Hospice Survey and Deficiencies Report Form (CMS-643)

Forms and Documents

Document	Type	Status	Availability
Form CMS-643 Hospice Survey and Deficiencies Report Form (CMS-643)	Form	Modified	Repair queued
CMS-643 - Supporting Statement part A [rev 07-18-2012].doc	Supporting Statement A	Uploaded 2012-07-18	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
8022	Hospice Survey and Deficiencies Report Form (CMS-643)	Form	Modified

ICR Details

OMB Control No: 0938-0379	ICR Reference No: 201207-0938-003
Status: Historical Active	Previous ICR Reference No: 200906-0938-005
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Hospice Survey and Deficiencies Report Form (CMS-643)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/18/2012
	Date Received in OIRA: 07/18/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2015	36 Months From Approved	09/30/2012
Responses	1,217	0	1,130
Time Burden (Hours)	1,217	0	1,130
Cost Burden (Dollars)	0	0	0

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Abstract: In order to participate in the Medicare program, a hospice must meet certain Federal health and safety conditions of participation. This form will be used by State surveyors to record data about a hospice's compliance with these conditions of participation in order to initiate the certification or recertification process.

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Authorizing Statute(s): US Code: 42 USC 488.26 Name of Law: Determining Compliance
   US Code: 42 USC 442.30 Name of Law: Agreement as evidence of Certification
  

Citations for New Statutory Requirements: None

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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:
	77 FR 27777	05/11/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 42316	07/18/2012
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Hospice Survey and Deficiencies Report Form (CMS-643)	CMS-643	Hospice Survey and Deficiencies Report

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ICR Summary 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	1,217	1,130	0	0	87	0
Annual Time Burden (Hours)	1,217	1,130	0	0	87	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:

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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]? No

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: 07/18/2012

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