Hospice Conditions of Participation and Physician Narrative on the Certification or Recertification of Terminal Illness (42 CFR 418.22(b)(3))

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10277.Response to 30-day comment-9-10-09 (1000AM).doc	Supplementary Document	Uploaded 2009-09-10	Available
CMS-10277 Supporting_Statement_Part_A - 7.30.09.doc	Supporting Statement A	Uploaded 2009-07-31	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
189585	Hospice Conditions of Participation (418.114 - annual)		New
189584	Hospice Conditions of Participation (418.114 - first year)		New
189583	Hospice Conditions of Participation (418.112)		New
189582	Hospice Conditions of Participation (418.110 - annual)		New
189581	Hospice Conditions of Participation (418.110 - first year)		New
189580	Hospice Conditions of Participation (418.106)		New
189579	Hospice Conditions of Participation (418.78)		New
189578	Hospice Conditions of Participation (418.76)		New
189577	Hospice Conditions of Participation (418.56)		New
189576	Hospice Conditions of Participation (418.52)		New

ICR Details

OMB Control No: 0938-1067	ICR Reference No: 200906-0938-010
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Hospice Conditions of Participation and Physician Narrative on the Certification or Recertification of Terminal Illness (42 CFR 418.22(b)(3))
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: 09/21/2009
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/15/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2012	36 Months From Approved
Responses	28,720	0	0
Time Burden (Hours)	1,339,383	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The CoPs and accompanying requirements specified in the regulations are used by Federal or State surveyors as a basis for determining whether a hospice qualifies for approval or re-approval under Medicare. CMS and the healthcare industry believe that the availability to the hospice of the type of records and general content of records, which this regulation specifies, is standard medical practice, and is necessary in order to ensure the well-being and safety of patients and professional treatment accountability.

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Authorizing Statute(s): US Code: 42 USC 1395x Name of Law: Hospice Care; Hospice Program
   PL: Pub.L. 97 - 248 122 Name of Law: Tax Equity & Fiscal Responsibility Act
   PL: Pub.L. 101 - 239 6005(b) Name of Law: Omnibus Reconciliation Act of 1989
   PL: Pub.L. 105 - 33 Title IV, Chapter 4 Name of Law: BBA of 1997
   PL: Pub.L. 108 - 173 946 Name of Law: Medicare Prescription Drug, Improvement, & Modernization Act of 2003
  

Citations for New Statutory Requirements: US Code: 42 USC 1395x Name of Law: Hospice Care; Hospice Program

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 10917	03/19/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 27041	06/05/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
Hospice Conditions of Participation (418.106)
Hospice Conditions of Participation (418.110 - annual)
Hospice Conditions of Participation (418.110 - first year)
Hospice Conditions of Participation (418.112)
Hospice Conditions of Participation (418.114 - annual)
Hospice Conditions of Participation (418.114 - first year)
Hospice Conditions of Participation (418.52)
Hospice Conditions of Participation (418.56)
Hospice Conditions of Participation (418.76)
Hospice Conditions of Participation (418.78)

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ICR Summary of Burden

table that charts list 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	28,720	0	28,720	0	0	0
Annual Time Burden (Hours)	1,339,383	0	1,339,383	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement: This is a new information collection.

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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)? No

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: 06/15/2009

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