Hospice Conditions of Participation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMS-10277.Supporting Statement Part A.doc	Supporting Statement A	Uploaded 2010-08-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
194310	Hospice Certification of Terminal Illness (418.22): Including Benefit Periods		New
194309	Hospice Certification of Terminal Illness (418.22): Completion of Attestation Form		New
194308	Hospice Certification of Terminal Illness (418.22, first year): Development of Attestation Form		New
189585	Hospice Conditions of Participation (418.114 - annual)		Modified
189584	Hospice Conditions of Participation (418.114 - first year)		Modified
189583	Hospice Conditions of Participation (418.112)		Modified
189582	Hospice Conditions of Participation (418.110 - annual)		Modified
189581	Hospice Conditions of Participation (418.110 - first year)		Modified
189580	Hospice Conditions of Participation (418.106)		Modified
189579	Hospice Conditions of Participation (418.78)		Modified
189578	Hospice Conditions of Participation (418.76)		Modified
189577	Hospice Conditions of Participation (418.56)		Modified
189576	Hospice Conditions of Participation (418.52)		Modified

ICR Details

OMB Control No: 0938-1067	ICR Reference No: 201008-0938-012
Status: Historical Inactive	Previous ICR Reference No: 200906-0938-010
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Hospice Conditions of Participation
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Comment filed on proposed rule and continue	Conclusion Date: 10/04/2010
	Date Received in OIRA: 08/19/2010
Terms of Clearance: OMB files this comment in accordance with 5 CFR 1320.11(c). This OMB action is not an approval to conduct or sponsor an information collection under the Paperwork Reduction Act of 1995. This action has no effect on any current approvals. If OMB has assigned this ICR a new OMB Control Number, the OMB Control Number will not appear in the active inventory. For future submissions of this information collection, reference the OMB Control Number provided. In accordance with 5 CFR 1320, the agency should resubmit this ICR at the final rule stage.

table that charts list comparision

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

---

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.

---

Authorizing Statute(s): 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
   US Code: 42 USC 1395x Name of Law: Hospice Care; Hospice Program
   PL: Pub.L. 108 - 173 946 Name of Law: Medicare Prescription Drug, Improvement, & Modernization Act of 2003
   PL: Pub.L. 111 - 148 3132 Name of Law: Hospice reform.
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3132 Name of Law: Hospice reform

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AP88	Proposed rulemaking	75 FR 43236	07/23/2010

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 13

table that charts list of burden

IC Title	Form No.	Form Name
Hospice Conditions of Participation (418.110 - 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)
Hospice Conditions of Participation (418.106)
Hospice Certification of Terminal Illness (418.22, first year): Development of Attestation Form
Hospice Conditions of Participation (418.110 - annual)
Hospice Conditions of Participation (418.112)
Hospice Conditions of Participation (418.114 - first year)
Hospice Conditions of Participation (418.114 - annual)
Hospice Certification of Terminal Illness (418.22): Completion of Attestation Form
Hospice Certification of Terminal Illness (418.22): Including Benefit Periods

---

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: The burden increase is the result of program changes required by statue, the Patient Protection and Affordable Care Act of 2010.

---

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]? Yes

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

---

Common Form ICR:  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:

(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: 08/19/2010

---