Hospice Quality Reporting Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10390 Hospice Data Submission Form	Form and Instruction	New	Available
Form CMS-10390 User Guide for Hospice Quality Reporting Data Entry Site	Form and Instruction	Removed	Available
Burden Calculation for Mandatory Submission 07 18 12.docx	Supplementary Document	Uploaded 2012-08-07	Available
Summary of Public Comments Responses RD 8-7.docx	Supplementary Document	Uploaded 2012-08-07	Available
Hospice_QRP_Data_Entry_Tech_Guide_v1.3.pdf	Supplementary Document	Uploaded 2012-08-07	Available
Y1_User_Guide_2012 - REVISED 0209 dates 8-2-12.pdf	Supplementary Document	Uploaded 2012-08-07	Available
CMS-10390 Supporting Statement Part A Final 9-28-12.docx	Supporting Statement A	Uploaded 2012-09-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203679	Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	Form and Instruction	New	Hospice Data Submission Form
200291	Hospice Voluntary Quality Data Reporting Form	Form and Instruction	Removed	User Guide for Hospice Quality Reporting Data Entry Site

ICR Details

OMB Control No: 0938-1153	ICR Reference No: 201208-0938-005
Status: Historical Active	Previous ICR Reference No: 201112-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Hospice Quality Reporting Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/28/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/13/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2015	36 Months From Approved	01/31/2014
Responses	3,632	0	1,766
Time Burden (Hours)	657,392	0	442
Cost Burden (Dollars)	0	0	0

---

Abstract: Section 1814(i)(5) of the Act added by section 3004 of the 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 Social Security Act requires that the Secretary, beginning with FY 2014, reduce the market basket update by 2 percentage points for any hospice that does not submit quality data submission for a fiscal year. We are requesting approval, under the Paperwork Reduction Act of 1995, of a revised internet based, data submission form that hospice providers will use to submit quality measures data to CMS for the Hospice Quality Reporting Program (Hospice QRP). Use of this revised internet data submission form shall begin during the second Hospice QRP reporting period which shall take place from 10/01/2012 through 12/31/2012. Thereafter, the revised hospice data submission form shall be used for all subsequent data collection timeframes, which shall commence on January 1st and end on December 31st each year. To meet the quality reporting requirements which were set forth in the Hospice Wage Index Final Rule (76 F.R. Vol. 76, No. 150, August 4, 2011), hospices are to report quality data pertaining to two quality measures: (1) a structural measure titled "Participation in a Quality Assessment and Performance Improvement (QAPI) Program that Includes at Least Three Quality Indicators Related to Patient Care" and; (2) the NQF endorsed #0209 pain measure which is further described as: the percentage of patients who report being uncomfortable because of pain at the initial assessment (after admission to hospice services) who report pain was brought to a comfortable level within 48 hours.

---

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

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 32977	06/04/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 48158	08/13/2012
Did the Agency receive public comments on this ICR? No

---

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
Submission of Hospice Quality Reporting Program Quality Data using a web based data entry form	CMS-10390	Hospice Data Submission Form

---

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	3,632	1,766	0	1,866	0	0
Annual Time Burden (Hours)	657,392	442	0	656,950	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The reporting period which took place between 10/01/2011 and 12/31/2011 was completed on 01/31/2012. The reporting period which affects the APU for FY 2014 is 10/01/2012 to 12/31/2012. There will be a change in burden caused by the addition of a second quality measure to the Hospice Quality Reporting Program, upon which providers will have to collect & submit data. The addition of this measure was already finalized in the FY 2012 Hospice Wage Index Final Rule. The data collection submission format must be revised to allow for the collection of the additional data.

---

Annual Cost to Federal Government: $250,000

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

---

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: 08/13/2012

---