CMS-10105 Medicare In-Center Hemodialysis Survey (English)

OMB #: 0938-0926
Expiration Date: December 31, 2022

Medicare In-Center Hemodialysis
Survey

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0926. The time required to complete this
information collection is estimated to average 16 minutes per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and
review the information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA
Reports Clearance Officer, 7500 Security Boulevard, Mail Stop C1-25-05, Baltimore, Maryland
21244-1850.

Survey Instructions
This survey is about your experiences with dialysis care at [SAMPLE FACILITY
NAME].

Answer each question by marking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens
you will see an arrow with a note that tells you what question to answer next, like this:
1
2

Yes
No

If No, Go to Question 25

1.

Where do you get your dialysis
treatments?
1

2
3

3.

At home or at a skilled nursing
home where I live If At
home or at a skilled nursing
home where I live, Go to
Question 45
At the dialysis center

In the last 3 months, how often
did your kidney doctors listen
carefully to you?
1
2
3
4

4.

I do not currently receive
dialysis If I do not
currently receive dialysis,
Go to Question 45

In the last 3 months, how often
did your kidney doctors explain
things in a way that was easy for
you to understand?
1

2.

How long have you been getting
dialysis at [SAMPLE FACILITY
NAME]?
1

2
3
4
5

2
3
4

Less than 3 months If Less
than 3 months, Go to
Question 45
At least 3 months but less
than 1 year
At least 1 year but less than
5 years
5 years or more
I do not currently receive
dialysis at this dialysis center
If I do not currently
receive dialysis at this
dialysis center, Go to
Question 45

5.

2
3
4

2
3
4

Your kidney doctors are the doctor or
doctors most involved in your
dialysis care now. This includes
kidney doctors that you see inside
and outside the center.

1

Never
Sometimes
Usually
Always

In the last 3 months, how often
did your kidney doctors spend
enough time with you?
1

YOUR KIDNEY DOCTORS

Never
Sometimes
Usually
Always

In the last 3 months, how often
did your kidney doctors show
respect for what you had to say?
1

6.

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

7.

In the last 3 months, how often
did you feel your kidney doctors
really cared about you as a
person?
1
2
3
4

8.

For the next questions, dialysis
center staff does not include doctors.
Dialysis center staff means nurses,
technicians, dietitians, and social
workers at this dialysis center.

Never
Sometimes
Usually
Always

10. In the last 3 months, how often
did the dialysis center staff
listen carefully to you?

Using any number from 0 to 10,
where 0 is the worst kidney
doctors possible and 10 is the
best kidney doctors possible,
what number would you use to
rate the kidney doctors you have
now?
0
1
2
3
4
5
6
7
8
9
10

9.

THE DIALYSIS CENTER STAFF

1
2
3
4

11. In the last 3 months, how often
did the dialysis center staff
explain things in a way that was
easy for you to understand?

0 Worst kidney doctors
possible
1
2
3
4
5
6
7
8
9
10 Best kidney doctors
possible

1
2
3
4

2

Never
Sometimes
Usually
Always

12. In the last 3 months, how often
did the dialysis center staff
show respect for what you had
to say?
1
2

Do your kidney doctors seem
informed and up-to-date about
the health care you receive from
other doctors?
1

Never
Sometimes
Usually
Always

3
4

Never
Sometimes
Usually
Always

13. In the last 3 months, how often
did the dialysis center staff
spend enough time with you?

Yes
No

1
2
3
4

2

Never
Sometimes
Usually
Always

14. In the last 3 months, how often
did you feel the dialysis center
staff really cared about you as a
person?
1
2
3
4

19. The dialysis center staff can
connect you to the dialysis
machine through a graft, fistula,
or catheter. Do you know how to
take care of your graft, fistula, or
catheter?

