Form CMS-643 Hospice Survey and Deficiencies Report

Form Approved

OMB No. 0938-0379

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Hospice Survey and Deficiencies Report
Page ____ of ____
Certification Number

1.

2.

3.

5.

Name of Facility

Survey Date

❏ Yes

❏ No

L50

❏ Yes

❏ No

L51

❏ Yes

❏ No

Was this hospice surveyed for compliance with 42 CFR 418.110?

If this hospice provides inpatient care directly, is the inpatient care provided on the premises?

Has a waiver of core nursing services been granted?

❏ Private residence ❏ SNF

❏ NF

L52 4. If “Yes” indicate date

L53

❏ Other (specify)

Indicate type of setting(s) in which the hospice provides routine home care.

L54

6.

Number of hospice patients residing in a SNF, NF or other residential facility who receive routine home care
from the hospice.

L55

7.

Number of hospice patients admitted during recent 12 month period.

L56

8.

Number of records reviewed during survey.

L57

9.

Number of home visits conducted to patients in a private residence.

L58

10. Number of home visits conducted to patients in residential facilities.

L59

11. Does this hospice operate under the same certification
number at more than one location?

L60 12. If “Yes” enter
number of locations.

L61

13. Does this hospice operate as part of another entity that participates
in the Medicare program?

L62 14. If “Yes” enter the Medicare provider
number of the entity.

L63

❏ Yes
❏ Yes

Surveyor Signature

❏ No
❏ No

Title

Date

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-0379. The time required to complete this information collection is estimated to average 1
hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports
Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
CMS-643 (06/08)

Hospice Survey and Deficiencies Report
Page ____ of ____
Deficiencies

Data Tag Number

CoP/Stnd. No.

Comments

I certify that I have reviewed each hospice Condition of Participation and related standards and except as indicated on this
form the facility was found to be in compliance with the standards and/or the Conditions of Participation.
Surveyor Signature

Title

Date

Surveyor Signature

Title

Date

CMS-643 (06/08)