View Information Collection Request (ICR) Package

OMB Control No: 0938-0391	ICR Reference No: 202201-0938-003
Status: Active	Previous ICR Reference No: 202107-0938-004
Agency/Subagency: HHS/CMS	Agency Tracking No: CCSQ
Title: Statement of Deficiencies and Plan of Correction (CMS-2567)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/18/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/07/2022
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2025	36 Months From Approved	03/31/2022
Responses	65,948	0	65,948
Time Burden (Hours)	1,187,064	0	1,210,376
Cost Burden (Dollars)	0	0	0

Abstract: This Paperwork package provides information regarding the form used by the Medicare, Medicaid, and the Clinical Laboratory Improvement Amendments (CLIA) programs to document a health care facility's compliance or noncompliance (deficiencies) with regard to the Medicare/Medicaid Conditions of Participation and Coverage, the requirements for participation for Skilled Nursing Facilities and Nursing Facilities, and for certification under CLIA. This form becomes the evidentiary basis for CMS certification decisions (including termination or denial of participation), and the form of public disclosure. 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: Accreditation Commission for Health Care, Inc. (ACHC), Community Health Accreditation Partner (CHAP), and The Joint Commission (TJC). These three 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 a field 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 COI/RIA burden calculations from CMS-1747-P related to the one-time update needed to each AO’s proprietary electronic systems in order to use the form CMS-2567 as directed by the CAA, 2021.

Authorizing Statute(s): US Code: 42 USC 488.26 Name of Law: Determining Compliance
   US Code: 42 USC 488.18 Name of Law: Documentation Findings
   US Code: 42 USC 488.28 Name of Law: Providers or Suppliers, other than SNFs and NFs, with deficiencies

Citations for New Statutory Requirements: None

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

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 58664	10/22/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 979	01/07/2022
Did the Agency receive public comments on this ICR? Yes

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

IC Title	Form No.	Form Name
Statement of Deficiencies and Plan of Correction	CMS-2567	Statement of Deficiencies and Plan of Correction

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	65,948	65,948	0
Annual Time Burden (Hours)	1,187,064	1,210,376	-23,312
Annual Cost Burden (Dollars)	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: No

Burden Reduction Due to:

Short Statement: The total annual time burden has decreased by 23,312 hours, and the total annual cost burden has decreased by $1,349,706. in the previous PRA package a one-time cost and time burden added for the time required for the AOs to incorporate the CMS-2567 format into their proprietary electronic documentation systems. As this was a one-time burden, we have not included this time and cost burden in this PRA package.

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

Agency Contact: Denise King 410 786-1013 Denise.King@cms.hhs.gov

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