Hospice Voluntary Quality Data Reporting Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10390 Hospice Voluntary Quality Data Reporting Form	Form and Instruction	Modified	Available
CMS-10390 Supporting Statement part A rev 01-03-12.doc	Supporting Statement A	Uploaded 2012-01-03	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
200291	Hospice Voluntary Quality Data Reporting Form	Form and Instruction	Modified

ICR Details

OMB Control No: 0938-1153	ICR Reference No: 201112-0938-011
Status: Historical Active	Previous ICR Reference No: 201111-0938-013
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Hospice Voluntary Quality Data Reporting Program
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 with change	Conclusion Date: 01/03/2012
	Date Received in OIRA: 12/30/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2014	36 Months From Approved
Responses	1,766	0	0
Time Burden (Hours)	442	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Section 1814(i)(5) of the Social Security Act (Act)added by section 3004 of Patient Protection and Affordable Care Act, Pub. L. 111 148, enacted on March 23, 2010 (Affordable Care Act), authorizes the Secretary to establish a quality reporting program for hospices. Section 1814(i)(5)(A)(i) of the Act requires that the Secretary, beginning with FY 2014, reduce the market basket update by 2 percentage points for any hospice that does not comply with the quality data submission requirements with respect to that fiscal year. To meet the quality reporting requirements for hospices, as set forth in the proposed Hospice Wage Index for Fiscal Year 2012 rule, we propose that there shall be a voluntary hospice quality reporting cycle which will consist of data collection cycle beginning on October 1, 2011 and continuing through December 31, 2011. This data shall be reported to CMS by no later than January 31, 2012. There shall be a mandatory hospice quality reporting cycle which will consist of data collected from October 1, 2012 through December 31, 2012. This data shall be reported to CMS by no later than April 1, 2013. Thereafter, it is proposed that all subsequent hospice quality reporting cycles will be based on the calendar-year basis(that is, January 1, 2013 through December 31, 2013 for determination of the Hospice market basket increase factor for each Hospice in FY 2015, etc.). We are requesting an initial approval of a data collection instrument entitled "Quality Data Submission Form" that hospice providers will use to submit quality measures data to CMS during the proposed voluntary reporting period of 10/01/2011 through 12/31/2011. This form shall be used by hospices to report quality data pertaining to one structural measure, which is entitled: Participation in a Quality Assessment and Performance Improvement (QAPI) Program that Includes at Least Three Quality Indicators Related to Patient Care.

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Authorizing Statute(s): PL: Pub.L. 111 - 148 3004 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 148 3004 Name of Law: Patient Protection and Affordable Care Act

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AQ31	Final or interim final rulemaking	76 FR 47302	09/04/2011

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 54776	09/02/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 73649	11/29/2011
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Hospice Voluntary Quality Data Reporting Form	CMS-10390	User Guide for Hospice Quality Reporting Data Entry Site

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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	1,766	0	1,766	0	0	0
Annual Time Burden (Hours)	442	0	442	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 collection.

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Annual Cost to Federal Government: $123,300

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]? No

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: 12/30/2011

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