Crosswalk

Form CMS-1572(a) – (e) Home Health Agency Survey and Deficiencies Change Description

Current Item	Current 1572 (a – e/6 pgs) (08/90)	Change Description
Form Title	Home Health Agency Survey and Deficiencies Report	The information on this form is collected during recertification surveys (every three years); there is no change to the frequency of data collection. The name of Form is now “Home Health Agency Survey Report”. Survey deficiency information formerly recorded on Forms 1572(c), (d) and (e) are now documented in the Automated Survey Processing Environment (ASPEN) computer application; therefore, the last 4 pages of this form that were once used to manually record deficiencies are obsolete. The information collected on this form is updated to reflect the changes in: CMS 3819-F, Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies; Current HHA business characteristics; Items that are tracked for certification tracking and ensuring up to date provider information; and Electronic processes used to document the survey findings.
1	Name of Facility:	No Change
2	Street Address:	Combined fields 2, 3, 4 and 5 s into one field at #3
3	City and/or County:
4	State:
5	Zip Code:
6	Telephone No.	Renumbered at #4
7	State/County Code:	Not used in QIES, eliminated
8	State/Region Code:	Not used in QIES, eliminated
9	Name of Administrator:	Renumbered at #5
10	Discipline of Administrator:	Renumbered at #6. Changed to “Qualification of administrator” to reflect the updated definition of administrator as per CMS 3819-F, Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies.
11	Provider No.:	Renumbered at #2
12	Type of Survey:	Renumbered at #13. All surveyor-collected data is now located at the end of the form. The current term “Resurvey” is clarified as “Recertification”
13	Eligibility:	This data collection is discontinued; all certified providers are Medicare eligible.
14	Has there been a change of ownership since last survey?	Renumbered at #8; No change in data collection.
15A	Is this home health agency also a Medicare certified hospice? If yes, give the hospice Medicare provider number: (G11)	Renumbered at #9; No change in data collection; clarified to read: “14. Is this home health agency co-located with a separately Medicare certified Hospice? If yes, provide Hospice provider number”
15B	Does this home health agency operate sub-units?	The revised form discontinues collection of sub-unit data in 15B and 15C;CMS 3819-F, Medicare and Medicaid Program: Conditions of Participation for Home Health Agencies effective January 2018, eliminated the category of home health agency sub-units.
15C	Is this home health agency a sub-unit?
15D	Does this home health agency operate one or more branches? If yes, how many: (G17) Indicate all official name and mailing address of each branch (include street, state and zip code):	Renumbered at #10. No change in data collection
16	Type of agency	Discontinued collection of this data; the types of agencies that are listed in the form do not reflect current HHA business characteristics nor do the characteristics have any impact on the survey and certification processes.
17	Type of Control	Renumbered at # 7, reduced the number of responses from 7 to 2 to reflect prevalent HHA business characteristics: Proprietary Government Operated
18	Services Offered:	Renumbered at #11, reduced the number of responses from 13 to 10. Eliminated the rarely reported categories of: Intern/Resident Nutritional Guidance Appliance and Equipment Service Vocational Guidance Other Updated with 2 new categories of “Infusion Services” and “Outpatient Therapy Services” to reflect current CMS HHA policies.
19	Staffing (List full-time equivalent):	Renumbered at #12; The staffing is broken down into direct hire and services under arrangement; Eliminated the staffing categories of pharmacist, dietitian, other; Added 3 categories to reflect the personnel qualifications in the CoPs: physical therapist assistant, occupational therapy assistant, and social work assistant.
20	Home Health Aide Training or Competency Program?	Discontinued collection of this data; this information has no implications for certification processes.
21	Number records reviewed with home visits Number records reviewed, no home visits Number of home visits	Relocated to #14 Survey Data--for the state surveyor to complete; the number of responses are reduced from 4 to 2 under the heading, Survey Data: Total Home Visits Records reviewed, no home visits This data is used to assist with state agency survey scheduling.
22	Patient Census since last survey	Discontinued collection of this data; this information has no implications for the survey and certification process.
23	Surveyor Summary	Discontinued manual collection of this surveyor reported data—form obsolete
1572(d)	Deficiencies	Discontinued manual collection of this surveyor reported data—form obsolete due to ASPEN
1572(c)	Instructions for using the 1572(d)	Discontinued manual collection of this surveyor reported data—form obsolete
1572(e)	Standard, Partial Extended, and Extended surveyor certification statement.	Discontinued collection of this surveyor reported data—form obsolete. Information recorded in ASPEN.

Item #	Revised Form 1572
Title	Home Health Agency Certification Report
1	Name of Facility:
2	Provider Number
3	Street Address:
4	Telephone No
5	Name of Administrator:
6	Administrator Qualification: 1. RN 2. Physician 3. Undergraduate degree
7	Type of Control 01 = Proprietary 02 = Government Operated
8	Has there been a change of ownership since last survey? Yes/No
9	Is this home health agency co-located with a separately Medicare certified Hospice? Yes/No If yes, provide Hospice provider number______
10	Does this home health agency operate branches? If so, how many? Yes/No List official name and full address of all branches 3 lines
11	Services Offered 01 = Nursing Care 02 = Physical Therapy 03 = Occupational Therapy 04 = Speech Therapy 05 = Medical Social Worker 06 = Home Health Aide 07 = Pharmaceutical Services 08 = Infusion Services 09 = Laboratory Services
12	Staffing - List full-time equivalents (not hours), Broken down by direct hire and services under arrangement for greater clarity
P. 2 of 2	1572(b)
13	Type of Survey: (Reported by surveyor)
14	Survey Data: (Reported by surveyor) -Total home visits -Records reviewed, no home visits
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