Read the following instructions carefully.

1. Complete this survey by the last day of each month.
WARNING: DO NOT USE PATIENT SPECIFIC INFORMATION SUCH AS NAMES, DOB, SOC SECURITY #, ETC. IN THIS SURVEY.
SECURITY VIOLATIONS WILL BE REPORTED TO CMS.

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* 1. Provide first and last name of person completing this survey.

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* 4. How many patients were at your facility for the reporting month?

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* 5. Does your facility have at least one Facility Patient Representative (FPR) (may be a patient or family member)?

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* 6. Has your facility invited patients, family members and/or caregivers to participate in staff meetings (I.e.Governing Body Meetings, QAPI Meetings)? If yes, please indicate how often in the comment box.

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* 7. Please indicate whether a patient or family member attended/participated in the most recent QAPI/QA meeting.

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* 8. Please enter the last time the Home Project was reviewed during QAPI/QA.

Date / Time

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* 9. Please indicate who from your facility attended the most recent Home NCC Learning and Action Network (LAN) Call. National calls are scheduled every other month.

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* 10. Did you utilize any resources provided by the Network or the ESRD National Coordinating Center (NCC)?

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* 11. Has your facility implemented a Patient Engagement (PE) Activity related to Home modalities this month? If "Yes", please select any of the appropriate options AND add a short description in the provided space below. REMINDER: At least one Home PE activity is required during this project.

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* 12. Does your facility have a Facility Support Group(s)?

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* 13. What method(s) are you using to develop support group?

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* 14. What are the barriers in developing and maintaining a patient support group?

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* 15. Is your facility interested in participating in pilot peer mentoring program “Buddies Wanted”? The Buddies Wanted Program is a mentoring group which utilizes a patient pairing system. New patients will be paired with patients who have been in the facility for at least 6 months and have adjusted to the facility, staff and challenges faced by ESRD patients. Potential participants and candidates will be selected by the facility staff members. Participation in the Buddies Wanted Program is optional.

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* 16. Do you meet with your patients one-on-one to review their Plan of Care (POC) report?

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* 17. Does you facility have the Grievance Poster and Patient Engagement Calendar poster displayed for patients to view?

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* 18. Did your facility include patient feedback while completing this survey?

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* 19. Any barriers or challenges you would like to share about the patient engagement this month?

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* 20. Any successes or promising practices you would like to share about your home therapy program or in-center best practices this month?

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