Form CMS-3427 PDF Details

The CMS 3427 form is an essential document for facilities offering End Stage Renal Disease (ESRD) services and seeking Medicare certification or undergoing recertification. Managed by the Department of Health and Human Services and specifically the Centers for Medicare & Medicaid Services, this form plays a crucial role in ensuring facilities comply with federal standards for providing renal dialysis services. It captures detailed information on the facility's operations, including types of applications such as initial certification, recertification, relocation, service expansion, change of ownership, and more. Additionally, it requires information on the facility's name, contact details, administrator, ownership status, services currently offered, and staffing, among others. Notably, it also addresses the facility's capacity for providing isolation for dialysis treatment and includes a section for remarks for any additional information the facility wishes to provide. The second part of the form is completed by the state agency responsible for the survey and certification process, ensuring that all information provided by the facility is accurate and meets the required standards for the provision of ESRD services. This document is a comprehensive tool for maintaining high-quality care standards in renal dialysis facilities and ensuring they are prepared to meet the needs of patients requiring such specialized care.

QuestionAnswer
Form Name Form CMS-3427
Form Length 3 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 45 sec
Other names form cms onsite, 3427, esrd forms needed, esrd medicare application

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

 

 

 

 

 

FORM APPROVED

CENTERS FOR MEDICARE & MEDICAID SERVICES

 

 

 

 

 

 

OMB NO. 0938-0360

 

 

 

 

 

 

 

 

 

END STAGE RENAL DISEASE APPLICATION AND SURVEY AND CERTIFICATION REPORT

 

 

 

 

 

 

 

 

 

 

PART 1 – APPLICATION – TO BE COMPLETED BY FACILITY

 

1.

Type of Application/Notification (check all that apply; if “Other,” specify in “Remarks” section [Item 33]): (V1)

 

 

1.

Initial

2. Recertification

3. Relocation

4. Expansion/change of services

 

5. Change of ownership

 

 

6.

Other, specify:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Name of Facility

 

 

 

 

3.

CCN

 

 

 

 

 

 

 

 

 

 

4.

Street Address

 

 

 

 

5.

NPI

 

 

 

 

 

 

 

 

 

 

 

6.

City

 

 

 

7. County

 

8.

Fiscal Year End Date

 

 

 

 

 

 

 

 

9.

State

 

 

10. Zip Code:

 

11. Administrator’s Email Address

 

 

 

 

 

12. Telephone No.

 

13. Facsimile No.

 

14. Medicare Enrollment (CMS 855A)

 

 

 

 

 

 

 

 

completed? Yes No

NA

 

 

 

 

 

 

 

 

 

 

 

15.Facility Administrator Name: Address:

City:

State:

Zip Code:

Telephone No:

 

 

 

 

16. Ownership (V2)

1. For Profit

2. Not for Profit

3. Public

17. Is this facility owned and managed by a hospital and on the hospital campus (i.e., hospital-based)? (V3)

1. Yes

Is this facility owned and managed by a hospital and located off the hospital campus (i.e., satellite)? (V4)

1. Yes

Is this facility not owned or managed by a hospital (i.e., independent)? (V5)

1. Yes

If owned and managed by a hospital: hospital name: (V6)

CCN: (V7)

2.No

2.No

2.No

18. Is this facility located in a SNF/NF (check one): (V8) If Yes, SNF/NF name: (V9)

1. Yes

2. No

CCN: (V10)

19. Is this facility owned &/or managed by a multi-facility organization? (V11)

If Yes, name of multi-facility organization: (V12)

Multi-facility organization’s address:

1. No

2. Yes, Owned

3. Yes, Managed

20. Current Services (check all that apply): (V13)

1.

In-center Hemodialysis (HD)

2.

In-center Peritoneal Dialysis (PD)

5.

Home HD Training & Support

6.

Home PD Training & Support

3. In-center Nocturnal HD

4. Reuse

7. Home Training & Support only

 

21.

New services being requested (check all that apply): (V14)

 

 

 

 

 

 

 

1. N/A

2. In-center HD

3. In-center PD

4. In-center Nocturnal HD

5. Reuse

 

 

 

6. Home HD Training & Support

7. Home PD Training & Support

8. Home Training & Support only

 

 

 

 

 

 

22.

Does the facility have any home dialysis (PD/HD) patients receiving dialysis in long-term care (LTC) facilities?

