Form Cms-2744a - Esrd Facility Survey (Dialysis Unit Only)

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Form Approved
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OMB No. 0938-0447
CENTERS FOR MEDICARE & MEDICAID SERVICES
FOR THE PERIOD
END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
ESRD FACILITY SURVEY (DIALYSIS UNITS ONLY)
Facility Physical Address
(If different than mailing address)
Suite/Room Street
City
State/Zip Code
Number of Dialysis Stations:
Facility Telephone: (
)
■ ■
■ ■
Facility Ownership Type:
Profit
Non-Profit
Facility Local/National Affiliation/Chain Information
(i.e. Gambro, etc.)
Types of dialysis services offered:
■ ■
■ ■
■ ■
Incenter Hemodialysis
Peritoneal Dialysis
Home Hemodialysis Training
Does your facility offer a dialysis shift that starts at 5:00 p.m. or later?
■ ■
■ ■
Yes
No
DIALYSIS PATIENTS AND TREATMENTS
DIALYSIS PATIENTS
Additions During Survey Period
Losses During Survey Period
Trans-
Returned
Recov-
Received
Trans-
Dis-
Other
ferred
Started
Restarted
after
from
Deaths
ered
continued
trans-
ferred to
(LTFU)
for first
other
transplan-
kidney
dialysis
plant
other dial-
Patients Receiving Care
function
dialysis
time ever
tation
Beginning of Survey Period
ysis unit
unit
Total
Home
In-
Incenter
Fields 01
thru 02
center
Home
01
02
03
04A
05A
06A
07A
08A
09A
10A
11A
12A
13A
04B
05B
06B
07B
08B
09B
10B
11B
12B
13B
Patients Receiving Care at End of Survey Period
Total
Total
Total
Incenter
Self-Dialysis Training
Home Dialysis
Incenter
Home
Dialysis
Patients
Dialysis
Dialysis
Fields 21
Hemo-
Other
Hemo-
CAPD
CCPD
Other
Fields 14
Hemo-
CAPD
CCPD
Other
Fields 20
thru 24
Dialysis
Dialysis
thru 19
Dialysis
and 25
14
15
16
17
18
19
20
21
22
23
24
25
26
Patient Eligibility Status
Hemodialysis Patients Dialyzing
Vocational Rehabilitation
End of Survey Period
More Than 4 Times Per Week
Patients
Patients
Patients
Currently
Medicare
Setting
Day
Nocturnal
Patients
receiving
attending
Employed
enrolled
applica-
Non-
aged 18
services
school
full-time or
in
tion
Medicare
Incenter
through 54
from Voc
full-time or
part-time
Medicare
pending
Rehab
part-time
Home
30A
31A
30B
31B
27
28
29
32
33
34
35
TREATMENT AND STAFFING
Staffing
Number of Staff
Number of Open Pos.
Incenter Dialysis Treatments
Position
Full Time
Part Time
Full Time
Part Time
(Include Training Treatments)
a. RNs
b. LPN/LVNs
Hemodialysis
Other
c. PCTs
d. APNs
e. Dietitians
f. Social Workers
36
37
38
39
40
41
COMPLETED BY (Name)
DATE
TITLE
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)

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