Supporting Statement A
For the Comprehensive Outpatient Rehabilitation Facility (CORF)
Certification and Survey Forms (CMS-359 & CMS-360)
Background
This information collection is for the reinstatement of forms CMS-359 and CMS-360. The purpose of these forms is described below
CMS-359 CORF Eligibility Form
This form is an application for health care providers that seek to participate in the Medicare program as a Comprehensive Outpatient Rehabilitation Facility (CORF). This form initiates the process for facilities to become certified as a CORF and it provides the CMS Location and State Survey Agency (SA) 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 SAs 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
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.
The COPs are the minimum health and safety requirements that each CORF must meet in order to successfully 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 SA’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.
Information Users
The request for certification and the survey form are used by CMS in making certification decisions about CORFs. When a provider initially expresses an interest in participating in the Medicare program as a CORF, they must first contact the applicable SA, which will then forward the Request for Certification (CMS-359) to the provider. The provider is required to complete and return the CMS-359 form to the SA, which is then forwarded to the designated CMS Location. The information on the completed CMS-359 form assists the CMS Location staff in determining if the provider meets basic eligibility requirements for the provision of CORF services. The CMS Location will then request that the SA perform a survey of that provider.
The basic identifying information from the CMS-359 form and individual compliance codes from the CMS-360 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 SA to assess for compliance with the COPs during initial Medicare certification and periodically thereafter for recertification.
Improved Information Technology
The CMS-360 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 SAs and easy automation of basic findings.
Duplication and Similar Information
The CMS-359 and CMS-360 are survey and certification forms that 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 CMS-359 and CMS-360 forms address specific regulatory requirements of CORFs for participating in the Medicare program. SAs conduct these reviews with Federal funds under contract with CMS. This form is a basic deliverable under the contracts and is the only one of its kind collected by CMS for CORFs.
Small Business
The majority of CORFs are small businesses. These information collection requirements do not have a significant impact on small businesses. This information collection requirement is necessary in order for a provider to participate in the Medicare program as a CORF whether they are a small or large business.
Less frequent Collection
Providers are only required to complete the CMS-359 once upon initial application to Medicare. The CMS-360 forms are completed by the SA surveyors and the frequency of submission depends on the frequency of surveys which is specified by CMS policy. Currently CORFs are surveyed upon initial application to Medicare and once every six years thereafter.
Special Circumstances for Information Collection
There are no special circumstances.
Federal Register and Outside Consultants
The 60-day Federal Register notice published on June 22, 2020 (85 FR 34756). There were no public comments.
The 30-day Federal Register notice published on September 11, 2020 (85 FR 56227).
Payments or Gifts
There are no payments or gifts associated with this collection.
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.
Sensitive Questions
There are no questions of a sensitive nature.
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 30 minutes to complete this form, including the time required to read the instruction and gather the information necessary prior to filling out the form.
The burden for this request is based on a current total of 49 existing CORFs that would be surveyed every 6 years, which would equate to the SA surveying 8 existing CORFs per year. We also estimate that there would be 10 new CORFs per year completing the CMS-359.
Burden Related to Completion of the CMS-359 Form
The burden related to the CMS-359 form would only apply to the providers that are applying for participation in the Medicare program as a CORF. We have estimated that there are approximately 10 new CORFs per year.
Information Used in the Burden Calculations for Completion of form CMS-359:
The CMS-359 is likely to be completed by a manager at a CORF.
According to the U.S. Bureau of Labor Statistics would be a Medical Health Services Manager with an estimated hourly wage of $54.68. (See: https://www.bls.gov/oes/current/oes119111.htm).
This wage, adjusted to account for the employers overhead and fringe benefits, would be $109.36 per hour.
There are approximately 10 new CORFs established each year.
The time burden for completion of the CMS-359 form. This time burden includes the time required to review the instructions and gather the information required to complete the form.
Annual time burden per each CORF supplier for completion of form CMS-359
It would take 30 minutes per each new CORF to complete the CMS-359 form.
Annual time burden across all new CORF suppliers for completion of form CMS-359
The annual time burden across the10 new CORFs to compete the CMS-359 form would be 5 hours.
0.5 hours x 10
Cost burden per each new CORF supplier for completion of form CMS-359
The annual cost burden per each new CORF to complete the CMS-359 form would be $54.68.
$109.36 per hour x by 0.5 hours
Cost burden across all new CORF suppliers for completion of form CMS-359
The annual cost burden across the 10 new CORFs would be $546.80
$54.68 x 10 CORFs
Burden Related to Submission of the completed form CMS-359
Information Used in the Burden Calculations for Completion of form CMS-359
After completion of the CMS-359 form, the provider must submit this form by regular mail to the applicable SA.
