National Implementation of the Hospice Experience of Care Survey (CAHPs Hospice Survey)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10537 National Implementation	Form and Instruction	New	Available
HospiceDevelop_For_OMB_Appdx_A_10-24-14.docx	Supplementary Document	Uploaded 2014-11-14	Available
Sample Cover Letter ENG_For_OMB_Appdx_B.docx	Supplementary Document	Uploaded 2014-11-14	Available
CAHPS_Hospice_Survey_Technical_Corrections_and_Clarifications_10_29_14.pdf	Supplementary Document	Uploaded 2014-11-14	Available
CAHPS_Hospice_Survey_QAG_V1 0_August2014.pdf	Supplementary Document	Uploaded 2014-11-14	Repair queued
CMS-10537.FINAL - Supporting Statment Part B (10-29-14).docx	Supporting Statement B	Uploaded 2014-11-14	Available
CMS-10537.FINAL - Supporting Statment Part A (10-29-14).docx	Supporting Statement A	Uploaded 2014-11-14	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212900	Mode Experiment		New
212899	National Implementation	Form and Instruction	New

ICR Details

OMB Control No: 0938-1257	ICR Reference No: 201408-0938-015
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: National Implementation of the Hospice Experience of Care Survey (CAHPs Hospice 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 with change	Conclusion Date: 11/17/2014
	Date Received in OIRA: 08/29/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2017	36 Months From Approved
Responses	561,026	0	0
Time Burden (Hours)	98,179	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. This submission requests approval for national implementation of the CAHPS® Hospice Survey and as well as approval for a mode experiment to test for mode effects, if any, when the survey is implemented. The CAHPS® Hospice Survey will sample caregivers of patients who died while under hospice care. Survey administration will start between 2 and 3 months after the death of the patient. The sample will be provided by the hospice program. This information will ultimately be used to improve hospice care throughout the country. The mod experiment is intended to determine what mode effects, if any, are found while implementing the survey. Three modes will be tested: mail-only, telephone-only, and mixed-mode (mail with telephone follow up). The mode experiment will occur simultaneously with the first year of National Implementation of the survey, which is also covered as part of this submission.

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

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0938-AS10	Final or interim final rulemaking	79 FR 49854	08/22/2014

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 26537	05/08/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 51569	08/29/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Mode Experiment
National Implementation	CMS-10537	Hospice Experience of Care Survey

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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	561,026	0	0	561,026	0	0
Annual Time Burden (Hours)	98,179	0	0	98,179	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: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection request.

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Annual Cost to Federal Government: $2,184,375

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: 08/29/2014

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