 

 

(V15) 1. Yes

 

2. No

 

 

 

 

 

 

 

LTC (SNF/NF) facility name: (V16)

 

 

 

CCN: (V17)

 

 

 

Staffing for home dialysis in LTC provided by: (V18)

1. This dialysis facility

2. LTC staff

3. Other, specify

 

 

Type of home dialysis provided in this LTC facility: (V19)

1. HD

 

2. PD

 

 

 

For additional LTC facilities, record this information and attach to the “Remarks” (item 33) section.

 

 

 

 

 

 

 

 

 

 

 

23.

Number of dialysis patients currently on census:

 

 

 

 

 

 

In-Center HD: (V20) ____

In-Center Nocturnal HD: (V21) ____

In-Center PD: (V22)

____

 

 

Home PD: (V23) ____

Home HD <= 3x/week:

(V24) ____

Home HD >3x/week: (V25) ____

 

 

 

 

 

 

 

 

 

 

 

 

24. Number of approved in-center dialysis stations: (V26) ___ Onsite home training room(s) provided? (V27)

1. Yes

2. N/A

25. Additional stations being requested: (V28) In-center PD: (V31) _____

None In-center HD: (V29) _____ In-center nocturnal HD: (V30) _____

FORM CMS-3427 (Revision 05/13)

1

26. How is isolation provided? (V32)

 

 

1. Room

2. Area (established facilities only)

3. CMS Waiver/Agreement (Attach copy)

27.If applicable, number of hemodialysis stations designated for isolation: (V33)

28.Days & time for in-center patient shifts (check all days that apply and complete time field in military time): (V34)

1st shift starts:

M

T

W

Th

F

Sat

Sun

Last shift ends:

M

T

W

Th

F

Sat

Sun

 

 

 

 

 

 

 

 

29. Dialyzer reprocessing system: (V35)

1. Onsite

2. Centralized/Offsite

3. N/A

30. Staff (List full-time equivalents): Registered Nurse: (V36)

Certified Patient Care Technician: (V37)

LPN/LVN: (V38)

Technical Staff (water, machine): (V39)

Registered Dietitian: (V40)

Masters Social Worker: (V41)

Others: (V42)

 

31. State license number (if applicable): (V43)

32. Certificate of Need required? (V44)

1. Yes

2. No

3. NA

33. Remarks (copy if more and attach additional pages if needed):

34.The information contained in this Application Survey and Certification Report (Part I) is true and correct to the best of my knowledge. I understand that incorrect or erroneous statements may cause the request for approval to be denied, or facility approval to be rescinded, under 42 C.F.R. 494.1 and 488.604 respectively.

I have reviewed this form and it is accurate:

Signature of Administrator/Medical Director

Title

Date

PART II TO BE COMPLETED BY STATE AGENCY

35. Medicare Enrollment (CMS 855A approved by the MAC/FI)? (V45)

(Note: approved CMS 855A required prior to certification)

1. Yes

2. No

36. Type of Survey: (V46)

1. Initial

2. Recertification

5. Change of ownership 6. Complaint

3.Relocation

7.Revisit

4. Expansion/change of services

8. Other, specify

37. State Region: (V47)

38. State County Code: (V48)

39. Network Number: (V49)

My signature below indicates that I have reviewed this form and it is complete.

40. Surveyor Team Leader (sign)

41. Name/Number (print)

42.Professional Discipline (Print)

43. Survey Exit Date:

FORM CMS-3427 (Revision 05/13)

2

INSTRUCTIONS FOR FORM CMS-3427

PART 1 – DOCUMENTATION NEEDED TO PROCESS FACILITY APPLICATION/NOTIFICATION TO BE

COMPLETED BY APPLICANT

A completed request for approval as a supplier of End Stage Renal Disease (ESRD) services in the Medicare program (Part I – Form CMS-3427) must include:

∙A narrative statement describing the need for the service(s) to be provided, and

∙A copy of the Certificate of Need approval, if such approval is required by the state.

TYPE OF APPLICATION (ITEM 1)

Check appropriate category. A “change of service” refers to an addition or deletion of services. “Expansion” refers to addition of stations. If you relocate one of your services to a different physical location, you may be required to obtain a separate CCN for that service at the new location.

IDENTIFYING INFORMATION (ITEMS 2-24)

Enter the name and address (actual physical location) of the ESRD facility where the services are performed. If the mailing address is different, show the mailing address in Remarks (Item 33). Check the applicable blocks (Item 17 and Item 18) to indicate the facility’s

hospital and/or SNF/NF affiliation, if any. If so, enter the CCN of the hospital and/or SNF/NF. Check whether the facility is owned and/or managed by a “multi-facility” organization (Item 19) and provide the name and address of the parent organization. A “multi-facility organization” is defined as a corporation or a LLC that owns more than one facility.

