0920-1317 / Form 5 COVID–19 Module - Dialysis Outpatient Facility

COVID–19 Module

Dialysis Outpatient Facility

*required to save as complete

**conditionally required

Facility Operational Information For the following questions, please collect data for the current reporting week. The reporting week is defined as Wednesday through Tuesday with reporting to occur on Wednesday by 3 PM ET. You should report on the same day each week, either close of business on Tuesday or Wednesday by the deadline. We advise you not to alternate reporting days.
_________	*Facility ID (OrgID)
_________	*CMS Certification Number (CCN)
_________	*Facility Name
_________	*Week of Data Collection
_________	*In-center Patient Census
_________	*Date last modified
_________	*Home Patient Census
_________	*Total Certified Stations
_________	*Isolation Stations Included in Total Certified Stations
 Yes  No	*Is your facility a designated COVID unit?
 Yes  No	*Does your facility have designated COVID shifts?
________	*Total number of staff (physician, nurses, techs, environmental services, biomed, etc.) who worked at least 1 day during the current reporting week
_________	How many patients on the current in-center census reside in nursing homes?
_________	How many patients on the current home census reside in nursing homes?

For the following questions, report data during the current reporting week which is Wednesday through Tuesday each week. For questions requiring counts, include only new data which has occurred during the current reporting week. Data should not be cumulative.

SARS-CoV-2 Positive (+) Patients and Staff
_________	*Number of newly confirmed in-center patients during the current reporting week
_________	*Number of newly confirmed in-center patients that reside in nursing homes during the current reporting week
_________	*Number of newly confirmed patients during the current reporting week that are home patients
_________	*Number of newly confirmed staff during the current reporting week
_________	*Number of SARS-CoV-2 patients who are currently admitted to the hospital during the current reporting week
_________	*Number of confirmed patients currently self-monitoring and continuing in-center therapy during the current reporting week
_________	*Number of confirmed patients currently self-monitoring and continuing home therapy during the current reporting week

Suspected SARS-CoV-2 Infection
_________	*Number of new suspect patient cases during the current reporting week
_________	*Number of new suspect staff cases during the current reporting week

Testing for SARS-CoV-2 Infection
_________	*Number of patients who were tested for SARS-CoV-2 during the current reporting week
_________	*Of those patients who were tested for SARS-CoV-2, how many had a negative SARS-CoV-2 test result during the current reporting week
_________	*Of those patients who were tested for SARS-CoV-2, how many had a positive SARS-CoV-2 test result during the current reporting week
_________	*Of those patients who were tested for SARS-CoV-2, how many had an unknown SARS-CoV-2 test result during the current reporting week

COVID-19 Vaccination Status: For the patients who tested positive during the current reporting week, provide counts for the following categories.
_________	* Number of patients who have tested positive this current reporting week and have not received a COVID-19 vaccine or it has been 13 days or less after dose one.
Pfizer-BioNTech
_________	* Number of patients who have been vaccinated with dose one of the Pfizer-BioNTech COVID-19 vaccine and have tested positive for COVID-19 14 days or more after receiving the vaccine : Dose 1_______
_________	* Number of patients who have been vaccinated with dose one and dose two of the Pfizer-BioNTech COVID-19 vaccine and have tested positive for COVID-19 14 days or more after receiving dose two. Dose 2_______
Moderna
_________	* Number of patients who have been vaccinated with dose 1 of the Moderna COVID-19 vaccine and have tested positive for COVID-19 14 days or more after receiving the COVID-19 vaccine: Dose 1 ______
_________	* Number of patients who have been vaccinated with dose 1 and dose 2 of the Moderna COVID-19 vaccine and have tested positive for COVID-19 14 days or more after receiving the COVID-19 vaccine: Dose 2 _______
Janssen
_________	*Number of patients who have been vaccinated with Janssen COVID-19 vaccine and have tested positive 14 days or more after receiving the COVID-19 vaccine Dose 1 _______
Unspecified
	* Number of patients who have been vaccinated with dose 1 of an Unspecified COVID-19 vaccine and have tested positive for COVID-19 14 days or more after receiving the COVID-19 vaccine:
_________	* Number of patients who have been vaccinated with dose 1 and dose 2 an Unspecified COVID-19 vaccine and have tested positive for COVID-19 14 days or more after receiving the COVID-19 vaccine.

