CMS-10639 Request Letter to Facilities - List

TO: Facility Administrators, Clinical Managers

FROM: XXXXXX

SUBJECT: ESRD QIP Data Validity and Reliability Study – Request for Patient Lists

ACTION REQUIRED: Please submit your patient lists by XXXX

The Centers for Medicare & Medicaid Services (CMS) contracted with XXX to validate positive blood culture “candidate dialysis events” in a sample of dialysis facilities and assess the accuracy of the Dialysis Event data entered into the Center for Disease Control (CDC) NHSN system. Your dialysis facility has been randomly selected to participate in this effort.

To prepare for the medical record reviews, we need you to provide the lists of patients outlined below. Each list should include a patient name, patient medical record number, date of birth, and gender. Please send these lists only by QualityNet to XXXXXX. by the due date.

List	Description	Time Period
1	All patients who had one or more in-center hemodialysis treatment(s)	1/1/2019-6/30/2019
2	All patients who had any positive blood cultures	1/1/2019-6/30/2019
3	All patients who received any intravenous antimicrobials	1/1/2019-6/30/2019
4	All patients who had any pus, redness or swelling at the vascular access site	1/1/2019-6/30/2019
5	All patients who were hospitalized for any reason	1/1/2019-6/30/2019

These lists will be maintained and securely destroyed by us per CMS requirements at the end of the study to protect the release of any patient identifiers.

Using the lists provided, we will select patients for the study and notify your facility. Your facility will be requested to send patient medical records for those patients. Your facility will have 60 days to respond to the request of medical records.

Please see the Paperwork Reduction Act (PRA) disclosure statement on page 2 of this letter.

We appreciate your time and cooperation with this study. If you have any questions or concerns regarding this study, please contact me using the information below.

Sincerely,

XXXX

PRA Disclosure Statement

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 0938-1298 (Expires 02/28/2019).  The time required to complete this information collection is estimated to average 2.5 hours per response, including the time to review instructions, search existing data resources, and 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:

XXXX

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