Form CMS-2744A&B END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM ESRD

Form Approved
OMB No. 0938-0447
Expires: XX/XXXX

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

END STAGE RENAL DISEASE MEDICAL INFORMATION SYSTEM
ESRD FACILITY SURVEY (DIALYSIS UNITS ONLY)
Survey Period
Facility Mailing Address

Suite/room

City

State

ZIP code

Facility Physical Address (if different than mailing address)

Suite/room

City

State

Number of dialysis stations

Facility Telephone

ZIP code

Facility Ownership Type:
Profit

Non-profit

Facility Local/National Affiliation/Chain Information (i.e. Satellite Healthcare, etc.)
Types of Dialysis Services offered:
In-center Hemodialysis

Peritoneal Dialysis

Home Hemodialysis Training

Does your facility offer a dialysis shift that starts at 5:00 p.m. or later? ......................................................................

Yes

No

Days and shifts your dialysis facility is open:
Monday

Shifts per day:

1

2

3

4

Friday

Shifts per day:

1

2

3

4

Tuesday

Shifts per day:

1

2

3

4

Saturday

Shifts per day:

1

2

3

4

Wednesday

Shifts per day:

1

2

3

4

Sunday

Shifts per day:

1

2

3

4

Thursday

Shifts per day:

1

2

3

4

DIALYSIS PATIENTS AND TREATMENTS
Dialysis
Patients Receiving Care
Beginning of Survey Period
In-center

Home

Total
Fields 01 – 02

01

02

03

Additions during Survey Period
Started
First Time
Ever

Restarted

Transferred
from Other
Dialysis
Facility(ies)

Returned
after
Transplant
Failed

06A
06B

07A
07B

In-center
Home
04A
04A

05A
05B

Losses during Survey Period
Deaths

Recovered
Kidney
Function

Received
Transplant

Transferred
to Other
Care Facility

Discontinued
Dialysis

Other
(LTFU)

08A
08B

09A
09B

10A
10B

11A
11B

12A
12B

13A
13B

In-center
Home

Form CMS-2744A (XX/XX)

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Patients Receiving Care at End of Survey Period
In-center Dialysis

Total
In-center
Dialysis

Self-Dialysis Training

Home Dialysis

Total
Home
Dialysis

Total
Patients

Hemodialysis

Other

Hemodialysis

CAPD

CCPD

Other

Fields
14 – 19

Hemodialysis

CAPD

CCPD

Other

Fields
21 – 24

Fields
20 – 25

14

15

16

17

18

19

20

21

22

23

24

25

26

Patient Eligibility Status
End of Survey Period
Currently
enrolled
in Medicare

Medicare
application
pending

Hemodialysis Patients Dialyzing
4 or more times per week
Setting

NonMedicare

Day

Nocturnal

30A
30B

31A
31B

In-center
Home

27

28

29

Vocational Rehabilitation
Patients
aged 18 – 64

Patients
receiving
services from
Voc Rehab

Patients
Employed
full-time or
part-time

32

33

34

Treatment and Staffing
In-center Dialysis Treatments
(Include Training Treatments)
Hemodialysis

35

Other

36

Staffing
Position

Number of Staff

Number of Open Positions

Full Time

Part Time

Full Time

Part Time

37

38

39

40

Staff to
Patient Ratio

a. RNs
b. LPN/LVNs
c. PCTs
d. APNs
e. Dietitians
f. Social Workers

Completed by (Name)

Date

Title

41

Phone number

REMARKS REGARDING INFORMATION PROVIDED ON THIS SURVEY SHOULD BE ENTERED ON THE LAST PAGE OF THE SURVEY
This report is required by law (42 USC 426; 42 CFR 405.2133). Individually identifiable patient information will not be disclosed except as
provided for in the Privacy Act of 1974 (5 USC 5520; 45 CFR, Part 5a). 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 two (2) hours 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.
Form CMS-2744A (XX/XX)

