Medicare In-Center and Home Dialysis Survey

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OMB #: 0938-0926
Expiration Date: XXX

Medicare In-Center and Home
Dialysis 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. This information collection produces comparable data from dialysis facilities to help
individuals choose a facility and improve care. The time required to complete this information collection is
estimated to average less than 11 minutes per response, including the time to review instructions, search existing
data resources, gather the data needed, to review and complete the information collection. This information
collection is mandatory for qualifying dialysis facilities under 42 CFR §413.178(c)(iii) to meet program
requirements and voluntary for survey respondents. Confidentiality is assured under 5 U.S.C. 552a (Privacy Act of
1974). 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 [email protected].

Survey Instructions
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

THE DIALYSIS CENTER STAFF

This survey is about your experiences
with dialysis care through [SAMPLE
FACILITY NAME]. When answering each
question, please think about this dialysis
center that supports your dialysis care,
whether that is in a dialysis center (incenter hemodialysis) or in your home
(home hemodialysis or peritoneal dialysis
[PD]).

The next questions ask about your
interactions with dialysis center staff
such as nurses, technicians, dietitians,
and social workers. For these questions,
dialysis center staff does not include
doctors, Nurse Practitioners (NPs), or
Physician Assistants (PAs).

1.

3.

What type of dialysis do you
currently receive most often? Please
mark only one response.

Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐

In-center hemodialysis
Home hemodialysis
Peritoneal dialysis (PD)
Any type of dialysis at a skilled
nursing home where I live → If Any
type of dialysis at a skilled
nursing home where I live, Go to
Question 35
5
☐ I do not currently receive any type
of dialysis → If I do not currently
receive any type of dialysis, Go
to Question 35
1

☐
2
☐
3 ☐
4
☐

2.

2 ☐

4.

2 ☐
3 ☐
4 ☐
5 ☐

In the last 3 months, how often did
the dialysis center staff explain
things in a way that was easy for you
to understand?
Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐
2 ☐

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

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

5.

Less than 3 months → If Less than
3 months, Go to Question 35
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
through this dialysis center → If I
do not currently receive dialysis
through this dialysis center, Go
to Question 35

In the last 3 months, how often did
the dialysis center staff show respect
for what you had to say?
Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐
2 ☐

6.

In the last 3 months, how often did
the dialysis center staff spend
enough time with you?
Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐
2 ☐

3

7.

11. Do you know how to take care of
your graft, fistula, catheter, or PD
catheter?

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

1 ☐

Yes
2 ☐ No
1 ☐

8.

2 ☐

12. 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?

In the last 3 months, how often did
dialysis center staff behave in a
professional manner?
Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐
2 ☐

9.

Yes
No

1 ☐
2 ☐

Yes
No

13. Did dialysis center staff ever review
your rights as a patient with you?

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

1 ☐
2 ☐

Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐
2 ☐

Yes
No

14. Did dialysis center staff ever tell you
what to do if you experience a health
problem at home?
1 ☐

10. You can receive hemodialysis
through a graft, fistula, or catheter
and peritoneal dialysis (PD) through
a PD catheter. In the last 3 months,
which one was used most often for
your dialysis?

2 ☐

Yes
No

15. Did dialysis center staff ever tell you
how to get off the dialysis machine if
there is an emergency during
dialysis, either at the center or at
home?

Graft
Fistula
3 ☐ Catheter
4 ☐ PD Catheter
5 ☐ I don’t know
1 ☐
2 ☐

1 ☐
2 ☐

4

Yes
No

18. 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?

16. 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?

Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐
2 ☐

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

19. 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?
Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐
2 ☐

If you receive home hemodialysis or
home peritoneal dialysis (PD) → Go to
Question 23

20. In the last 3 months, how often was
the dialysis center as clean as it
could be?

If you receive in-center hemodialysis →
Continue to Question 17

Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐
2 ☐

IN-CENTER HEMODIALYSIS

21. In the last 3 months, did any
problems occur during your
dialysis?

Answer Questions 17-22 if you receive INCENTER HEMODIALYSIS.

1 ☐

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

2 ☐

Yes
No → If No, Go to Question 26

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

Never
Sometimes
3 ☐ Usually
4 ☐ Always
5 ☐ I receive dialysis at home → If you
receive dialysis at home, Go to
Question 23
1 ☐
2 ☐

Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐
2 ☐

5

25. Think about any other problems you
had with your home dialysis, not
including problems with your
equipment or receiving supplies. In
the last 3 months, when you had any
other problems with your home
dialysis, how often did dialysis center
staff help you solve them?