Never
Sometimes
Usually
Always

1
2

20. In the last 3 months, which one
did they use most often to
connect you to the dialysis
machine?

15. In the last 3 months, how often
did dialysis center staff make
you as comfortable as possible
during dialysis?
1
2
3
4

1

Never
Sometimes
Usually
Always

2
3
4

16. In the last 3 months, did dialysis
center staff keep information
about you and your health as
private as possible from other
patients?
1
2

2

Yes
No

1
2
3
4
5

2

Never
Sometimes
Usually
Always
I insert my own needles

22. In the last 3 months, how often
did dialysis center staff check
you as closely as you wanted
while you were on the dialysis
machine?

Yes
No

18. In the last 3 months, has anyone
on the dialysis center staff
asked you about how your
kidney disease affects other
parts of your life?
1

Graft
Fistula
Catheter If Catheter, Go to
Question 22
I don’t know If Don’t
Know, Go to Question 22

21. In the last 3 months, how often
did dialysis center staff insert
your needles with as little pain
as possible?

17. In the last 3 months, did you feel
comfortable asking the dialysis
center staff everything you
wanted about dialysis care?
1

Yes
No

1
2
3
4

Yes
No

3

Never
Sometimes
Usually
Always

23. In the last 3 months, did any
problems occur during your
dialysis?
1
2

27. In the last 3 months, how often
did dialysis center staff explain
blood test results in a way that
was easy to understand?

Yes
No If No, Go to
Question 25

1
2
3
4

24. In the last 3 months, how often
was the dialysis center staff able
to manage problems during your
dialysis?
1
2
3
4

28. As a patient you have certain
rights. For example, you have
the right to be treated with
respect and the right to privacy.
Did this dialysis center ever give
you any written information
about your rights as a patient?

Never
Sometimes
Usually
Always

1

25. In the last 3 months, how often
did dialysis center staff behave
in a professional manner?
1
2
3
4

2

1
2

Yes
No

30. Has dialysis center staff ever
told you what to do if you
experience a health problem at
home?
1
2

26. In the last 3 months, did dialysis
center staff talk to you about
what you should eat and drink?
2

Yes
No

29. Did dialysis center staff at this
center ever review your rights as
a patient with you?

Never
Sometimes
Usually
Always

Please remember that for these
questions, dialysis center staff does
not include doctors. Dialysis center
staff means nurses, technicians,
dietitians, and social workers at this
dialysis center.

1

Never
Sometimes
Usually
Always

Yes
No

31. Has any dialysis center staff
ever told you how to get off the
machine if there is an
emergency at the center?

Yes
No

1
2

4

Yes
No

32. Using any number from 0 to 10,
where 0 is the worst dialysis
center staff possible and 10 is
the best dialysis center staff
possible, what number would
you use to rate your dialysis
center staff?
0
1
2
3
4
5
6
7
8
9
10

35. Using any number from 0 to 10,
where 0 is the worst dialysis
center possible and 10 is the
best dialysis center possible,
what number would you use to
rate this dialysis center?
0

0 Worst dialysis center staff
possible
1
2
3
4
5
6
7
8
9
10 Best dialysis center staff
possible

1
2
3
4
5
6
7
8
9
10

TREATMENT

THE DIALYSIS CENTER

The next few questions ask about
your care in the last 12 months. As
you answer these questions, think
only about your experience at
[SAMPLE FACILITY NAME], even if
you have not been receiving care
there for the entire 12 months.

33. In the last 3 months, when you
arrived on time, how often did
you get put on the dialysis
machine within 15 minutes of
your appointment or shift time?
1
2
3
4

Never
Sometimes
Usually
Always

36. You can treat kidney disease
with dialysis at a center, a
kidney transplant, or with
dialysis at home. In the last 12
months, did your kidney doctors
or dialysis center staff talk to
you as much as you wanted
about which treatment is right
for you?

