Approved for use through 7/2000 under the condition that HCFA immediately incorporates the new disclosure statements mandated by the Paperwork Reduction Act of 1995. For the public record, HCFA must submit to OMB the revised forms/instructions.
Inventory as of this Action
Requested
Previously Approved
08/31/2000
08/31/2000
07/31/1997
2,150
0
1,400
5,375
0
3,500
0
0
0
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.
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:
(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;
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.
Hospice Survey and Deficiencies Report Form and Supporting Regulations -- 42 CFR 488, 488.26(c), 442.30(a)(4), 442 subparts B, C, D, E, and F