DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0447 END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD FACILITY SURVEY (DIALYSIS UNITS ONLY) FOR THE PERIOD Facility Physical Address (If different than mailing address) Suite/Room Street City State/Zip Code Number of Dialysis Stations: Facility Ownership Type: Profit Facility Telephone: ( ) Non-Profit (i.e. Gambro, etc.) Facility Local/National Affiliation/Chain Information Types of dialysis services offered: Incenter Hemodialysis Peritoneal Dialysis No Home Hemodialysis Training Does your facility offer a dialysis shift that starts at 5:00 p.m. or later? Yes DIALYSIS PATIENTS AND TREATMENTS DIALYSIS PATIENTS Additions During Survey Period Started Restarted for first time ever Incenter Home 01 02 03 04A 04B 05A 05B 06A 06B 07A 07B 08A 08B 09A 09B 10A 10B 11A 11B 12A 12B 13A 13B Transferred from other dialysis unit Returned after transplantation Losses During Survey Period Recovered kidney function TransDisReceived ferred to continued transother dial- dialysis plant ysis unit Other (LTFU) Deaths Patients Receiving Care Beginning of Survey Period Incenter Home Total Fields 01 thru 02 Patients Receiving Care at End of Survey Period Incenter Dialysis HemoDialysis Other HemoDialysis Self-Dialysis Training Total Incenter Dialysis Other Fields 14 thru 19 HemoDialysis Home Dialysis Total Home Dialysis Other Fields 21 thru 24 Total Patients Fields 20 and 25 CAPD CCPD CAPD CCPD 14 15 16 17 18 19 20 21 22 23 24 25 26 Patient Eligibility Status End of Survey Period Currently Medicare enrolled applicain tion Medicare pending NonMedicare Hemodialysis Patients Dialyzing More Than 4 Times Per Week Setting Incenter Home 30A 30B 31A 31B Day Nocturnal Vocational Rehabilitation Patients Patients Patients attending Patients receiving Employed school aged 18 services full-time or full-time or through 54 from Voc part-time part-time Rehab 27 28 29 32 33 34 35 TREATMENT AND STAFFING Staffing Number of Staff Number of Open Pos. Incenter Dialysis Treatments (Include Training Treatments) Hemodialysis Other Position a. RNs b. LPN/LVNs c. PCTs d. APNs e. Dietitians f. Social Workers Full Time Part Time Full Time Part Time 36 COMPLETED BY (Name) 37 DATE 38 TITLE 39 40 41 TELEPHONE NO. REMARKS REGARDING INFORMATION PROVIDED ON THIS SURVEY SHOULD BE ENTERED ON THE LAST PAGE OF THE SURVEY This report is required by law (42 USC 426; 42 CFR 405.2133). Individually identifiable patient information will not be disclosed except as provided for in the Privacy Act of 1974 (5 USC 5520; 45 CFR, Part 5a). Form CMS-2744A (02/04) American LegalNet, Inc. www.USCourtForms.com