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 (7-18-19) .doc Supporting Statement A	2019-12-12

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: 201912-0938-007
Status: Active	Previous ICR Reference No: 201511-0938-015
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: Statement of Deficiencies and Plan of Correction (CMS-2567)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/05/2020
	Date Received in OIRA: 12/12/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2023	36 Months From Approved
Responses	64,500	0	0
Time Burden (Hours)	139,750	0	0
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:
	84 FR 42921	08/19/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 66913	12/06/2019
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	0	0	0	0	64,500
Annual Time Burden (Hours)	139,750	0	0	0	11,667	128,083
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: No

Burden Reduction Due to:

Short Statement: The program has not increased in survey frequency since 2015 and remains at 64,500 CMS-2567 forms. The increase is based on inflation of the average national salary since 2015. The annual burden hours increased slightly due to correction of an arithmetic error.

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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? 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: 12/12/2019

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