TYPES OF SERVICE, DIALYSIS STATIONS, AND DAYS/HOURS OF OPERATION (ITEMS 20-28)

Provide information on current services offered (Item 20). Check N/A or each New service for which you are requesting approval (Item 21).

Note that facilities providing home therapies must provide both training and support. If you are requesting to offer home training and support only (Item 21), you must have a functional plan/arrangement to provide backup dialysis as needed. A new “home training and support only” service applies to initial applications. If you request any home training and support program (Item 21), you must also indicate “Yes” for a

training room (Item 24). If you provide or support dialysis within one or more a LTC facilities (SNF/NF), list all LTCs (name, CCN, and address) participating in this service under Remarks (Item 33), and complete Item 22. Enter the number of stations for which you are asking approval (Item 25). Provide information on isolation (Items 26-27). Facilities not existing prior to October 14, 2008 which do not have an isolation room must attach evidence of CMS waiver and written agreement with geographically proximal facility with isolation room. Provide all days and start time for the first shift of patients and end time for the last shift of patients (in military time) for each day of operation (Item 28). Provide information on dialyzer reprocessing (Item 29).

STAFFING (ITEM 30)

“Other” includes non-certified patient care technicians, administrative personnel, etc. To calculate the number of full-time equivalents of any discipline (Item 30), add the total number of hours that all members of that discipline work at this facility and enter that number in the numerator. Enter into the denominator the number of hours that facility policy defines as full-time work for that discipline. Report FTEs in

0.25increments only. Example: An RD works 20 hours a week at Facility A. Facility A defines full time work as 40 hours/week. To calculate FTEs for the RD, divide 20 by 40. The RD works 0.50 FTE at Facility A.

REMARKS (ITEM 33)

You may use this block for explanatory statements related to Items 1-32.

LICENSING AND CERTIFICATE OF NEED

If your state requires licensing for ESRD facilities, include your current license number in Item 31. If your state requires a Certificate of Need (CON) for an initial ESRD or for the change you are requesting, mark the applicable box in Item 32 and include a copy of the documentation of the CON approval.

Upon completion, forward a copy of form CMS-3427 (Part I) to the State agency.

PART II - SURVEY AND CERTIFICATION REPORT TO BE COMPLETED BY STATE AGENCY

The surveyor should review and verify the information in Part I with administrator or medical director and complete Part II of this form.

Recognize that CMS cannot issue a CCN for an initial survey until all required steps are complete, including CMS-855A approved by the applicable MAC. Complete the Statement of Deficiencies (CMS Form 2567) in ASPEN. Complete the CMS-1539 in ASPEN entering recommended action(s). All required information must be entered in ASPEN and uploaded in order for the survey to be counted in the state workload.

FORM CMS-3427 (Revision 05/13)

3

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1. The certification esrd will require specific details to be entered. Ensure the subsequent blanks are completed:

esrd cms survey completion process described (portion 1)

2. Once the last part is completed, you're ready include the required specifics in Current Services check all that, Incenter Hemodialysis HD, Incenter Peritoneal Dialysis PD, Incenter Nocturnal HD, Reuse, Home HD Training Support, Home PD Training Support, Home Training Support only, New services being requested, Incenter HD, Incenter PD, Incenter Nocturnal HD, Reuse, Home HD Training Support, and Home PD Training Support so you're able to move on further.

Step no. 2 in filling in esrd cms survey

Be really attentive while completing Home PD Training Support and Reuse, because this is the part where many people make errors.

3. Throughout this step, examine How is isolation provided V, Room, Area established facilities only, CMS WaiverAgreement Attach copy, If applicable number of, Days time for incenter patient, Dialyzer reprocessing system V, Onsite, CentralizedOffsite, Staff List fulltime equivalents, LPNLVN V Technical Staff water, Registered Dietitian V Masters, Others V, State license number if, and Yes. These have to be filled in with greatest attention to detail.

Best ways to prepare esrd cms survey stage 3

4. Completing Signature of AdministratorMedical, Title, Date, Medicare Enrollment CMS A, Yes, Note approved CMS A required prior, PART II TO BE COMPLETED BY STATE, Type of Survey V, Initial, Recertification, Relocation, Expansionchange of services, Change of ownership, Complaint, and Revisit is crucial in this part - ensure that you be patient and fill in each and every blank!

Revisit, Yes, and PART II TO BE COMPLETED BY STATE in esrd cms survey

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