Hospice Survey and Deficiencies Report Form (CMS-643)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-643 Hospice Survey and Deficiencies Report	Form	Modified	Available
Supporting Statement for CMS-643 (clean 3-30-26).docx	Supporting Statement A	Uploaded 2026-07-20	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
8022	Hospice Survey and Deficiencies Report Form (CMS-643)	Form	Modified	Hospice Survey and Deficiencies Report

ICR Details

OMB Control No: 0938-0379	ICR Reference No: 202607-0938-007
Status: Received in OIRA	Previous ICR Reference No: 202212-0938-011
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Hospice Survey and Deficiencies Report Form (CMS-643)
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/21/2026

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	2,343	0
Time Burden (Hours)	1,172	0
Cost Burden (Dollars)	0	0

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Abstract: In order to participate in the Medicare program, a hospice must meet certain Federal health and safety conditions of participation. This form will be used by State surveyors to record data about a hospice's compliance with these conditions of participation in order to initiate the certification or recertification process.

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Authorizing Statute(s): US Code: 42 USC 442.30 Name of Law: Agreement as evidence of Certification
   US Code: 42 USC 488.26 Name of Law: Determining Compliance
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 23271	04/30/2026
30-day Notice:	Federal Register Citation:	Citation Date:
	91 FR 43642	07/16/2026
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Hospice Survey and Deficiencies Report Form (CMS-643)	CMS-643	Hospice Survey and Deficiencies Report

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ICR Summary of Burden

table that charts list of burden

	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	2,343	0	0	292	0	2,051
Annual Time Burden (Hours)	1,172	0	0	-48,052	0	49,224
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Tthe number of annual surveys has increased from 2,051 to 2,343 which is 292 based on hospice growth. The burden hours decreased significantly from 49,224 hours to 1,172 hours. The annual burden has been recalculated to reflect 30 minutes for completion of the hospice to gather the information for the surveyors to complete the CMS-643 form. We note the significant decrease in the burden hours, and cost is due to our reevaluation of the form and the survey entities which incur the burden. We have also revised the form to reduce duplication of information collected and also adjusted the burden calculations to reflect the time that the hospice will take to gather documentation to support the surveyor in completing this form as part of the standard survey process (refer to Section 14). In the prior cost analysis, calculated the burden hours and cost of surveyors collecting and reporting this information. CMS allocates funding to each state for the reasonable costs of surveying to certify compliance or non-compliance of providers and suppliers as specified in the 1864 Agreement, therefore calculation of surveyor costs was unnecessary in the prior form package. Completing the CMS-643 form imposes minimal cost burden to hospice providers as the documentation provided to the State Survey Agencies and Accrediting Organizations (AOs) for deemed hospices surveyors is part of documentation the hospice needs to provide to demonstrate compliance to participate in the Medicare program.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/21/2026

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