COVID-19 Vaccination Status - ADDITIONAL DOSES: For the patients who tested positive during the current reporting week, provide counts for the following. Any patient who has received an additional or booster dose and has tested positive should also be reported in the above COVID-19 Vaccination Status section.
Pfizer-BioNTech
_________	* Number of patients who have received an additional dose or booster dose of the Pfizer-BioNTech COVID-19 vaccine and have tested positive for COVID-19 14 days or more after receiving the additional dose or booster dose: Additional dose or booster_______
Moderna
_________	* Number of patients who have received an additional dose or booster dose of the Moderna COVID-19 vaccine and have tested positive for COVID-19 14 days or more after receiving the additional dose or booster dose. Additional dose _______
Janssen
	* Number of patients who have received an additional dose or booster dose of the Janssen COVID-19 vaccine and have tested positive for COVID-19 14 days or more after receiving the additional dose or booster dose. Additional dose _______
Unspecified
_________	* Number of patients who have received an additional dose or booster dose of an Unspecified COVID-19 vaccine and have tested positive for COVID-19 14 days or more after receiving the additional dose or booster dose. Additional dose _______

SARS-CoV-2 Positives (+) that have recovered
_________	*Number of patients recovered during the current reporting week
_________	*Number of staff recovered during the current reporting week

Suspected or Confirmed SARS-CoV-2 deaths
_________	*Number of patients with suspected or confirmed SARS-CoV-2 infection that have died during the current reporting week
_________	*Number of staff with suspected or confirmed SARS-CoV-2 infection that have died during the current reporting week

For the following questions, please collect data and report findings during the current reporting week

Staff and/or Personnel Impact
Will your facility have a critical shortage of staff and/or personnel within the next week?
Staffing Shortage?	Staff and Personnel Groups
 Yes  No	Nursing Staff: registered nurse, licensed practical nurse, vocational nurse
 Yes  No	Clinical Staff: physician, physician assistant, advanced practice nurse
 Yes  No	Tech: dialysis technician
 Yes  No	Other staff or facility personnel, regardless of clinical responsibility or patient contact not included in the categories above (for example, environmental services, biomed)

Supplies & Personal Protective Equipment (PPE)
Supply Item	Do you currently have any supply?	Do you have enough for one week if using conventional strategies?
N95 masks	 Yes  No	 Yes  No
Surgical masks or medical facemasks	 Yes  No	 Yes  No
Eye protection, including face shields or goggles	 Yes  No	 Yes  No
Single-use Isolation Gowns	 Yes  No	 Yes  No
Gloves	 Yes  No	 Yes  No
Alcohol-based hand sanitizer	 Yes  No	 Yes  No

Laboratory Testing
 Yes  No	Does your facility have the ability to collect specimens onsite for SARS-CoV-2 testing?
 Viral (PCR)  Antigen  Antibody	**If yes, what types of specimens are being collected?
 NP swab  Anterior Nares swab  Mid Turbinate swab  OP swab  Saliva	**If yes to viral (PCR) tests, what types of specimens are being collected?
Lack of recommended personal protective equipment (PPE) for personnel to wear during specimen collection Lack of supplies for specimen collection Lack of access to a laboratory for submitting specimens Lack of access to trained personnel to perform testing Uncertainty about testing reimbursement Other: Specify__________________________	**If no, indicate reasons why specimens are not being collected onsite for SARS-CoV-2 testing?
 Yes  No	If yes, does your facility have an in-house point-of-care test machine (capability to perform SARS-CoV-2 testing within your facility)?