Accredited Hospice Programs to Use CMS-2567 Form Beginning October 1, 2021

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

On July 13, 2021, the Federal Register published 2021-14866.  (CMS filed the notice on July 12, 2021.) This notice is for hospice programs and their survey process and involves the use of CMS-2567.  Note that there is a 1-month comment period.

(Bolding below added by me.)

1. Type of Information Collection Request: Revision of a currently approved collection; Title of Information Collection: Statement of Deficiency and Plan of Correction

Use: The form CMS-2567 is the means by which State and CMS surveyors document findings of compliance or noncompliance (deficiencies) resulting from inspection of Medicare, Medicaid, and Clinical Laboratory Improvement Amendments (CLIA) laboratories. The form CMS-2567 is the legal, documentary basis for CMS’ certification of a facility’s compliance or noncompliance with the Medicare/Medicaid Conditions of Participation or Coverage, and the requirements for Nursing Home participation and CLIA certification.

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. The 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 fields 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 burden calculations from CMS-1747-P (Medicare and Medicaid Programs; CY 2022 Home Health Prospective Payment System Rate Update), related to the one-time update needed to each of AO’s proprietary electronic systems in order to use the form CMS-2567 as directed by the CAA, 2021.  Form Numbers: CMS-2567 (OMB control number: 0938-0391); Frequency: Yearly and Occasionally; Affected Public: Private Sector (Business or for-profits and Not-for-profit institutions); Number of Respondents: 65,948; Total Annual Responses: 65,948; Total Annual Hours: 1,210,376. (For policy questions regarding this collection contact Caroline Gallaher at 410-786-8705.)

FYI: Supplementary Information

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. Public harm is reasonably likely to ensue if the normal, non-emergency clearance procedures are followed. CMS would miss the statutorily mandated deadline of October 1, 2021 for Accrediting Organizations (AOs), with a hospice program, to begin using the form CMS-2567. AOs will not have the revised form to include in their current survey documentation systems and processes and will not meet the deadline of October 1, 2021 for beginning use. If CMS misses the deadline, it will jeopardize another CAA, 2021 mandated provision deadline for public posting of these AO hospice program survey reports on our website. The purpose of this requirement is for public transparency of survey and certification information. This statutory provision requires that the hospice program survey reports be posted by no later than October 1, 2022. Additionally, the public may not have all the information necessary to make an informed decision regarding where they seek high quality, safe care hospice program organizations for themselves or loved ones. Beneficiaries and the public at large utilize survey findings when evaluating whether to receive care from certain facilities.

Under the PRA, federal agencies are required to publish notice in the Federal Register concerning each proposed ICR. Interested persons are invited to send comments regarding our burden estimates or any other aspect of this ICR including the necessity and utility of the proposed ICR for the proper performance of the agency’s functions, the accuracy of the estimated burden, ways to enhance the quality, utility, and clarity of the information to be collected and the use of automated collection techniques or other forms of information technology to minimize the information collection burden. The public inspection copy is found here.