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

3. 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)

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

5. 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”

6. 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)

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

8. 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

9. 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

10. 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

11. 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.

12. 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

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

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

15. 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

16. 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

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

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

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

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

21. 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

22. Thank You for Your Attention