CMS-10842 End Stage Renal Disease (ESRD) Annual Home Dialysis with

End Stage Renal Disease (ESRD) Annual Home Dialysis within Nursing Home
Survey Form (CMS-10842
In an effort to adapt our service to this specialized and growing segment of the End-Stage
Renal Disease (ESRD) community, CMS wants information from home dialysis providers.
Please complete a separate questionnaire for each LTC facility where your home dialysis
facility provides services by May 10th of each year. Thank you.
Certified Home Dialysis Facility Name:
LTC facility Name:
1.

If this Certified Home Dialysis Facility does not provide dialysis services in a long-term
care facility, does the home dialysis facility plan to start providing service in a long-term
care facility in the next 6 months?  Yes
 No

2. Does the dialysis patient receive treatment at a dialysis unit that is:
☐In-center within the nursing home ☐ In-center adjacent to the nursing home ☐Home
dialysis provided within the nursing home
3. How many residents are provided in-house dialysis services in the LTC facility?
Hemodialysis (via catheter)
Hemodialysis (via fistula/graft)
Peritoneal Dialysis
☐1-2
☐1-2
☐1-2
☐2-3
☐2-3
☐2-3
☐4-6
☐4-6
☐4-6
☐More than 6
☐More than 6
☐More than 6
☐ Not applicable (N/A)
☐ N/A
☐ N/A
4. Where do residents receive dialysis services?
Hemodialysis
Peritoneal Dialysis
☐Resident Room
☐Resident Room
☐Den Setting or
☐Den Setting or
room where > resident
room where > resident
receives dialysis simultaneously
receives dialysis simultaneously
☐Both
☐Both
☐Other
☐Other
The information will be maintained in system No. 09-700520, “End Stage Renal Disease Program Management and Medical Information System (ESRD PMMIS)”, published in the Federal
Register, Vol. 67, No. 116, June 17, 2002, pages 41244-41250 or as updated and republished.
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-XXXX (Expires XX/XX/XXXX). This is a mandatory information collection. The time required to complete this information collection is
estimated to average 45 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 comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments, medical records or any documents
containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the
associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please
contact Christina Goatee.

5. If dialysis occurs in a den setting or, room where >1 resident receives dialysis
simultaneously, how many residents are in the common room at one time?
Hemodialysis
Peritoneal Dialysis
☐1-2
☐1-2
☐3-4
☐3-4
☐5-6
☐5-6
☐more than 6
☐more than 6
☐Other
☐Other
6. Who provides dialysis services to residents most often?
Hemodialysis
Peritoneal Dialysis
☐LTC Facility RN
☐LTC Facility RN
☐LTC Facility LPN
☐LTC Facility LPN
☐Home Dialysis RN
☐ Home Dialysis RN
☐ Home Dialysis LPN
☐ Home Dialysis LPN
☐PCT
☐ PCT
☐ CNA
☐CNA
☐ Other
☐ Other
7. Which staff changes the dressing for the dialysis catheter most often?
Hemodialysis
Peritoneal Dialysis
☐LTC Facility RN
☐LTC Facility RN
☐LTC Facility LPN
☐LTC Facility LPN
☐Home Dialysis RN
☐ Home Dialysis RN
☐ Home Dialysis LPN
☐ Home Dialysis LPN
☐PCT
☐ PCT
☐ CNA
☐CNA
☐ Other
☐ Other
8. How frequently is the dressing for the dialysis catheter routinely changed?
Hemodialysis
Peritoneal Dialysis
☐more than 3 times a week
☐more than 3 times a week
☐3 times a week
☐3 times a week
☐1 time a week
☐ 1 time a week
☐ Other
☐ Other
9.

If long-term care facility staff performs dialysis services to residents, what was the length
of training provided by the home dialysis facility?
Hemodialysis
Peritoneal Dialysis
☐1-2 weeks
☐1-2 weeks
☐3-4 weeks
☐3-4 weeks
☐5-6 weeks
☐5-6 weeks
☐more than 6 weeks
☐more than 6 weeks
☐Other
☐Other

10. What type of training did the long-term care facility staff receive? Check all that apply
 In-person at LTC facility
 In-person at home dialysis facility
 Watching videos
 Computer modules  Webinars  Other
11. Are staff performing dialysis in the long-term care facility periodically audited for the
following quality improvement activities? (Check all that apply)
 Hand hygiene
 Hemodialysis catheter dressing change
 Environmental cleaning
 Competency evaluations  N/A
12. If long-term care staff perform hemodialysis, how often does the home dialysis facility
provide on-site oversight of LTC facility staff infection prevention practices?
Hemodialysis
Peritoneal Dialysis
☐Monthly
☐Monthly
☐Quarterly
☐Quarterly
☐Annually
☐Annually
☐Other
☐Other
13. Which CDC Core Interventions are followed by the staff performing hemodialysis?
Yes
No
Surveillance and feedback using NHSN


Hand hygiene observations


Catheter/vascular access care observations


Staff education and competency


Patient education/engagement


Catheter reduction


Chlorhexidine for skin antisepsis


Catheter hub disinfection


Antimicrobial ointment


Change impregnated dressings


14. Does staff providing dialysis care track infections for:
Hemodialysis catheter infections  Yes  No
Blood Stream Infections  Yes  No
Peritoneal catheter infections  Yes
 No
Peritonitis  Yes  No