Form CMS-685 Network Semi-Annual Report

(CMS-685) End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations

2016_Network_Semi_Annual_Report.xlsx

End-Stage Renal Disease (ESRD) Network Semi-Annual Cost Report Forms and Supporting Regulations in 42 CFR 405.2110 and 42 CFR 405.2112

OMB: 0938-0657

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Overview

Network Semi Annual Dec-May
Network Semi Annual June-Nov

Sheet 1: Network Semi Annual Dec-May

Network Semi Annual Report December-May



































































1. Contract #: 2. Name and Address of ESRD Network:


3. ESRD Network #:
4. Reporting Period Covered:

































































































































Medicare Costs 5. Transition Costs
6. General Requirements
7. Patient Engagement
8. Patient Experience of Care
9. Vascular Access Management
10. Patient Safety: Healthcare
11. AIM2: Better Health for the ESRD
12. Support for ESRD QIP & Performance
13. Support for Facility Data Submission
14. BASE CONTRACT ONLY
15. SPECIAL PROJECTS

















































(C.3)
(C.4.1.A)
(C.4.1.B)
(C.4.1.C)
Associated Infections (C.4.1.D)
Population (C.4.2)
Improvement on QIP Measures (C.4.3.A)
to CROWNWeb and NHSN (C.4.3.B)
(Columns 5 -13)
















































# of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS













































a. Direct Labor



































































1. Name (Position)

















0 $0.00















































2. Name (Position)

















0 $0.00















































3. Name (Position)

















0 $0.00















































4. Name (Position)

















0 $0.00















































5. Name (Position)

















0 $0.00















































6. Name (Position)

















0 $0.00















































7. Name (Position)

















0 $0.00















































8. Name (Position)

















0 $0.00















































9. Name (Position)

















0 $0.00















































10. Name (Position)

















0 $0.00















































11. Name (Position)

















0 $0.00















































12. Name (Position)

















0 $0.00















































13. Name (Position)

















0 $0.00















































14. Name (Position)

















0 $0.00















































15. Name (Position)

















0 $0.00















































16. Name (Position)

















0 $0.00















































17. Name (Position)

















0 $0.00















































18. Name (Position)

















0 $0.00















































19. Name (Position)

















0 $0.00















































20. Additional Staff (attach schedule)

















0 $0.00















































Black Black black Black black Black black Black black Black black Black black Black black Black black Black blalck Black black Black black













































Subtotal Direct Labor 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00













































b. Leave Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black

















































c. Fringe Benefits Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black














































SUBTOTAL - Leave/Fringe Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black 0 $0.00 0 $0.00













































d. Subcontracts: Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black













































1. Other Consultants Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black #VALUE! Black Black Black













































a. Name

















0 $0.00















































b. Name

















0 $0.00















































c. Name

















0 $0.00















































d. Name

















0 $0.00















































2. Other Subcontractors

















0 $0.00















































SUBTOTAL - Subcontracts 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00













































Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black













































e. Travel Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black














































f. Other Direct Costs Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black













































1. Postage & Express Mail Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black














































2. Meetings & Conferences Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black














































3. Printing & Reproduction Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black














































4. Teleconferences Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black














































5. Other (attach schedule) Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black














































SUBTOTAL - Travel & ODCs Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00













































SUBTOTAL - Direct Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black 0 $0.00 0 $0.00













































g. Indirect Costs (if applicable) Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black














































TOTAL COSTS 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00


























































































































































































































































































































































































































































































































































































































































































`



































































Sheet 2: Network Semi Annual June-Nov

Network Semi Annual Report June-November




























1. Contract #: 2. Name and Address of ESRD Network:


3. ESRD Network #:
4. Reporting Period Covered:












































Base Contract (Only)
Base & Special Projects



Medicare Costs 5. Transition Costs
6. General Requirements
7. Patient Engagement
8. Patient Experience of Care
9. Vascular Access Management
10. Patient Safety: Healthcare
11. AIM2: Better Health for the ESRD
12. Support for ESRD QIP & Performance
13. Support for Facility Data Submission
14. BASE CONTRACT ONLY
15. SPECIAL PROJECTS
16. CUMULATIVE TOTAL
17. CUMULATIVE TOTAL






(C.3)
(C.4.1.A)
(C.4.1.B)
(C.4.1.C)
Associated Infections (C.4.1.D)
Population (C.4.2)
Improvement on QIP Measures (C.4.3.A)
to CROWNWeb and NHSN (C.4.3.B)
(Columns 5 -13)

(December - November)
(December - November)




# of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS # of HOURS COSTS HOURS COSTS HOURS COSTS


a. Direct Labor




























1. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


2. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


3. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


4. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


5. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


6. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


7. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


8. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


9. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


10. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


11. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


12. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


13. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


14. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


15. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


16. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


17. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


18. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


19. Name (Position)

















0 $0.00

0 $0.00 0 $0.00


20. Additional Staff (attach schedule)

















0 $0.00

0 $0.00 0 $0.00


Black Black black Black black Black black Black black Black black Black black Black black Black black Black black Black black Black black black black black black


Subtotal Direct Labor 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00


b. Leave Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black



0 $0.00 0 $0.00


c. Fringe Benefits Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
Black $0.00 black $0.00


SUBTOTAL - Leave/Fringe Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black 0 $0.00 0 $0.00 0 $0.00 0 $0.00


d. Subcontracts: Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black black black black


1. Other Consultants Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black #VALUE! Black Black Black Black black black black


a. Name

















0 $0.00

0 $0.00 0 $0.00


b. Name

















0 $0.00

0 $0.00 0 $0.00


c. Name

















0 $0.00

0 $0.00 0 $0.00


d. Name

















0 $0.00

0 $0.00 0 $0.00


2. Other Subcontractors

















0 $0.00

0 $0.00 0 $0.00


SUBTOTAL - Subcontracts 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00


Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black


e. Travel Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black

$0.00 Black $0.00


f. Other Direct Costs Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black

Black



1. Postage & Express Mail Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black
Black $0.00 Black $0.00


2. Meetings & Conferences Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black
Black $0.00 Black $0.00


3. Printing & Reproduction Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black
Black $0.00 Black $0.00


4. Teleconferences Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black
Black $0.00 Black $0.00


5. Other (attach schedule) Black
Black
Black
Black
Black
Black
Black
Black
Black
Black $0.00 Black
Black $0.00 Black $0.00


SUBTOTAL - Travel & ODCs Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00 Black $0.00


SUBTOTAL - Direct Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black 0 $0.00 0 $0.00 0 $0.00 0 $0.00


g. Indirect Costs (if applicable) Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black Black
Black
Black $0.00 Black $0.00


TOTAL COSTS 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 0 $0.00 Black $0.00 Black $0.00
















































































































































































































































































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