CMS-1572 Home Health Agency and Deficiencies Report

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

FORM APPROVED
OMB N0. 0938-0355

HOME HEALTH AGENCY SURVEY REPORT
(CMS-1572)
PART 1: To Be Completed by Facility Staff
1. Name of Facility:

2. Provider No:

3. Street Address:

4. Telephone:

5. Name of Administrator:

6. Administrator Qualification:
1 = RN 2=Physician

7. Type of Control:
01 = Proprietary
03 = Non-Profit

3 = Undergrad degree 4=Other

8. Has there been a change of ownership of the
02 = Government Operated

facility since last survey?

Yes

9. Is this home health agency co-located with a separately Medicare-certified Hospice?
If yes, provide the hospice Medicare provider number:

10. Does this home health agency operate any branch locations?
If yes, how many branch locations?

Yes

No

Yes

No

No

Indicate all branch locations below (including official name and full mailing address).

If additional space is needed, attach separate page and check this box.
Branch No.

Branch Name

Branch Mailing Address

Branch #1
Branch #2
Branch #3

Branch #4
Form CMS-1572 / OMB Approval Expires 07/31/2024

Page 1

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

FORM APPROVED
OMB N0. 0938-0355

11. Services Provided:
For each type of care services provided, indicate how this service is provided:
1 = HHA staff

Response

Type of Service Provided

01 – Skilled Nursing

2 = Under Arrangement

02 – Physical Therapy

3 = Combination

03 – Occupational Therapy
04 – Speech Therapy
05 – Social Worker

06 – Home Health Aide

07 – Pharmaceutical Services
08 – Infusion Services

09 – Laboratory Services
12. Staffing - List full-time equivalents (not hours):

Direct Hire Staff

FTE(s)

10 – Outpatient Therapy Services

Staff Under Arrangement

Registered Nurses

Registered Nurses

Physical Therapist Assistants

Physical Therapist Assistants

Licensed Practical Nurses
Physical Therapists

Occupational Therapists

Occupational Therapist Assistants

Licensed Practical Nurses
Physical Therapists

Occupational Therapists

Occupational Therapist Assistants

Speech-Language Pathologists

Speech-Language Pathologists

Home Health Aides

Home Health Aides

Social Workers

Social Work Assistants

Name and Title of Person Completing Form:

FTE(s)

Social Workers

Social Work Assistants

Date Form Completed:

Form CMS-1572 / OMB Approval Expires 07/31/2024

Page 2

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

FORM APPROVED
OMB N0. 0938-0355

PART 2: To Be Completed By The Surveyor
13. Type of Survey:
Initial Survey:

Recertification:

1 = Standard
2 = Partial Extended
3 = Extended
4 = 1 and 2
5 = 1 and 3
6 = 1, 2, and 3

14. Survey Data:

Total Number of Home Visits:

Number of Records Reviewed, No Home Visits:
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 0938-0355. The time required to complete this information collection is
estimated to average 30 minutes per response, including the time to review instructions, search existing
data resources, and 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 Disclaimer*****
Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to
the 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]. OMB approval expiration date:
07/31/2024

Form CMS-1572 / OMB Approval Expires 07/31/2024

Page 3