34. In the last 3 months, how often
was the dialysis center as clean
as it could be?
1
2
3
4

0 Worst dialysis center
possible
1
2
3
4
5
6
7
8
9
10 Best dialysis center
possible

Never
Sometimes
Usually
Always

1
2

5

Yes
No

37. Are you eligible for a kidney
transplant?
1
2
3

42. In the last 12 months, did you
ever talk to someone on the
dialysis center staff about this?

Yes If Yes, Go to
Question 39
No
I don’t know If Don’t
Know, Go to Question 39

1
2

43. In the last 12 months, how often
were you satisfied with the way
they handled these problems?

38. In the last 12 months, has a
doctor or dialysis center staff
explained to you why you are
not eligible for a kidney
transplant?
1
2

1
2
3

Yes
No

4

2

1
2

Yes
No

2

45. In general, how would you rate
your overall health?
1
2

Yes
No

3
4
5

41. In the last 12 months, were you
ever unhappy with the care you
received at the dialysis center or
from your kidney doctors?
1
2

Yes
No
ABOUT YOU

40. In the last 12 months, were you
as involved as much as you
wanted in choosing the
treatment for kidney disease that
is right for you?
1

Never
Sometimes
Usually
Always

44. Medicare and your State have
special agencies that check the
quality of care at this dialysis
center. In the last 12 months, did
you make a complaint to any of
these agencies?

39. Peritoneal dialysis is dialysis
given through the belly and is
usually done at home. In the last
12 months, did either your
kidney doctors or dialysis center
staff talk to you about peritoneal
dialysis?
1

Yes
No If No, Go to
Question 45

Yes
No If No, Go to
Question 45

6

Excellent
Very good
Good
Fair
Poor

46. In general, how would you rate
your overall mental or emotional
health?
1
2
3
4
5

52. Because of a physical, mental,
or emotional condition, do you
have serious difficulty
concentrating, remembering, or
making decisions?

Excellent
Very good
Good
Fair
Poor

1
2

53. Do you have serious difficulty
walking or climbing stairs?

47. Are you being treated for high
blood pressure?
1
2

1
2

Yes
No

2

1
2

Yes
No

2

Yes
No

1
2

50. Are you deaf or do you have
serious difficulty hearing?
1
2

1

2

Yes
No

56. What is the highest grade or
level of school that you have
completed?

Yes
No

51. Are you blind or do you have
serious difficulty seeing, even
when wearing glasses?
1

Yes
No

55. Because of a physical, mental,
or emotional condition, do you
have difficulty doing errands
alone, such as visiting a
doctor’s office or shopping?

49. Are you being treated for heart
disease or heart problems?
1

Yes
No

54. Do you have difficulty dressing
or bathing?

48. Are you being treated for
diabetes or high blood sugar?
1

Yes
No

2
3
4

Yes
No

5
6
7
8

7

No formal education
5th grade or less
6th, 7th, or 8th grade
Some high school, but did not
graduate
High school graduate or GED
Some college or 2-year
degree
4-year college graduate
More than 4-year college
degree

57. What language do you mainly
speak at home?
1
2
3
4
5
6
7
8

60. Did someone help you complete
this survey?

English
Spanish
Chinese
Samoan
Russian
Vietnamese
Portuguese
Some other language (please
identify):
_______________________

1
2

61. Who helped you complete this
survey?
1
2
3

58. Are you of Spanish, Hispanic, or
Latino origin or descent?
1
2
3
4
5

4

No, not Spanish/Hispanic/
Latino
Yes, Puerto Rican
Yes, Mexican, Mexican
American, Chicano
Yes, Cuban
Yes, other Spanish/Hispanic/
Latino

2
3
4
5
6
7
8
9
10
11
12
13
14

A family member
A friend
A staff member at the dialysis
center
Someone else (please print):
________________________

62. How did that person help you?
Check all that apply.
1
2
3

59. What is your race? (One or more
categories may be selected.)
1

Yes
No Thank you. Please
return the completed
survey in the postage-paid
envelope.

4
5

White
Black or African American
American Indian or Alaska
Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

Read the questions to me
Wrote down the answers I
gave
Answered the questions for
me
Translated the questions into
my language
Helped in some other way
(please print):
________________________

Thank you. Please return the
survey in the enclosed envelope
to:
VENDOR’S NAME
STREET ADDRESS 1
STREET ADDRESS 2
CITY, STATE, ZIP

8