We believe that after the Medical or Health Services Manager completes the CMS-359 form, they would give it to a Medical Secretary for copying and mailing to the SA.
According to the U.S. Bureau of Labor Statistics, the average hourly wage for a Medical Secretary is $17.83. (See: https://www.bls.gov/oes/current/oes436013.htm).
This wage adjusted for the employer’s overhead and fringe benefits would be $35.66.
To complete this task, the Medical Secretary would have to perform the following activities:
photocopy the completed CMS-359 form,
file this photocopy in the appropriate place,
type an envelope and cover letter,
place the cover letter and completed CMS-359 form into the prepared envelope,
seal the envelope,
affix the correct amount of postage to the envelope, and
put the envelope into the outgoing mail or mailbox
Time burden per each new CORF supplier for submission of form CMS-359
The total annual time burden per each new CORF would be approximately 30 minutes (0.5 hours).
Time burden across all new CORF suppliers for submission of form CMS-359
The total annual time burden across the 10 new CORFs would be 5 hours.
0.5 hours x 10 CORFs
Cost burden per each new CORF for submission of form CMS-359
The cost burden associated with the preparation of each completed CMS-359 form for mailing to the SA would $17.83
0.5 hour x $35.66 per hour
Annual cost burden across all new CORFs for the submission of the CMS-359
The annual time burden across all new CORFs per year would be $178.30.
$17.83 x 10 CORFs
Burden Related to Completion of the CMS-360 Survey Report
The CMS-360 survey report is completed by the SA surveyor upon a provider’s initial participation in the Medicare program and during each renewal survey, which are performed once every six years as required by the Medicare regulations.
Factors Used in the Burden Calculation for Completion of CMS-360 Survey Report.
We estimate that it would take the SA surveyor approximately 8 hours to complete the CMS-360 report, including the time it takes to perform the survey activities required to gather the information necessary to complete to form.
There are currently 49 existing CORFs. All of these CORFs are accredited by the SA.
As per the CMS regulations, CORFs are surveyed by the SA every 6 years.
Therefore, we estimate that the SAs would survey approximately 8 CORFs per year.
Time burden estimate for completion of each CMS-360 survey report
The time burden for the completion the survey of the CORF and the CMS-360 survey report is 8 hours.
Time burden across all CORFs to be surveyed for completion of CMS-360 survey report.
The annual time burden across all CORFs for completion of the survey and CMS-360 survey report is 64 hours
8 hours x 8 CORFs
Factors Use in the Burden Calculations for Completion of CMS-360 Survey Report.
The CMS-360 report is completed by a SA surveyor.
These surveyors are typically Registered Nurses (RNs).
According to the U.S. Bureau of Labor Statistics, the average hourly wage for an RN is $36.30.
This wage adjusted for the employer’s overhead and fringe benefits is $72.60 (See: https://www.bls.gov/oes/2018/may/oes291141.htm.)
Cost burden for completion of each CMS-360 survey report
The estimated cost burden per each CORF for the completion of the CMS-360 report would be $580.80
$72.60 x 8 hours per survey
Cost burden across all CORFs to be surveyed for completion of CMS-360 Survey Report
The annual cost burden across the 8 CORFs surveyed by the SA each year is $4,646.40.
$580.80 x 8 CORFs
or
64 hours X $72.60
Burden Related to Submission of the completed CMS-360 Survey Report
After completion of the CMS-360 report, the surveyor must submit this form to the designated CMS Location.
Factors Used in the Burden Calculation for Completion of CMS-360 Survey Report.
After completing the CMS-360 report, the surveyor would give it to a Medical Secretary for emailing to the appropriate CMS Location.
The Medical Secretary would have to perform the following activities:
Photocopy the completed CMS-360 form;
File this photocopy in the appropriate place;
Prepare a cover letter, scan; and,
Send both the cover letter and the CMS-360 report via email to the appropriate CMS Location.
According to the U.S. Bureau of Labor Statistics, the average hourly wage for a Medical Secretary is $17.83. (See: https://www.bls.gov/oes/current/oes436013.htm).
This wage adjusted for the employer’s overhead and fringe benefits would be $35.66.
Time burden per each CORF supplier for submission of form CMS-360
We estimate that it would take the Medical Secretary approximately 15 minutes to prepare the CMS-360 report for mailing to the CMS Location.
Time burden across all CORF suppliers to be surveyed for submission of form CMS-360
The annual time burden across the 8 surveys that are performed by the SA per year would be 2 hours.