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ESRD FACILITY SURVEY (CMS-2744)
INSTRUCTIONS FOR COMPLETION REPORTING RESPONSIBILITY
The ESRD Facility Survey is designed to capture only a limited amount of information concerning each Federally
approved renal facility’s operation. It is not intended to yield information on the full range of ancillary services or
activities, e.g., referrals, graft outcome, etc. These concerns are more appropriately addressed by the ESRD Network
in supplemental requests or through other segments of the Program Management and Medical Information
System (PMMIS). Every facility/center approved by Medicare to provide services to ESRD patients must furnish the
information requested in the ESRD Facility Survey (42 U.S.C. 426; 20 CFR 405, Section 2112). It is also the facility’s/
center’s responsibility to provide patient and treatment counts to their local ESRD Network upon termination
of operations. Facilities certified as only providing acute hospital inpatient dialysis services are not requested or
required to complete this survey.
For purposes of this document, the word “facility” will be used interchangeably when referring to renal dialysis
facilities, renal dialysis centers, or renal transplant centers, as applicable depending on the use of the CMS-2744A or
the CMS-2744B.
Survey period
The Facility Survey is completed annually between January 1st and the second Friday in April. The survey period is
January 1st through December 31st of the previous year. Unless specified otherwise, all data entered on the Facility
Survey is to cover the entire survey period. The form should be completed and submitted in the ESRD Quality
Reporting System (EQRS).

General instructions
Please complete the following information, which will be used to update the CMS Dialysis Facility Compare
website. This information should reflect your facility status as of December 31 of the previous year.
• Facility Physical Address: Complete this information if your physical address is different from your mailing
address.
• Number of Dialysis Stations: Provide the number of approved dialysis stations in your facility, as of December 31.
• Facility Telephone: Provide your facility telephone number including area code.
• Facility Ownership Type: Check the appropriate block for profit or non-profit type of ownership.
• Facility Local/National Affiliation/Chain Information: Provide information if your facility is owned or managed
by a national corporation, e.g., Satellite Healthcare, etc.
• Types of dialysis services offered: Provide information on the types of dialysis services your facility is approved
to provide, as of December 31. These are the types of services that are listed on the Dialysis Facility Compare
website; In-center Hemodialysis, Peritoneal Dialysis and/or Home Hemodialysis.
• Does your facility offer a dialysis shift that starts at 5:00 p.m. or later? Provide information as to whether your
facility offers dialysis shifts that begins on or after 5:00, as of December 31.
• Days and shifts your facility is open: Select all the days of the week your facility is open and the number of
shifts staffed to provide dialysis services per day, as of December 31.

Dialysis patients, treatments and staffing (for completion by dialysis units only) patient load
All patient and treatment counts requested are to include only the diagnosed chronic ESRD population; no
reversible failure (Acute) patients or treatments may be counted. All diagnosed chronic ESRD patients treated at
the facility should be counted and reported as (1) regular, continuing caseload (fields 01 through 03); (2) added
to the regular caseload (fields 04A through 07B); or (3) lost from the regular caseload (fields 08A through 13B).
Inclusion of patients in counts should not depend on entitlement determination; newly diagnosed chronic unit
admissions should be included, including peritoneal or hemodialytic therapy, and transplantation.

Patients Receiving Care Beginning of Survey Period
• Field 01: In-center. Enter the number of patients that were dialyzing in your facility, as of January 1, of the
survey period. This number should reflect your “permanent” patient population; i.e., those patients for whom
your facility had ongoing medical responsibility for the routine care of the patient until he/she/they was/were
formally transferred elsewhere. Include those routine patients who were hospitalized or were away from your
facility as of January 1, of the survey period.
• Field 02: Home. Enter the number of patients who were dialyzing at home (hemodialysis, continuous ambulatory
peritoneal dialysis, continuous cycling peritoneal dialysis or other dialysis, e.g., intermittent peritoneal dialysis),
as of January 1, of the survey period.
Instructions: Form CMS-2744A (XX/XX)

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• Field 03: Total. Enter the sum of fields 01 and 02. This should equal the number of patients on your facility’s
register, as of January 1 of the survey period.

