Hospice Experience of Care Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10475 Hospice Experience Survey - Inpatient Version	Form and Instruction	New	Available
Form CMS-10475 Hospice Experience Survey - Nursing Home Version	Form and Instruction	New	Available
Form CMS-10475 Hospice Experience Survey - Home Version	Form and Instruction	New	Available
Hospice Survey OMB_Statement_B 2013_4.doc	Supporting Statement B	Uploaded 2013-06-11	Available
Hospice Survey OMB_Statement_A 2013_June2013_update [rev 6-10-2103 by OSORA PRA].doc	Supporting Statement A	Uploaded 2013-06-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
207312	Hospice Experience of Care Survey	Other-HOSPICE SURVEY COVER LETTER	New
207312	Hospice Experience of Care Survey	Form and Instruction	New	Hospice Experience Survey - Inpatient Version
207312	Hospice Experience of Care Survey	Form and Instruction	New	Hospice Experience Survey - Nursing Home Version
207312	Hospice Experience of Care Survey	Form and Instruction	New	Hospice Experience Survey - Home Version

ICR Details

OMB Control No: 0938-1208	ICR Reference No: 201306-0938-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No: 19765
Title: Hospice Experience of Care Survey
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 without change	Conclusion Date: 08/23/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/11/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2016	36 Months From Approved
Responses	730	0	0
Time Burden (Hours)	185	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Hospice currently serves approximately 42% of dying patients in the United States. Medicare covers most hospice patients under a benefit created in 1983 to provide palliative care at the end of life. Despite its 30-year history as a Medicare benefit, to date no single survey has been systematically administered by all hospices across the country to assess experiences of hospice care. The Hospice Experience of Care Survey will support the Affordable Care Act and enhance Medicare's capacity to evaluate hospice care and assess the value of hospice services to patients and their families. This submission is in support of a field test of the survey. The field test is intended to examine how well items in the instrument perform under real-world survey administration conditions and how appropriate they are for making objective comparisons between hospices across the U.S. In addition, CMS plans to submit the instrument for certification as a Consumer Assessment of Healthcare Providers and Systems (CAHPS?) survey, which requires a field test as part of the certification process.

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Authorizing Statute(s): Statute at Large: 42 Stat. 1814
  

Citations for New Statutory Requirements: Statute at Large: 42 Stat. 1814

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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:
	78 FR 20323	04/04/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 34390	06/07/2013
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 Experience of Care Survey	CMS-10475, CMS-10475, CMS-10475	Hospice Experience Survey - Home Version ,   Hospice Experience Survey - Nursing Home Version ,   Hospice Experience Survey - Inpatient Version

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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	730	0	730	0	0	0
Annual Time Burden (Hours)	185	0	185	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: $1,003,129

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 06/11/2013

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