Statement of Deficiencies and Plan of Correction (CMS-2567)

ICR 202201-0938-003

OMB: 0938-0391

Federal Form Document

Forms and Documents
Form and Instruction
Supplementary Document
Supporting Statement A
IC Document Collections
ICR Details
0938-0391 202201-0938-003
Received in OIRA 202107-0938-004
Statement of Deficiencies and Plan of Correction (CMS-2567)
Extension without change of a currently approved collection   No
Regular 01/07/2022
  Requested Previously Approved
36 Months From Approved 02/28/2022
65,948 65,948
1,187,064 1,210,376
0 0

This Paperwork package provides information regarding the form used by the Medicare, Medicaid, and the Clinical Laboratory Improvement Amendments (CLIA) programs to document a health care facility's compliance or noncompliance (deficiencies) with regard to the Medicare/Medicaid Conditions of Participation and Coverage, the requirements for participation for Skilled Nursing Facilities and Nursing Facilities, and for certification under CLIA. This form becomes the evidentiary basis for CMS certification decisions (including termination or denial of participation), and the form of public disclosure. In December, 2020, Congress passed the Consolidated Appropriations Act, 2021 (CAA, 2021). Section 407 of CAA, 2021, amended Part A of Title XVIII of the Social Security Act (the Act) at section 1822 establishing hospice program survey and enforcement requirements. This amendment, in part, now requires the Accrediting Organizations (AOs) that accredit hospice programs to include the form CMS-2567 to document the findings of their hospice program surveys beginning on October 1, 2021. As of June 2021, there are three AOs with CMS-approved hospice accreditation programs: Accreditation Commission for Health Care, Inc. (ACHC), Community Health Accreditation Partner (CHAP), and The Joint Commission (TJC). These three AOs survey approximately half of the over 5,000 Medicare-certified hospice programs, while the SAs survey the remaining half. To enable AOs to use the form CMS-2567, we must revise it by adding a field for the AO name. Also, the instructions must be updated to include AOs as another group which utilizes the form CMS-2567. We have also included the COI/RIA burden calculations from CMS-1747-P related to the one-time update needed to each AO’s proprietary electronic systems in order to use the form CMS-2567 as directed by the CAA, 2021.

US Code: 42 USC 488.26 Name of Law: Determining Compliance
   US Code: 42 USC 488.18 Name of Law: Documentation Findings
   US Code: 42 USC 488.28 Name of Law: Providers or Suppliers, other than SNFs and NFs, with deficiencies

Not associated with rulemaking

  86 FR 58664 10/22/2021
87 FR 979 01/07/2022

IC Title Form No. Form Name
Statement of Deficiencies and Plan of Correction CMS-2567 Statement of Deficiencies and Plan of Correction

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 65,948 65,948 0 0 0 0
Annual Time Burden (Hours) 1,187,064 1,210,376 0 0 -23,312 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
The total annual time burden has decreased by 23,312 hours, and the total annual cost burden has decreased by $1,349,706. in the previous PRA package a one-time cost and time burden added for the time required for the AOs to incorporate the CMS-2567 format into their proprietary electronic documentation systems. As this was a one-time burden, we have not included this time and cost burden in this PRA package.

Denise King 410 786-1013 [email protected]


On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

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