CMS-643 - Supporting Statement part A SCG 061515_Passback 2

SUPPORTING STATEMENT

HOSPICE SURVEY AND DEFICIENCIES REPORT FORM

AND SUPPORTING REGULATIONS CMS-643, OMB 0938-0379

BACKGROUND

A hospice is a heath care entity that provides palliative care (relief of pain and uncomfortable symptoms), as opposed to curative care, to terminally ill individuals. In addition to meeting the patient’s medical needs, hospice care addresses the physical, psychosocial, and spiritual needs of the patient, as well as psychosocial needs of the patient’s family/caregiver related to the terminal illness. The emphasis of the hospice program is on keeping the hospice patient at home with family and friends as long as possible. All hospices must meet specific Conditions of Participation (CoPs) and be separately certified and approved as such for Medicare participation.

When an entity expresses an interest in participating in the Medicare program as a hospice, it contacts the Medicare State survey agency, which forwards the Hospice Request for Certification in the Medicare Program form (CMS-417)(OMB# 0938-0313), to the hospice. The hospice completes the form and returns it to the State Agency. If the hospice meets the preliminary requirements, a survey is conducted to determine if the hospice complies with the hospice conditions.

The Hospice Survey and Deficiencies Report form is primarily a coding worksheet designed to facilitate data collection and entry into the Online Survey, Certification, and Reporting (OSCAR) System in the State and at the Central and Regional Offices of the Centers for Medicare & Medicaid Services (CMS). State Agency surveyors who do not have access to the computerized data entry system while they are onsite at the hospice use this form to record data about a hospice’s noncompliance with the Federal conditions that they have identified during the survey. Only deficiencies are cited on this survey form. Surveyors also collect 14 data elements related to patient health and safety. They then sign the form, certifying their review of the Federal requirements, and report this information to the Federal Government.

A. JUSTIFICATION

1. Need and Legal Basis

Section 1864 of the Social Security Act (the Act) requires the Secretary to enter into agreements with States to survey providers and certify compliance or

noncompliance with the Medicare conditions of participation. Section 1902(a)(33)(B) of the Act requires the State Medicaid Agency to contract with the State Survey Agency used by Medicare to determine whether providers meet the requirements for participation in the Medicaid program.

42 CFR 488.26(c) and 42 CFR 442.30(a)(4) require that State Survey Agencies must use the survey forms, methods and procedures prescribed by CMS.

2. Information Uses

CMS uses the information collected as the basis for certification decisions for hospices that wish to obtain or retain participation in the Medicare and Medicaid programs. The information is used by CMS regional offices, which have the delegated authority to certify Medicare facilities for participation, and by State Medicaid agencies, which have comparable authority under Medicaid. The information on the Hospice Survey and Deficiencies Report Form is coded for entry into the OSCAR system. These data are analyzed by the CMS Regional Offices and by the CMS Central Office components for program evaluation and monitoring purposes. This information is also available to the public upon request.

3. Improved Information Technology

The coded information on the Hospice Survey and Deficiencies Report Form provides essential data on a hospice’s performance. This improves the OSCAR database as a means of monitoring and evaluating the survey and certification activities.

4. Duplication of Similar Information

This form is to be used in all hospice surveys and does not duplicate any other collection instrument. This form is the only standardized mechanism available for the surveyor to record data on hospice compliance with the Federal regulatory requirements.

5. Small Business

These requirements do not affect small businesses. The form is only used by State Survey Agencies to conduct surveys of hospice agencies.

6. Less Frequent Collection

State submission of the survey report form depends on the frequency of provider surveys. These submissions, in turn, depend on the frequency of surveys specified in regulations and the availability of survey funds. It is a basic contract requirement that State surveyors transmit their compliance findings for each survey they conduct.

7. Special Circumstances for Information Collection

There are no special circumstances for this information collection. These requirements comply with all general information collection guidelines in 5 CFR 1320.6.

8. Federal Register and Outside Consultations

The 60-day Federal Register notice soliciting comments on this information collection was published June 19, 2015. No comments were received.

We did not seek further outside consultation for this collection.

9. Payment or Gifts

There are no payments or gifts associated with this collection.

10. Confidentiality

We do not pledge confidentiality. Hospice surveys may be made public and are subject for Freedom of Information Act requests.

11. Sensitive Questions

There are no questions of a sensitive nature associated with this form.

12. Estimate of Burden

The Hospice Survey and Deficiencies Report Form is completed by the State Agency or Federal surveyor based on the results of his/her investigation of each provider’s compliance with each individual hospice condition. The surveyor then records any deficiency (ies) found during the survey on this form, listing them by data tag number and a brief statement supporting the conclusion of noncompliance. Surveyors also collect 14 data elements related to patient health and safety. They then sign the form, certifying their review of the Federal Requirements.

Since the survey form is basically completed by recording data tag numbers supported by a few explanatory statements and by responses to questions asked of the hospice representative, we estimate that surveyors will be able to complete the survey form in approximately one hour. Due to the enactment of the “Improving Medicare Post-Acute Care Transformation Act of 2014 (also known as the IMPACT Act of 2014), hospice survey interval will be not less frequently than every 36 months, through 2025. The estimated burden below, was derived using the total number of hospices in the CMS 2014 financial report to Congress, divided by 3 to get an average then multiplied by 1 (estimated hours to complete the form).

(3,976¹ providers / 3) x 1 = 1,325 hours per year; or,

1 hour per provider x 1,325 providers.

13. Capital Costs

There are no capital costs.

14. Cost to Federal Government

There are no direct costs to the Government, except for the cost of printing the forms.

15. Program/Burden Changes

While there are no program changes, the burden has increased as a result of the increased number of hospice providers (3,377 in 2009, 3,644 in 2012, and 3,976 in 2014). Additionally, the number of hours per response in the form's PRA disclosure statement has been corrected. That number is slightly higher due to the increased frequency of survey as a result of the implementation of the IMPACT Act of 2014.

16. Publication and Tabulation Dates

There are no publication and tabulation dates with this collection.

17. OMB Expiration Date

CMS does not seek an exemption from displaying the OMB expiration date.

1 Taken from the CMS 2014 Fiscal Report (Original Publication Date: November 10, 2014Publication Number: 952014 Inventory Control Number: 909159), found online at, http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CFOReport/Downloads/CMS-Financial-Report-for-Fiscal-Year-2014.pdf.

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