CMS 2744 ESRD Facility Survey

1. CMS 2744 ESRD Facility Survey Instruction for Completing the Survey

2. Materials Mailed • Packet mailed on 01/22/2008 • Materials include: • Memo • CMS 2744 Survey Instructions • CMS 2007 Survey (on yellow paper) • Facility Roster for 01/01/2007 to 12/31/2007 • List of vocational rehabilitation patients ages 18 – 54 • Blank Network Patient Activity Report (NPAR)

3. Facility Information • Facility Information • Verify information at the top of the form • Make any corrections on the form Used to update Dialysis Facility Compare (DFC)

4. Patients Receiving Care at the Beginning of the Survey Period • Fields 01- 03 • Use Beginning Population data on Roster to complete these fields • Field 01 • Use the number in unit • Field 02 • Use the number in home • Total • Use the number after “total beginning population”

5. Additions During Survey Period • Fields 04A- 07B • Additional incenter and home dialysis patients • Add missing patients on the patient event list to the Network Patient Activity Report (NPAR)

6. Losses During Survey Period • Fields 08A – 13B • Includes losses for both incenter and home patients

7. Patients Receiving Care at End of Survey Period • Fields 14 - 25 • Do not count a patient in more than one field • Incenter Dialysis • Patients dialyzing incenter without staff assistance • Self-Dialysis Training • Patients in a training program • Home Dialysis • Patients dialyzing at home with the assistance of staff provided by a dialysis supplier of facility • Total Patients, field 26 • Sum field 20 + 25

8. Patient Eligibility Status End of Survey Period • Fields 27 - 29 • Counts reflect entitlement only, not based on reimbursement • Example, a Department of Veterans Affairs patient whose reimbursement made by the VA, but is Medicare entitled should be counted in field 27

9. Hemodialysis Patients Dialyzing More Than 4 Times Per Week • Fields 30A – 31B • Report patients dialyzing more than 4 times a week on 12/31/2007 • Nocturnal defined as hemodialysis while the patient sleeping for approximately 8 hours

10. Vocational Rehabilitation • Fields 32 - 35 • Use patients living and between the ages of 18 – 54 on 12/31/2007 • A list of vocational rehabilitation patients was included in the packet as a guide • Can count patients as both attending school and employed, etc.

11. InCenter Dialysis Treatments • Fields 36 – 37 • Include all outpatient treatments from 01/01/2007 – 12/31/2007 • Include transient treatments • Do not include acute treatments

12. Staffing • Fields 38 – 41 • Information based on staff positions opened or vacant on 12/31/2007

13. Signatures • Provides information for the Network or CMS contact to discuss the Survey • Name • Date • Title • Telephone Number

14. Patients Who Received Transplant at This Facility • Field 42 • Count every kidney transplant even if the transplant never functioned • If patient received more than one transplant count the patient once

15. Eligibility Status of Patients Transplanted at This Facility During the Survey Period • Fields 43 – 46 • Based on patients actually transplanted during 01/01/2007 – 12/31/2007 • US. Res and Other • Refers to foreign nationals • Defined as any person who is not a U.S. citizen • Includes permanent resident aliens

16. Transplant Procedures Performed at This Facility • Fields 47 – 50 • Enter the number of transplant performed at the facility for each category

17. Patients Awaiting Transplant • Fields 51 – 52 • Enter the number of transplants recipients awaiting a transplant

18. Signatures • Provides information for the Network or CMS contact to discuss the Survey • Name • Date • Title • Telephone Number

19. Remarks/Comments • Include any remarks or additional information • Use for dialysis and transplant

20. Need Additional Help • Call 919-855-0882 ask for: • Wanda Boddie ext 29 • Margo Clay ext 27 • Deborah Jackson ext 16 • Dee Tyburski ext 30

21. Thank You for Your Attention