SUPPORTING STATEMENT
HOSPICE SURVEY AND DEFICIENCIES REPORT FORM
AND SUPPORTING REGULATIONS CMS-643, OMB Control number: 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 published on February 22, 2019 (84 FR 5691). There was one public comment and it has been addressed.
The 30-day Federal Register notice published on July 31, 2019 (84 FR 37303).
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 Quality Certification and Oversight Report as part of CASPER CMS reporting system, divided by 3 to get an average then multiplied by 1 (estimated hours to complete the form).
(4,801/ 3) x 1 = 1,600 hours per year
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 (4,281 in 2014, 4,625 in 2016, and 4801 in 2018). The burden hours have increased from 1,325 to 1,600.
16. Publication and Tabulation Dates
There are no publication and tabulation dates with this collection.
17. OMB Expiration Date
CMS will display the expiration date on the collection instrument.
| File Type | application/msword |
| Author | Greenwald, Elyse |
| Last Modified By | SYSTEM |
| File Modified | 2019-08-05 |
| File Created | 2019-08-05 |