Statement of Deficiencies and Plan of Correction and Supporting Regulations Contained in 42 CFR 488.18, 488.26, and 488.28

ICR 199909-0938-002

OMB: 0938-0391

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
ICR Details
0938-0391 199909-0938-002
Historical Active 199808-0938-003
HHS/CMS
Statement of Deficiencies and Plan of Correction and Supporting Regulations Contained in 42 CFR 488.18, 488.26, and 488.28
Extension without change of a currently approved collection   No
Regular
Approved without change 11/01/1999
Retrieve Notice of Action (NOA) 09/02/1999
Approved for use through 11/2002 under the condition that the next submission includes all provider survey and certification guidance (including the CLIA and OPO guidance) unless such guidance has been incorporated into other OMB clearance submis- sions.
  Inventory as of this Action Requested Previously Approved
11/30/2002 11/30/2002 11/30/1999
60,000 0 60,000
120,000 0 120,000
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 disclosure.

None
None


No

1
IC Title Form No. Form Name
Statement of Deficiencies and Plan of Correction and Supporting Regulations Contained in 42 CFR 488.18, 488.26, and 488.28 HCFA-2567

  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 60,000 60,000 0 0 0 0
Annual Time Burden (Hours) 120,000 120,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  No

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.
09/02/1999


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