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View ICR - OIRA Conclusion

OMB Control No: 0938-0379	ICR Reference No: 202212-0938-011
Status: Active	Previous ICR Reference No: 201907-0938-005
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
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/16/2023
	Date Received in OIRA: 12/27/2022
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2026	36 Months From Approved
Responses	2,051	0	0
Time Burden (Hours)	49,224	0	0
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses	2,051	451	1,600
Annual Time Burden (Hours)	49,224	47,624	1,600
Annual Cost Burden (Dollars)	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: The number of annual responses has increased by 451 and the annual burden hours have increased by 47,624 hours. The increase in time and cost burdens are directly attributable to 2 factors. First, the number of annual responses has increased by 451, which would cause an increase in the time and cost burdens. Second, the writers of the previous PRA packages allowed only 1 hour for completion of the CMS-643 form. However, no time was allotted for the performance of the survey, during which the data used to complete the CMS-643 form is collected. We estimate that a hospice survey takes approximately 24 hours to complete, including completion of the CMS-643 form and input of the data into the CASPER system.

Annual Cost to Federal Government: $125

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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