Nephrologist:
_______________________________________________________
Tel: ___________________ Fax: _____________________________
No. of hemodialysis beds: _______ No. of backup machine (if any) _______
Staffing:
No. of qualified nephrologists: ______
No. of qualified Dialysis Technicians: _______
No. of qualified renal nurses: _______
Availability of doctor during emergency. (R) yes / no
All staffs practicing universal precautions. yes / no
All staffs (Technicians & Staff nurses) got dialysis training yes / no
1

Space and equipment:
Cleanliness of the patient treatment area, water treatment plant
and hemodialysis machines. (R) yes / no
Separate area for hemodialysis and washing. (D) yes / no
Whether separate consumable washing area available for
positive & negative patients Yes/no
Enough hand washing sinks readily accessible to staff. (R) yes / no
Central water treatment system. (Reverse Osmosis membranes or
Deionization tanks) (R) yes / no
Automatic Back wash system yes / no
No. of HD machines :
No. of backup HD machines :
No. of brand new HD machines :
No. of refurbished HD machines :
The date of manufacturing of all the HD machines available in the Centre
1. 6.
2. 7.
3. 8.
4. 9.
5. 10.
Designated area and hemodialysis machines for HBsAg
positive patient. (R) yes / no
Designated hemodialysis machines for HCV/HIV positive patient. (D) yes / no
Availability of Resuscitation equipment in the HD Room: (R) yes / no
2

Fumigation Dispenser yes / no
Interval of HD Room fumigation :
Quality Assurance Activities:
Preventive maintenance and repair record of hemodialysis
machine and water treatment system. (R) yes / no
Procedure guidelines for disinfection of water treatment system,
product water delivery system and hemodialysis machines. (R) yes / no
Written record on results of microbiological and chemical testing
of water. (R) yes / no
Written record on results of dialysate microbiological culture
of the hemodialysis machines. (R) yes / no
Procedure guidelines for dialyzer re-use. (R) yes/no/NA
Accumulative record of blood tests results of each patient taken
at regular interval. (R) yes / no
How long this HD room is functioning :
Survival rate of the maintenance HD Patients :
How much patients survived more than 5 years :
How many patients got Hep.B, Hep.C infections? :
Present HD charge :
Interval of Dialysis :
The treatment has to be provided continuously for
121 weeks per patient. Hence how may machines can
be made available for KBF beneficiaries :
The HD rate offered for KBF beneficiaries including
consumables & erythropoietin :
Annual Statement regarding total Haemodialysis for the last 3 years :
3

Death rate of Haemodialysis patients for the last 3 years :
Remarks:
• _________________
(Dialysis technecian)
• ________________
(Chief, Dialysis Unit)
• _________________
Nephrologist
Date:_______________
Place;_______________
For Office Use
Reason for Recommended/Rejected :
Forwarded Approved
Dr. In Charge Administrator
4