End-Stage Renal Dialysis Facility Doing Business as (DBA) Name Change - Minnesota Dept. of Health

Relocation of End-Stage Renal Dialysis Facility

This page contains instructions for submitting a location change of an end-stage renal dialysis facility in Minnesota.

Medicare Enrollment

  1. Submit CMS 855A application and all supporting documentation to the designated Medicare Administrative Contractor (MAC) for approval.
    CMS 855A Medicare Enrollment Application (PDF)

    (See Medicare Fee-for-Service Provider Enrollment Contact List)
  2. Send the following to MDH at the address below or submit via email:
    Provide written notice on facility letterhead including:
    1. Name of facility.
    2. CMS Certification Number (CCN).
    3. Current address.
    4. New address.
    5. Any change in services the facility is requesting to be provided at the new location.
    6. Number of stations and if requesting expansion of stations at the new location.
    7. Date when the relocation will occur.
    8. Name of contact person.
  3. Complete the ESRD Application and Survey and Certification Report (CMS-3427) (PDF).
  4. Complete the Life Safety Code Attestation for Exempt ESRD Facilities (PDF).

Prior to relocation of any patients, the facility must provide to MDH reports demonstrating acceptable results of water quality testing, including chemical analysis and reports of acceptable results from testing for bacteria and endotoxins from the new location.

Prior to relocation of any patients, the facility must provide to MDH if additional or replacement dialysis machines will be used at the new location, reports of each of these machines demonstrating acceptable results from testing for dialysate bacteria and endotoxin must also be submitted.

When the water quality testing results are accepted, MDH will notify the facility that it may open and operate as many treatment stations as were approved at its previous location and relocate its patients.

Unannounced Survey Process

When MDH has received the above documents, MDH engineering and State Fire Marshal (SFM) inspection may be required based on Life Safety Code (LSC) attestation.

A request for survey will be sent to the MDH health supervisor (engineers and SFM if needed) to schedule the relocation survey.

If no deficiencies are issued at the time of the relocation survey, MDH will recommend Medicare Certification to Region V Office of CMS effective the date of the survey.

If standard level deficiencies are issued at the time of the survey, a plan of correction is required. With an acceptable plan of correction, MDH will recommend Medicare certification to Region V Office of CMS effective the date the acceptable plan of correction is received in this office.

Certification recommendation to CMS

MDH will process the relocation survey, approved 855 and federal forms with our recommendation to Region V Office of CMS. Region V Office of CMS will review the application and send a letter to the facility when approved. 

Mail or email completed documents to:
Minnesota Department of Health
Health Regulation Division
Licensing and Certification Program
P.O. Box 64900
St. Paul, Minnesota 55164-0900
Attn: Certification Specialist
health.CM-Cert@state.mn.us

Friday, June 22, 2018 at 11:05AM