CAHPS Home Health Care Survey (CMS-10275)

Forms and Documents

Document Name	Status
Form CMS-10275 Participation Exemption Request (PER) Form Form	Modified
Form CMS-10275 HHCAHPS Survey Form	Modified
CMS-10275 - Supporting Statement A - aek edits ddw edits 1-3-18 [rev 01-25-2018 by OSORA PRA] CLEAN.doc Supporting Statement A	2018-01-26
HomeHealthCAHPS_OMB_PartB 5-18-17.doc Supporting Statement B	2017-05-31
HHCAHPS comment from 60-day 2-17-17 (002)_lg edits accepted.docx Supplementary Document	2017-05-31

IC Document Collections

IC ID	Document Title	Status
210204	Participation Exemption Request (PER) Form Form	Modified
195477	Patient Files Instruction	Modified
188901	HHCAHPS Survey Form	Modified

ICR Details

OMB Control No: 0938-1066	ICR Reference No: 201705-0938-013
Status: Historical Active	Previous ICR Reference No: 201401-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No: CM-CPC
Title: CAHPS Home Health Care Survey (CMS-10275)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 01/29/2018
	Date Received in OIRA: 05/31/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2021	36 Months From Approved	01/31/2018
Responses	1,296,895	0	2,978,890
Time Burden (Hours)	474,062	0	752,800
Cost Burden (Dollars)	0	0	0

---

Abstract: As part of the DHHS Transparency Initiative on Quality Reporting, CMS plans to implement a process to measure and publicly report patients' experiences with home health care they receive from Medicare-certified home health agencies through the data collection effort described in this request: the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Home Health Care Survey. The Home Health Care CAHPS Survey, which was developed and tested by the Agency for Healthcare Research and Quality (AHRQ) and is part of the family of CAHPS surveys, is a standardized survey for home health patients to assess their home health care providers and the quality of the home health care they receive. Prior to the Home Health Care CAHPS survey, there was no national standard for collecting data about home health care patients' experience with their home health care. This is a revision to the original PRA package which covered the voluntary implementation of the survey among Medicare-certified agencies and a randomized mode experiment to test the impact of different modes of data collection on survey responses. This is a revised PRA package because it now includes the burden to the home health agencies (HHAs) to contract with an approved HHCAHPS survey vendor to administer the HHCAHPS survey on their behalf.

---

Authorizing Statute(s): US Code: 42 USC 301 Name of Law: US Public Health Service 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:
	81 FR 89104	12/09/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 11222	02/21/2017
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
HHCAHPS Survey	CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275, CMS-10275	Home Health Care CAHPS Survey (English) ,   Home Health Care CAHPS Survey (Russian) ,   Home Health Care CAHPS Survey (Spanish) ,   Home Health Care CAHPS Survey (Telephone) ,   Home Health Care CAHPS Survey (Telephone/Proxy) ,   Consent to Share Question #35 (English) ,   Consent to Share Question #35 (Chinese) ,   Consent to Share Question #35 (Russian) ,   Consent to Share Question #35 (Traditional Chinese) ,   Consent to Share Question #35 (Vietnamese)
Patient Files
Participation Exemption Request (PER) Form	CMS-10275	Participation Exemption Request (PER) Form

---

ICR Summary 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	1,296,895	2,978,890	0	0	-1,681,995	0
Annual Time Burden (Hours)	474,062	752,800	0	0	-278,738	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: We are not proposing any program changes. The number of participating HHAs varies from year to year which carries over to the number of completed surveys. In this iteration we are adjusting the number of HHAs based on April 2015 – March 2016 data. We are also changing our estimated time per response. We increase the time based on what home health agencies have reported to CMS as the amount of time that it takes them to put together the monthly file. Typically, it is done electronically and by the agencies’ administrative vendors that run the patient lists for many purposes in the daily operational needs of their agencies.

---

Annual Cost to Federal Government: $1,679,832

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

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: 05/31/2017

---