Statement of Deficiencies and Plan of Correction (CMS-2567)

Forms and Documents

Document Name	Status
Form CMS-2567 Statement of Deficiencies and Plan of Correction Form and Instruction	Modified
CMS-2567 Final Supporting Statement (08-06-15) .doc Supporting Statement A	2015-11-30

IC Document Collections

IC ID	Document Title	Status
8038	Statement of Deficiencies and Plan of Correction Form and Instruction	Modified

ICR Details

OMB Control No: 0938-0391	ICR Reference No: 201511-0938-015
Status: Historical Active	Previous ICR Reference No: 201209-0938-007
Agency/Subagency: HHS/CMS	Agency Tracking No:
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: 07/06/2016
	Date Received in OIRA: 11/30/2015
Terms of Clearance: The agency is required to display the OMB Control Number and inform respondents of its legal significance in accordance with 5 CFR 1320.5(b).

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2019	36 Months From Approved	07/31/2016
Responses	64,500	0	62,000
Time Burden (Hours)	128,083	0	134,333
Cost Burden (Dollars)	0	0	0

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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.

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

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 53516	09/04/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 70810	11/16/2015
Did the Agency receive public comments on this ICR? No

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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

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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	64,500	62,000	0	2,500	0	0
Annual Time Burden (Hours)	128,083	134,333	0	-6,250	0	0
Annual Cost Burden (Dollars)	0	0	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The increase from 62,000 to 64,500 CMS-2567 forms is due to an increase in the survey frequency for some provider types, the increase in the number of certified providers, and an increase in the number of complaint surveys conducted.

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Annual Cost to Federal Government: $1,600

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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Common Form ICR:  No

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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: 11/30/2015

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