If you receive in-center
hemodialysis, after
answering Question 22 →
Go to Question 26

HOME DIALYSIS

1 ☐
2 ☐

Answer Questions 23-25 if you receive
HOME DIALYSIS (hemodialysis or PD).

3 ☐
4 ☐

23. In the last 3 months, when you had
problems with your home dialysis
equipment, how often did dialysis
center staff help you solve them?
1 ☐
2 ☐
3 ☐
4 ☐
5 ☐
6 ☐

5 ☐
6 ☐

Never
Sometimes
Usually
Always
I did not have any problems with my
dialysis equipment
I had a problem with my dialysis
equipment but did not need dialysis
center staff help

THE DIALYSIS CENTER
Answer Question 26 if you receive INCENTER HEMODIALYSIS or HOME
DIALYSIS (hemodialysis or PD).
26. 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?

24. In the last 3 months, when you had
problems receiving supplies for your
home dialysis, how often did dialysis
center staff help you solve them?
1 ☐
2 ☐
3 ☐
4 ☐
5 ☐
6 ☐

Never
Sometimes
Usually
Always
I did not have any other problems
I had other problems but did not
need dialysis center staff help

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

Never
Sometimes
Usually
Always
I did not have any problems
receiving dialysis supplies
I had a problem receiving dialysis
supplies but did not need dialysis
center staff help

6

30. In the last 12 months, did your
kidney doctors, NPs, PAs, or dialysis
center staff give your family/friends
information about your care or
treatment plan if you asked them to?

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

Yes
No
3 ☐ I did not ask them to in the last 12
months
1 ☐
2 ☐

27. Kidney disease can be treated with
dialysis at a center, with dialysis at
home, or with a kidney transplant. In
the last 12 months, did your kidney
doctors, Nurse Practitioners (NPs),
Physician Assistants (PAs), or
dialysis center staff talk to you as
much as you wanted about which
treatment is right for you?
1 ☐
2 ☐

31. In the last 12 months, were you ever
unhappy with the care you received
through the dialysis center?
1 ☐
2 ☐

32. In the last 12 months, did you ever
talk to your kidney doctors, NPs,
PAs, or the dialysis center staff
about this?

Yes
No

2

Yes → If Yes, Go to Question 30
No
3 ☐ I don’t know → If I don’t know, Go
to Question 30
1 ☐

33. In the last 12 months, how often were
you satisfied with the way they
handled your concerns?

2 ☐

Never
Sometimes
3 ☐ Usually
4 ☐ Always
1 ☐
2 ☐

29. In the last 12 months, have your
kidney doctors, NPs, PAs, or dialysis
center staff explained to you why
you are not eligible for a kidney
transplant?
2 ☐

Yes
☐ No → If No, Go to Question 34

1 ☐

28. Are you eligible for a kidney
transplant?

1 ☐

Yes
No → If No, Go to Question 34

34. In the last 12 months, if you receive
in-center hemodialysis, did your
kidney doctors, NPs, PAs, or dialysis
center staff talk with you about home
hemodialysis or peritoneal dialysis
(PD)?

Yes
No

Yes
No
3 ☐ I do not receive in-center
hemodialysis
1 ☐
2 ☐

7

39. What is your race or ethnicity?
Please mark one or more.

ABOUT YOU
35. In general, how would you rate your
overall health?
1 ☐
2 ☐
3 ☐
4 ☐
5 ☐

1 ☐
2 ☐
3 ☐

Excellent
Very good
Good
Fair
Poor

4 ☐
5 ☐
6 ☐
7 ☐

HELP

36. In general, how would you rate your
overall mental or emotional health?

40. Did someone help you complete this
survey?

Excellent
Very good
3 ☐ Good
4 ☐ Fair
5 ☐ Poor
1 ☐
2 ☐

1 ☐
2 ☐

37. What is the highest grade or level of
school that you have completed?
1 ☐
2 ☐
3 ☐
4 ☐
5 ☐
6 ☐
7 ☐
8 ☐

2 ☐
3 ☐
4 ☐
5 ☐
6 ☐
7 ☐
8 ☐

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

41. How did that person help you?
Please mark one or more.

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

Read the questions to me
Wrote down the answers I gave
3 ☐ Answered the questions for me
4 ☐ Translated the questions into my
language
5 ☐ Helped in some other way (please
specify):______________________
1 ☐
2 ☐

Thank you. Please return the survey in
the enclosed envelope to:

38. What language do you mainly speak
at home? Please mark only one
response.
1 ☐

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White

DIALYSIS SURVEY
C/O RTI International
ATTENTION: Data Capture (38031)
3040 Cornwallis Road
Durham, NC 27713

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

8