Form CMS-643 Hospice Survey and Deficiencies Report

Form Approved
OMB No. 0938-0379

DePArtMeNt OF HeAltH AND HuMAN ServiCeS
CeNterS FOr MeDiCAre & MeDiCAiD ServiCeS

Hospice survey and deficiencies report
CertiFiCAtiON NuMBer

1.

2.

3.

5.

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NAMe OF FACility

Survey DAte

Was this hospice surveyed for compliance with 42 CFR 418.110?

L50

If this hospice provides inpatient care directly, is the inpatient care provided on the premises?

L51

Has a waiver of core nursing services been granted?

L53

o Yes
o Yes
o Yes

o No

o No

L52 4. If “Yes” indicate date

o No

Indicate type of setting(s) in which the hospice provides routine home care.

L54

6.

Number of hospice patients residing in a SNF, NF or other residential facility who receive routine home care
from the hospice.

L55

7.

Number of hospice patients admitted during recent 12 month period.

L56

8.

Number of records reviewed during survey.

L57

9.

Number of home visits conducted to patients in a private residence.

L58

o Private residence o SNF

o NF

o Other (specify)

10. Number of home visits conducted to patients in residential facilities.

L59

11. Does this hospice operate under the same certification
number at more than one location?

L60 12. If “Yes” enter
number of locations.

L61

13. Does this hospice operate as part of another entity that participates
in the Medicare program?

L62 14. If “Yes” enter the Medicare
certification number of the entity.

L63

o Yes
o Yes

SurveyOr SigNAture

o No
o No

title

DAte

According to the Paperwork reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0379 (Expiration date: XX/XX/XXXX). The time required to complete this information collection is estimated to average 1 hour per
response,including the time to review instructions,search existing data resources,gather the data needed, and complete and review the information collection. ****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you
have any comments concerning the accuracy of the time estimate(s), or suggestions for improving this form, or where to submit your documents contact: [email protected].
CMS-643 (XX/XX/XXXX)

Hospice survey and deficiencies report

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DeFiCieNCieS

DAtA tAg NuMBer

COP/StND. NO.

COMMeNtS

I certify that I have reviewed each hospice Condition of Participation and related standards and except as indicated on this
form the facility was found to be in compliance with the standards and/or the Conditions of Participation.
SurveyOr SigNAture

title

DAte

SurveyOr SigNAture

title

DAte

CMS-643 (XX/XX/XXX)