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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0938-0355
ICR Reference No:
202301-0938-012
Status:
Active
Previous ICR Reference No:
202102-0938-001
Agency/Subagency:
HHS/CMS
Agency Tracking No:
20516
Title:
Home Health Agency Survey and Deficiencies Report and Supporting Regulations (CMS-1572)
Type of Information Collection:
Revision of a currently approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
06/20/2023
Retrieve Notice of Action (NOA)
Date Received in OIRA:
01/31/2023
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
06/30/2026
36 Months From Approved
07/31/2024
Responses
3,833
0
3,833
Time Burden (Hours)
1,917
0
1,917
Cost Burden (Dollars)
142,778
0
142,778
Abstract:
In order to participate in the Medicare program as a Home Health Agency (HHA) provider, the HHA must meet Federal standards. The survey forms summarize data relative to provider characteristics, the patient population, and special needs of the patient populations. These forms are used to record information about patients’ health and provider compliance with requirements and report information to the Federal Government.
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
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:
87 FR 67036
11/07/2022
30-day Notice:
Federal Register Citation:
Citation Date:
88 FR 2930
01/18/2023
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
Home Health Agency Survey and Deficiencies Report
CMS-1572, CMS-1572
Home Health Agency And Deficiences Report
,
Home Health Agency and Deficiencies Report
ICR Summary of Burden
Total Approved
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
3,833
3,833
0
0
0
0
Annual Time Burden (Hours)
1,917
1,917
0
0
0
0
Annual Cost Burden (Dollars)
142,778
142,778
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:
No
Burden Reduction Due to:
Short Statement:
Annual Cost to Federal Government:
$9,818
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
Common Form ICR:
No
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:
01/31/2023
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