Additions During the Survey Period
Note: This section requires counts for additional in-center and home dialysis patients accepted during the survey
period.
Newly Diagnosed Patients:
• Field 04A: In-center—Started for the First Time Ever. Enter the number of newly diagnosed ESRD patients who
were admitted to your facility as chronic maintenance dialysis patients for the first time ever. This is a count of
patients who have begun their initial course of in-center maintenance dialysis therapy during the survey period
and for whom your facility will have major medical responsibility. Do not include patients who transferred to
your facility from another dialysis facility; that data is to be reported in field 06A.
• Field 04B: Home—Started for the First Time Ever. Enter the number of newly diagnosed ESRD patients who
successfully completed a course of self-dialysis training and began home dialysis (their initial course of home
dialysis after training) during the survey period. If they are still in training at the end of the survey period,
report them in field 04A.
Restarted Dialysis:
• Field 05A: In-center—Restarted. Enter the number of patients who restarted in-center dialysis during the survey
period. This is a count of persons who had temporarily recovered kidney function, had discontinued dialysis, or
had been lost to follow-up but, restarted routine in-center dialysis during the survey period.
• Field 05B: Home—Restarted. Enter the number of patients who restarted home dialysis during the survey period.
This is a count of patients who had temporarily recovered kidney function, had discontinued dialysis, or had
been lost to follow-up but, restarted regular home dialysis during the survey period.
Transferred from Another Facility:
Note: Include those patients who received their first outpatient dialysis (or transplant) at a Non-Medicare facility
including a prison or a facility in another country.
• Field 06A: In-center —Transferred from Other Dialysis Unit. Enter the number of patients admitted to your
facility who were formally transferred from another dialysis facility during the survey period and who are
continuing a regular course of dialysis at your facility. A formal transfer is the transfer of a patient, including his/
her/their medical records, to another facility that will permanently become the primary dialysis provider.
• Field 06B: Home—Transferred from Other Dialysis Unit. Enter the number of home patients who were formally
transferred by another facility, during the survey period, to your unit for ongoing medical supervision and
responsibility. A formal transfer is the transfer of a patient, including his/her/their medical records, to another
facility that will permanently become the primary home dialysis provider.
Returned After Transplantation Failed:
Note: Do not include dialysis patients who were post-transplant and were waiting for their graft to function
(Dialysis in support of transplant). Include only those patients for whom a physician had written a prescription
after a transplant failed.
• Field 07A: In-center—Returned After Transplantation Failed. Enter the number of patients who returned to
in-center dialysis during the survey period after a transplant failure. (Do not include patients in this field who
were on temporary backup dialysis due to an Acute failure episode or patients who were receiving dialysis posttransplant while waiting for their graft to function [Dialysis in Support of Transplant].)
• Field 07B: Home—Returned After Transplantation Failed. Enter the number of patients who returned to home
dialysis, during the survey period, after a transplant failure. (Do not include patients in this field who were
on temporary backup dialysis due to an Acute failure episode or patients who were receiving dialysis posttransplant while waiting for their graft to function [Dialysis in Support of Transplant].)

Instructions: Form CMS-2744A (XX/XX)

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Losses During the Survey Period
Note: These fields describe losses to your facility of both in-center and home patients that occurred during the
survey period. For purposes of this survey, “in-center” includes patients who routinely dialyzed in-center at the
time of loss to the reporting facility, and “home” includes patients who routinely dialyzed at home at the time of
loss to the reporting facility.
Deaths:
Note: If a patient death occurred within 30 days of stopping dialysis, then submit a CMS2746, Death Notification
Form, and count the patient as a death.
• Field 08A: In-center—Deaths. Enter the number of in-center dialysis patients who died during the survey period.
These deaths must be shown in 08A if patient was on in-center dialysis at time of death or training for home
dialysis.
• Field 08B: Home—Deaths. Enter the number of home dialysis patients who died during the survey period. These
deaths must be shown in 08B if patient was on home dialysis at time of death.
Recovered Kidney Function:
• Field 09A: In-center —Recovered Kidney Function. Enter the number of in-center dialysis patients who recovered
function of their native kidneys and ceased in-center dialysis during the survey period.
• Field 09B: Home—Recovered Kidney Function. Enter the number of home dialysis patients who recovered
function of their native kidneys and ceased home dialysis during the survey period.
• Transplanted: Note: Any patient who received a kidney transplant, during the survey period must be listed in
this category, even if the graft never functioned.
• Field 10A: In-center —Received Transplant. Enter the number of in-center dialysis patients who received a kidney
transplant, during the survey period.
• Field 10B: Home—Received Transplant. Enter the number of home dialysis patients who received a kidney
transplant, during the survey period.
Transferred Out:
Note: Include patients who left the facility to dialyze elsewhere (at a Medicare approved or a non-Medicare
approved facility). Include patients who had been involuntarily discharged regardless of where patients received
services after discharge.
• Field 11A: In-center —Transferred to Other Dialysis Unit. Enter the number of in-center dialysis patients who
permanently transferred to another dialysis facility for their ongoing dialysis, during the survey period; that is,
those patients whose ongoing, routine medical supervision became the responsibility of another dialysis facility.
• Field 11B: Home—Transferred to Other Dialysis Unit. Enter the number of home dialysis patients who
permanently transferred to another home dialysis program, during the survey period.
Discontinued Dialysis:
Note: These fields should contain counts of patients whose last known activity was that they discontinued
dialysis. Patients who make the conscious decision to stop dialysis. You must follow the patient for 30 days after
his/her/their last dialysis session. If a patient death occurs within 30 days of stopping dialysis, then submit a
CMS-2746, Death Notification Form, and count the patient as a death.
• Field 12A: In-center —Discontinued Dialysis. Enter the number of in-center dialysis patients who consciously,
permanently discontinued dialysis (exclude those reported in fields 08A, 09A, 10A, 11A and 13A, these have not
discontinued dialysis), during the survey period.
• Field 12B: Home—Discontinued Dialysis. Enter the number of home dialysis patients who permanently
discontinued dialysis (excluding those reported in fields 08B, 09B, 10B, 11B and 13B, these have not discontinued
dialysis), during the survey period.
Lost to Follow-Up:
Note: Do not use this event when a patient has voluntarily discontinued dialysis (report in Fields 12/A or 12/B) or
has transferred out to another facility (report in Field 11/A or 11/B). Patients should be included in Field 13A or 13B,
only after every effort has been made to locate the patient.
• Field 13A: In-center – Other - Lost to Follow-Up (LTFU). Enter the number of patients, who had been dialyzing
In-center, left your dialysis program and whose current status was unknown to your facility (lost to follow-up),
during the survey period. Do not include those patients reported in fields 08A, 09A, 10A, 11A, or 12A.
Instructions: Form CMS-2744A (XX/XX)

