CMS-643 Hospice Survey and Deficiencies Report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB No. 0938-0379

HOSPICE SURVEY AND DEFICIENCIES REPORT
(CMS-643)

Medicare Certification Number:

Name of Facility:

Survey Date:

1. Was this Hospice surveyed for compliance with 42 CFR 418.110?

1.50

2. If this hospice provides inpatient care directly, is this inpatient care provided on the premises?

1.51

3. Has a waiver of core nursing services been granted?

1.53

YES

NO

YES

NO

YES

NO

1.52

4. If “Yes” indicate date

5. Indicate type of setting(s) in which the hospice provides routine home care.
Private Residence

SNF

NF

Other

1.54

Specify:

6. Number of hospice patients residing in a SNF, NF, or other residential facility who receive routine
home care from the hospice.

1.55

7. Number of hospice patients admitted during the most recent 12-month period.

1.56

8. Number of records reviewed during survey.

1.57

9. Number of home visits conducted to patients in a private residence.

1.58

10. Number of home visits conducted to patients in residential facilities.

1.59

11. Does this hospice operate under the same certification
number at more than one location?

1.60

12. If YES, enter number of
locations

1.61

13. Does this hospice operate as part of another entity
that participates in the Medicare Program?

1.62

14. If YES, enter the Medicare
certification number of the entity

1.65

YES

NO

YES

NO

Surveyor’s Signature:

CMS-643 / OMB Approval Expires 09/30/2022

Title:

Date:

Page 1

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB No. 0938-0379

HOSPICE SURVEY AND DEFICIENCIES REPORT
(CMS-643)

Deficiencies
Data Tag Number

COP/Standard No.

CMS-643 / OMB Approval Expires 09/30/2022

Comments

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

FORM APPROVED
OMB No. 0938-0379

ATTESTATION STATEMENT
I certify that I have reviewed each CMS hospice Condition of Participation and related standards and except as
indicated on this form the above-stated facility was found to comply with the CMS standards and/or the
Conditions of Participation.
Surveyor’s Signature

Title

Date

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 0938-0379 (Expires 09/30/2022). This is a mandatory information collection. The time
required to complete this information collection is estimated to average twenty-four hours per response,
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.

****CMS Disclosure****
Please do not send applications, claims, payments, medical records or any documents containing sensitive
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information collection burden approved under the associated OMB control number listed on this form will not
be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your
documents, please contact [email protected].

CMS-643 / OMB Approval Expires 09/30/2022

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