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 patientsâ health and provider compliance with requirements and report information to the Federal Government.
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
The slight change in annual hourly burden is due to a decrease in the estimated number of surveys per year, for which we look to the number of surveys in the prior calendar year. The new hourly burden is estimated to be 849 hours per year, compared to 958 in the currently approved package.
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.
Form CMS-1572 Home Health Agency Survey and Deficiencies Report
2017 CMS-1572 supp stmt 01-05-18.doc
Home Health Agency Survey and Deficiencies Report