5

• Field 13B: Home—Other - Lost to Follow-Up (LTFU). Enter the number of patients, followed by your facility, who
had been dialyzing at home, left your dialysis program and whose current status was unknown to your facility
(lost to follow-up), during the survey period.). Do not include those patients reported in fields 08B, 09B, 10B,
11B, or 12B.

Patients Receiving Care at the End of the Survey Period
Note: No not count a patient in more than one field. Patients receiving care at the beginning of the survey period
plus the additions during the survey period minus the losses during the survey period should equal the patients
receiving care (remaining) at the end of the survey period. Please ensure that field 03 plus field 04A through 07B,
minus fields 08A through 13B, equals field 26.
In-center Dialysis:
Note: Patients who are dialyzing in-center but, are performing all dialysis procedures without the assistance of
staff, are to be counted either in fields 14 or 15. (Not all facilities will have patients that fall into this category.)
Treatments for these patients should be counted as outpatient treatments in fields 35 or 36.
• Field 14: Hemodialysis. Enter the number of patients who, at the end of the survey period, were receiving staffassisted hemodialysis or performing in-center self-hemodialysis.
• Field 15: Other Dialysis. Enter the number of patients who, at the end of the survey period, were receiving
dialysis, other than hemodialysis. For example, those patients who were on staff-assisted intermittent peritoneal
dialysis (IPD) or performing in-center self- peritoneal dialysis would be counted in this field.
Self-Dialysis Training:
• Field 16: Hemodialysis. Enter the number of patients who were in a self-hemodialysis training program, as of the
end of the survey period. Patients are to be reported in this category only if the training is designed to enable
them to perform their own self-dialysis in-center or at home.
• Field 17: Continuous Ambulatory Peritoneal Dialysis (CAPD). Enter the number of patients who were in a CAPD
training program, as of the end of the survey period. Patients are to be reported in this category only if the
training is designed to enable them to independently perform CAPD.
• Field 18: Continuous Cycling Peritoneal Dialysis (CCPD). Enter the number of patients who were in a CCPD
training program, as of the end of the survey period. Patients are to be reported in this category only if the
training is designed to enable them to independently perform CCPD.
• Field 19: Other Dialysis. Enter the number of patients who were in a self-dialysis training program, e.g., a
self-intermittent peritoneal dialysis (IPD) training program, as of the end of the survey period. Patients are to be
reported in this category only if the training is designed to enable them to perform their own self-dialysis
in-center or at home.
• Field 20: Total In-center. Enter the total number of patients who were in-center status, as of the end of the
survey period (the sum of fields 14 through 19).
Home Dialysis
Note: Patients who were dialyzing at home with the assistance of staff provided by a dialysis supplier or facility
should be counted as home patients (fields 21 through 24).
• Field 21: Hemodialysis. Enter the number of patients who were using hemodialysis at home, as of the end of the
survey period.
• Field 22: Continuous Ambulatory Peritoneal Dialysis (CAPD). Enter the number of patients who were on CAPD,
as of December 31 of the survey period.
• Field 23: Continuous Cycling Peritoneal Dialysis (CCPD). Enter the number of patients who were on CCPD, as of
December 31 of the survey period.
• Field 24: Other Dialysis. Enter the number of patients who were on another type of home dialysis, e.g.,
intermittent peritoneal dialysis (IPD), as of December 31 of the survey period.
• Field 25: Total Home. Enter the total number of patients who were in home status, as of December 31 of the
survey period (the sum of fields 21 through 24).
Total:
• Field 26: Total. Enter the total number of patients on your facility’s register, as of December 31 of the survey
period (the sum of fields 20 and 25).

