Crosswalk

Revisions to CMS-2567

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

Previous Page #	Current Page #	Section	Action to be performed	Changes to the Application	Reasons for the Change
1	1	Facility information	Added section for the name of the Accrediting Organization (AO) performing the survey (if applicable).	A box was added for the AO name to be filled in for transparency purposes.	Since § 407 of CAA of 2021 and §1822 of the Social Security Act require AOs to begin using the CMS-2567 form for hospice program surveys, effective 10/01/2021, we must modify the form CMS-2567 so that it can be used by the AOs. More specifically, we have added a new line (under the line containing data fields for “Name of Facility” and “Street Address, City, State, Zip Code” in which to insert the name of the State Survey Agency or Accrediting Organization performing the survey. Currently there is a different SA for each state in the U.S. and three AOs who would use this form and it needs to be clear to CMS and the public, who performed the survey.
1	2	Instructions	Instructions updated	The instructions were updated to include AOs as users of the form CMS-2567.	The instructions for the form CMS-2567 were updated to reflect that AOs can also utilize the form CMS-2567.