CMS-10692. Introductory- Email-for-IM Survey

Introductory Email - Draft
Hello,
The Centers for Medicare & Medicaid Services (CMS) is requesting your assistance in completing a
survey regarding incident management systems used for Home and Community Based Services (HCBS).
The purpose of this survey is to help identify best practices that states have adopted in identifying and
reporting incidents, responding to reported incidents, collecting information, training individuals involved in
incident management (IM), and employing tactics to prevent incidents. The CMS will use this information
to inform the provision of future training activities and technical assistance.
We request that states complete a unique survey for each HCBS waiver operated in the state, unless the
underlying IM process are aligned across waivers or the same individual is responsible for multiple
waivers. In these cases, you have an opportunity to indicate such in the survey and complete one survey
for multiple waivers. In light of this request, please note that as you distribute the survey for completion,
respondents completing the survey should be knowledgeable about their waiver program’s incident
management system, including information about the system’s functionalities, reporting and incident
resolution procedures, education/training initiatives, and strategies to improve quality, increase
collaboration, prevent future occurrences, and mitigate fraud, waste, and abuse.
We ask that respondents are honest and give the best possible answers.
Contents of this email
In this email, you will find two items:
1. Web-link to fill out the survey: CMS-CIMS-H&W-Survey
2. PDF document with the full list of survey questions.
Please note that states may only submit responses via the web-based link. The PDF is included for
reference purposes only.
Tips before you take the survey
It may be helpful to familiarize yourself with the questions in the PDF document before you start the webbased survey. However, the web-based survey contains survey logic that is not reflected in the PDF.
Accordingly, some questions in the PDF may not appear in the web-based survey depending on your
responses to previous questions. Please note that it is critical that you respond to all questions presented
to you in the web-based survey, therefore if you find that the question does not apply to you, please
enter/select “N/A” or the equivalent in the web-based link.
The total anticipated completion time for the survey is about 60-90 minutes.
We are requesting that states complete the survey no later than [ENTER DATE].
Should you have any questions or requests for clarification regarding this survey, please email
[email protected].
Thank you for your prompt attention and time addressing this request.
PRA Disclosure Statement: 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-TBD (Expires: TBD). This information
collection is mandatory for states with 1915(c) Home and Community-Based Services waivers (42 U.S.C.
1396n(f)(1)). The Secretary shall monitor the implementation of waivers granted under this section to
assure that the requirements for such waivers are being met and shall, after notice and opportunity for a
hearing, terminate any such waiver determined to be noncompliant. Under the Privacy Act of 1974 any

personally identifying information obtained will be kept private to the extent of the law. The time required
to complete the information collection is estimated to average 60-90 minutes, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.