Instructions: Form CMS-2744A (XX/XX)

6

Patient Eligibility Status-End of Survey Period
Note: Counts should reflect entitlement only, not based on how reimbursement is made for dialysis services
provided by your facility. For example, a VA (Department of Veterans Affairs) patient whose reimbursement is
made by the VA, but is a Medicare entitled patient, should be counted in Field 27. Please ensure that the sum of
fields 27, 28, and 29 equals field 26, the total number of patients at the facility, at the end of the survey period.
• Field 27: Currently Enrolled in Medicare. Enter the number of patients, at the end of the survey period, who
were enrolled in Medicare. This count should include patients who are Medicare Secondary Payer beneficiaries
or patients enrolled in Medicare HMO/Medicare+Choice.
• Field 28: Medicare Application Pending. Enter the number of patients, at the end of the survey period, who had
Medicare applications pending.
• Field 29: Non-Medicare. Enter the number of patients, at the end of the survey period, who were not enrolled in
Medicare and who did not have Medicare applications pending.

Hemodialysis Patients Dialyzing 4 or More Times Per Week
Note: Report only those patients on hemodialysis, as of December 31, who were dialyzing 4 or more times
per week. Nocturnal dialysis is defined as hemodialysis that takes place while the patient is sleeping for
approximately 8 hours.
• Field 30A: In-center/Day. Enter the number of hemodialysis patients who were dialyzing, at the end of the
survey period, in-center and during the day, for 4 or more times per week.
• Field 30B: Home/Day. Enter the number of hemodialysis patients, who at the end of the survey period, were
dialyzing at home and during the day, for more than 4 times per week.
• Field 31A: In-center/Nocturnal. Enter the number of hemodialysis patients, who at the end of the survey period,
were dialyzing in-center and nocturnal for 4 or more times per week.
• Field 31B: Home/Nocturnal. Enter the number of hemodialysis patients, who at the end of the survey period,
were dialyzing at home and nocturnal for 4 or more times per week.

Vocational Rehabilitation
Note: Enter the following information on patients reported, based on their activities during the survey period.
Information being provided is for patients, who as of December 31, were living and had attained the ages of 18
through 64 that are employed either full-time or part-time.
• Field 32: Patients Aged 18 through 64. Enter the number of dialysis patients who, as of the end of the survey
period, were ages 18 through 64, and were dialyzing at your facility.
• Field 33: Patients Receiving Services from Vocational Rehabilitation. For the dialysis patients counted in Field 32,
enter the number who were receiving Vocational Rehabilitation Services, during the survey period (January 1
through December 31). Include any patients for whom any of the following applies:
• Talked with VR personnel AND agreed to be evaluated for services by completing an application, having
medical records requested, or being assigned a counselor.
• Received evaluation services by participating in testing (for example: interest inventories, skills testing,
aptitude testing, work readiness inventories) or by attending an evaluation/testing center.
• Received vocational counseling, training at a community facility public educational/ training center.
• Received assistance with job seeking skills, with job placement, or with retaining or modifying a job through
a Vocational Rehabilitation counselor job placement specialist, or agencies.
• Field 34: Patients Employed Full-Time or Part-Time. Enter the number of patients who were employed either
full-time or part-time, during the survey period. Include any patient, aged 18 through 64 (Fields 32), who
received taxable wages from an employer or who was self-employed and paid taxes on earnings. Count only
those patients who were receiving taxable earnings.

