CMS 2744 ESRD Facility Survey

Instruction for Completing the Survey

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)

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)

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”

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)

Losses During Survey Period Fields 08A – 13B

Includes losses for both incenter and home patients

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

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

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

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.

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

Staffing Fields 38 – 41 Information based on staff

positions opened or vacant on 12/31/2007

Signatures Provides information for the

Network or CMS contact to discuss the Survey Name Date Title Telephone Number

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

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

Transplant Procedures Performed at This Facility Fields 47 – 50 Enter the number of transplant

performed at the facility for each category

Patients Awaiting Transplant Fields 51 – 52 Enter the number of transplants

recipients awaiting a transplant

Signatures Provides information for the

Network or CMS contact to discuss the Survey Name Date Title Telephone Number

Remarks/Comments Include any remarks or additional

information Use for dialysis and transplant

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

Thank You for Your Attention