0.25 hour x 8 surveys per year
iv. Cost burden per each CORF supplier for submission of form CMS-360
The estimated cost burden per each completed form CMS-360 would be $8.91.
0.25 hours x $35.66
Cost burden across all CORF suppliers surveyed for submission of completed form CMS-360s.
The cost burden across all CORF suppliers surveyed for submission of the completed CMS-360 forms would be $71.32.
2 hours X $35.66
Total Burden Related to Completion & Submission of forms CMS-359 and CMS-360
Time burden per each form CMS-359
Completion of each CMS-359 form 0.5 hours
Submission of each CMS-359 form 0.5 hours
TOTAL 1.0 hour
Time burden across all new CORFs for completion & submission of form CMS-359
Completion of all CMS-359 forms 5 hours
Submission of all CMS 359 forms 5 hours
TOTAL 10 hours
Time burden per each CMS-360 form
Completion of each CMS-360 form 8.00 hours
Submission of each CMS-360 form 0.25 hours
TOTAL 8.25 hours
Time burden across all CORFs surveyed per year for completion & submission of form CMS-360
Completion of all CMS-360 form by 8 CORFs per year 64 hours
Submission of all CMS 360 forms 2 hours
TOTAL 66 hours
Cost burden for completion of each form CMS-359
Completion of each CMS-359 form $54.68
Submission of each CMS-359 form $17.83
TOTAL $72.51
Cost burden across all new CORFs for completion of form CMS-359
Completion of CMS-359 forms by 10 new CORFs $546.80
Preparation & submission of all completed CMS-359 forms $178.30
TOTAL $725.10
Cost burden for completion of each form CMS-360
Completion of each CMS-360 report $580.80
Preparation for submission of each 360 report $ 8.91
TOTAL $589.71
Cost burden for completion of form CMS 360 across all CORF’s surveyed per year
Completion of CMS-360 survey report by 8 CORFs/year $4,646.40
Preparation & submission of all CMS-360 reports $ 71.32
TOTAL $4,717.72
Capital Costs
There is no capital costs associated with this collection.
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).
Changes in Burden/Program Changes
In this PRA package we have recalculated the burden based on the existing number of new CORFs per year and the estimated number of CORFs that are surveyed per year. This has result in an increase in the cost burden of $2,057.14 and a decrease in burden hours of 46.5 hours.
These changes in the burden is attributable to several factors. First, we determined that there are currently 49 CORFs. The CORFs are surveyed every 6 years, so on average, 8 CORFs are surveyed each year. Also, according to our statistics, there are 10 new CORFs each year.
In the previous PRA package submission, it was stated that there were 40 annual responses for the form CMS-360. We believe that this estimate was too high because it would be the total number of CORFs existing at the time.
The form CMS-360 is completed by a surveyor during the survey of a CORF that occurs only every 6 years. As these surveys occurs only every 6 years, the accrediting organizations (AOs) or the state survey agencies (SAs) cannot possibly survey all of the existing CORFs in the same year. Due to the limitation on their resources, they would divide the CORFs up and only do a certain number of surveys per year. We believe and assume for the sake of the burden calculations that the AO or SA would survey 1/6th of all CORFs each year. Therefore, if there are currently 49 CORFs, only 8 CORFs would be surveyed per year (49 divided by 6 = 8.18).
Second, we increased the estimated time burden for the CMS-359 form from 15 minutes to 30 minutes because we did not believe that 15 minutes is an adequate amount of time to read the instructions and gather the information required to complete the form. We also added a 30 minute time burden for the time required for an administrative staff person to copy and mail this form to the SA. This burden was not accounted for in the prior burden estimate.
We also increased the estimated time required to complete the CMS-360 report from 3 hours to 8 hours, because we believe that this burden was significantly underestimated in the prior burden estimate. The CMS-360 report is a survey report, and is based on the survey activities performed by the surveyor. The survey for a CORF takes approximately one day to complete. It would not be possible for a surveyor to complete the CMS-360 report in only 3 hours, if it takes the surveyor 8 hours to complete the survey. We also added a 15 minute time burden for an administrative staff person to copy, or scan and email the completed CMS-360 survey report to the appropriate CMS Location. This burden was not accounted for in the prior burden estimate, yet is a burden that is associated with the completion of the CMS-360 survey report.
Publication and Tabulation Dates
There are no publication and tabulation dates associated with this collection.
OMB Expiration Date
The expiration date is displayed on the collection instrument.
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 | 2021-01-13 |