Treatment and Staffing
Note: The following section (fields 35 and 36) should reflect all outpatient treatments given to ESRD patients
including self-care training treatments during the survey year. Please be certain to report treatments to correspond
with patients counted at the end of the survey period in a particular modality. If a situation occurs where a patient
is reported at the end of the survey period but, no treatments were provided, please explain why no treatments
were provided in the Remarks section of the survey form. DO NOT INCLUDE ACUTE TREATMENTS.

Instructions: Form CMS-2744A (XX/XX)

7

Hemodialysis
• Field 35: Outpatient Treatments. Enter the number of staff-assisted treatments, training hemodialysis treatments
and treatments performed by self-dialyzing patients, in-center, during the survey period.
Other
• Field 36: Other Treatments. Enter the number of all other types of treatments provided in-center. For all types of
peritoneal dialysis training, report the number of days for which exchanges were provided. Do not report the
number of exchanges and do not report days where no dialysis treatments or exchanges were furnished. For
example, report the number of staff-assisted and training intermittent peritoneal (IPD) treatments, CAPD and
CCPD training days and all other number of treatments performed by self-dialyzing patients or training patients,
in-center, during the survey period.

Staffing
Enter the number of Full Time and Part Time staff positions at your facility, as of December 31. Also provide the
number of Full Time and Part Time staff positions that are open and not filled, as of December 31 at your facility.
If a corporate entity is completing this form for a facility, only count the hours each employ spends at this facility.
Do not accumulate hours between facilities. The following definitions are provided as guidelines in completing this
section: Full Time Position is defined as a position with at least 32 hours employment per week Part time Position is
defined as a position with less than 32 hours per week and includes per diem staff.
RN: Staff holding a Registered Nurse degree.
LPN/LVN: Licensed Practical Nurse, Licensed Vocational Nurse: Staff holding either of those degrees.
PCT: Patient Care Technician. Include staff providing direct patient care.
APN: Advanced Practice Nurse. The Advanced Practice Nurse (APN) is a Certified Registered Nurse (RN) with
advanced certification as a nurse practitioner (NP) or a Clinical Nurse Specialist (CNS) who has met advanced
educational and clinical practice requirements. Do not report Certified Nephrology Nurses (CNNs) in this category.
Do not double count a registered nurse in this category.
Dietitian: Renal Dietitians. Staff with renal dietitian credentials.
Social Worker: Staff with LCSW, MSW, BSW or other professional social work degrees.
• Field 37: Enter the number of Full-Time staff, as of December 31: a) Registered Nurses, b) Licensed Practical
Nurses/Licensed Vocational Nurses, c) Patient Care Technicians, d) Advanced Practice Nurses, e) Dietitians, and f)
Social Workers.
• Field 38: Enter the number of Part Time staff, as of December 31: a) Registered Nurses, b) Licensed Practical
Nurses/Licensed Vocational Nurses, c) Patient Care Technicians, d) Advanced Practice Nurses, e) Dietitians, and f)
Social Workers.
• Field 39: Enter the number of Full-Time staff positions that are open, as of December 31: a) Registered Nurses, b)
Licensed Practical Nurses/Licensed Vocational Nurses, c) Patient Care Technicians, d) Advanced Practice Nurses, e)
Dietitians, and f) Social Workers.
• Field 40: Enter the number of Part Time staff positions that are open, as of December 31: a) Registered Nurses,
b) Licensed Practical Nurses/Licensed Vocational Nurses, c) Patient Care Technicians, d) Advanced Practice Nurses,
e) Dietitians, and f) Social Workers.
• Field 41: Enter Staff to Patient Ratio as of December 31: Enter the number of patients each a) Registered Nurses,
b) Licensed Practical Nurses/Licensed Vocational Nurses, c) Patient Care Technicians, d) Advanced Practice Nurses,
e) Dietitians, and f) Social Workers is responsible for at this facility.
Signatures for the Facility Survey requires signatures, as follows: Completed by: Enter the date completed and the
name, title, and telephone number of the person who completed the Facility Survey for your facility. This person
should be the individual who the ESRD network or CMS can contact to discuss any information provided in the
Facility Survey.

Instructions: Form CMS-2744A (XX/XX)

8