PILOT TEST - HOME HEALTH AGENCY SURVEY FORMS

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
113905	PILOT TEST - HOME HEALTH AGENCY SURVEY FORMS Form	Migrated

ICR Details

OMB Control No: 0938-0514	ICR Reference No: 198709-0938-008
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: PILOT TEST - HOME HEALTH AGENCY SURVEY FORMS
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/24/1987
	Date Received in OIRA: 09/30/1987
Terms of Clearance: The Home Health Agency Annual Questionnaire is approved for use through December 1988. The Patient Care Observation forms (Parts A-D) however, as discussed with HCFA staff, are not approved but will be resubmitted for OMB review with revisions ensuring that the design and forms meet home visit requirements of the Omnibus Budget Reconciliatio Act of 1987. For example: (1) The pilot study must specify case-mix sampling methodology for selecting beneficiaries for home visits. (2) HCFA should collect data as part of the pilot study demonstrating the cost-benefit of conducting home visits using the specified samplin methodology. (3) Home visits must only be made with the consent of the beneficiaries. The pilot study should be designed to assess the effectiveness of obtaining beneficiary cooperation. The final pilot study report should: (a) provide data on those beneficiaries declining to participate in the visits, and (b) discuss limitations on general utility findings. (4) The pilot study must be revised to contain a validation component for the home visit survey protocol. The forms should be reviewed and resubmitted to ensure that only questions designed to address regulatory and statutory requirements are included. OMB will review the revised clearance package on an expedited basis.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/1988	12/31/1988
Responses	1	0	0
Time Burden (Hours)	1	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: PILOT TEST OF REVISED PROCESS AND FORMS FOR SURVEYING HOME HEALTH AGENCIES FOR MEDICARE PARTICIPATION. STATE SURVEYORS WILL USE THE FORMS, HHAS WILL COMPLETE THE SELF-SURVEY FORM. SOME MEDICARE BENEFICIARIES WILL BE INTERVIEWED.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
PILOT TEST - HOME HEALTH AGENCY SURVEY FORMS	HCFA-1572, TEST

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	1	0	0	1	0	0
Annual Time Burden (Hours)	1	0	0	1	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/30/1987

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