Supporting Statement for the Comprehensive Outpatient Rehabilitation Facility (CORF)
Certification and Survey Forms
Background
The information collections that are included with this request are:
CMS-359 CORF Eligibility Form
This form is utilized as the application for health care providers seeking to participate in the Medicare program as Comprehensive Outpatient Rehabilitation Facility (CORF). This form initiates the process for facilities to become certified as a CORF and it provides the CMS Regional Office State Survey Agency staff identifying information regarding the applicant that is stored in the Automated Survey Processing Environment (ASPEN) system.
CMS-360 CORF Survey Report Form
The Form CMS-360 is a survey tool used by the State Survey Agencies to record information in order to determine a provider’s compliance with the CORF Conditions of Participation (COPs) and to report this information to the Federal government. The form includes basic information on the COP requirements, check boxes to indicate the level of compliance, and a section for recording notes. CMS has the responsibility and authority for certification decisions which are based on provider compliance with the COPs and this form supports this process.
A. Justification
1. Need and Legal Basis
This information collection is authorized by Section 933 of the Omnibus Budget Reconciliation Act of 1980 which allows CORFs to be recognized as Medicare providers of services, and amends sections of the Social Security Act, including Section 1861(cc)(1) and 1863. These sections recognize CORFs as Medicare providers and allow the Secretary to establish Conditions of Participation (COPs) and to use State resources under contract in determining compliance with these requirements. The COPs are specified at 42 CFR 485.54 through §485.66.
The certification form (CMS-359) is used as the application to participate in the Medicare program. The form establishes necessary provider identification data for entry into ASPEN and screens for the required CORF services that are necessary for the provider to participate in the Medicare program as a CORF.
The COPs are the minimum health and safety requirements that each CORF to participate in Medicare. To determine compliance with COPs, the Secretary has authorized States, through contracts, to conduct surveys of health care providers. For Medicare purposes, certification decisions are based on the State survey agency’s recording of a provider or supplier’s compliance or noncompliance with the COPs. The CORF Survey Report Form (CMS-360) contains a narrative listing of the COPs for use by State Agency surveyors. The information needed to determine compliance is only available to CMS through use of information abstracted from this survey tool. The surveyor reports on each condition by checking a box alongside the condition or standard indicating whether or not the State found that the provider met the requirement. Space is also provided for appropriate explanatory statements regarding negative findings.
2. Information Users
The request for certification and the survey form are used by CMS in making certification decisions. When a provider initially expresses an interest in participating in the Medicare program as a CORF, contact is made with the State Survey Agency (SA) which forwards the Request for Certification (CMS-359) to the provider. The provider completes and returns the form to the SA which is then forwarded to the CMS Regional Office. The information on the completed form assists staff in determining if the provider meets basic eligibility requirements for the provision of services. The basic identifying information from this form and individual compliance codes from the survey form are entered into ASPEN and serve as the information base for the creation of a record for future Federal certification for oversight activity. The Form CMS-360 is utilized by the State Survey Agency to assess for compliance with the COPs during initial Medicare certification and periodically thereafter for recertification.
3. Improved Information Technology
The survey form serves primarily as a coding worksheet for inputting compliance information into the ASPEN system. The standardized format and simple check box method provides for consistent reporting by State survey agencies and easy automation of basic findings.
4. Duplication and Similar Information
The survey and certification forms do not duplicate any information collection. The requirements are unique and are specified in a way so they do not duplicate existing facility information.
The forms address specific regulatory requirements of CORFs for participating in the Medicare program. State survey agencies conduct these reviews with Federal funds under contract with CMS. This form is a basic deliverable under the contracts and in the only one of its kind collected by CMS for CORFs.
5. Small Business
The requirements do not have a significant impact on small businesses.
6. Less frequent Collection
Providers are only required to complete the CMS-359 once upon initial application to Medicare. State submission of the CMS-360 depends on the frequency of surveys which is specified in CMS policy. Currently CORFs are surveyed upon initial application to Medicare and once every six years thereafter.
7. Special Circumstances for Information Collection
These requirements comply with all general information collection guidelines in 5 CFR 1320.6.
8. Federal Register and Outside Consultants
The 60-day Federal Register notice published on January 4, 2016. There were no comments received.
9. Payments or Gifts
There are no payments or gifts associated with this collection.
10. Confidentiality
Information collected will be utilized by CMS and its agents for certification and enforcement actions. This information is publicly disclosable. Any identifiable data subject to the Privacy Act is deleted prior to disclosure.
11. Sensitive Questions
There are no questions of a sensitive nature.
12. Estimate of Burden (Reporting)
Certification Form - CMS-359: Based on past usage of this form and the general nature of the questions, we estimate that it takes approximately 15 minutes to complete this form.
Survey Form - CMS-360: The survey report form is completed by the State agency surveyor on average once every six years per CORF. The estimated time to complete the form by State Agency Surveyors is 3 hours.
The burden for this request is based on an estimated 10 new CORFs per year completing the CMS-359 and 40 CORFs surveyed on an annual basis. The CMS-359 is likely to be completed by a manager at a CORF with an estimated hourly wage of $52.99. This wage is based on the 2014 Bureau of Labor Statistics National Occupational Employment and Wage Estimates. The burden to complete the form is $13.25 (based on 15 minutes at $52.99/hour). The burden to complete 10 forms annually is $132.48. The CMS-360 is completed by State Agency Surveyors with an estimated hourly wage of $27.11. The burden per survey is $81.33 (based on 3 hours at $27.11/hour). The burden for 40 surveys annually is $3253.20
Total estimated yearly burden:
Reporting
CMS-359 3 hours (10x15 min)
CMS-360 120 hours (3 hrs x 40)
TOTAL 123 hours
The total annual burden associated with both forms is 123 hours and $3385.68.
13. Capital Costs
There is no capital costs associated with this collection.
14. Federal Cost Estimates
Costs to produce these forms is estimated to be $30 for printing ($0.05 per page x 15 pages per CMS-360 x 40).
15. Changes in Burden/Program Changes
Burden changes are related to changes in the number of forms completed annually and an update to wage data. The number of CORFs completing the CMS-359 was adjusted downward since only new CORFs complete this form. The number of annual surveys was adjusted downward due to few CORFs enrolled in Medicare. Wage data was adjusted upward to reflect current values from the Bureau of Labor Statistics.
16. Publication and Tabulation Dates
There are no publication and tabulation dates associated with this collection.
17. OMB Expiration Date
CMS does not object to displaying the OMB expiration date.
B. Collections of Information Employing Statistical Methods.
There are no statistical methods associated with this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Supporting Statement of the Comprehensive Outpatient Rehabilitation Facility (CORF) |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-24 |