Approved for use through 10/99 under the condition that the next submission for OMB clearance includes the underlying CLIA and OPO state surveyor/regional office guidance.
Inventory as of this Action
Requested
Previously Approved
11/30/1999
11/30/1999
11/30/1998
60,000
0
98,400
120,000
0
196,800
0
0
0
This paperwork package provides information regarding the form used by the Medicare, Medicaid, and the Clinical Laboratory Improvement Amendments (CLIA) programs to document a health care facility's compliance or noncompliance (deficiencies) with regard to the Medicare/Medicaid Conditions of Participation and Coverage, the requirements for participation for Skilled Nursing Facilities and Nursing Facilities, and for certification under CLIA. This form becomes the evidentiary basis for HCFA certification decisions (including termination or denial of participation) and the form of public assistance.
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:
(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;
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.
Statement of Deficiencies and Plan of Correction -- 42 CFR 488.18, 488.26, and 488.28