Form Cms-643 - Hospice Survey And Deficiencies Report
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2Form Approved
DePArtMeNt OF HeAltH AND HuMAN ServiCeS
OMB No. 0938-0379
CeNterS FOr MeDiCAre & MeDiCAiD ServiCeS
Hospice survey and deficiencies report
Page ____ of ____
CertiFiCAtiON NuMBer
NAMe OF FACility
Survey DAte
1. Was this hospice surveyed for compliance with 42 CFR 418.110?
L50
o
o
Yes
No
2. If this hospice provides inpatient care directly, is the inpatient care provided on the premises?
L51
o
o
Yes
No
3. Has a waiver of core nursing services been granted?
4. If “Yes” indicate date
L52
L53
o
o
Yes
No
5.
Indicate type of setting(s) in which the hospice provides routine home care.
L54
o
o
o
o
Private residence
SNF
NF
Other (specify)
6. Number of hospice patients residing in a SNF, NF or other residential facility who receive routine home care
L55
from the hospice.
7. Number of hospice patients admitted during recent 12 month period.
L56
8. Number of records reviewed during survey.
L57
9. Number of home visits conducted to patients in a private residence.
L58
10. Number of home visits conducted to patients in residential facilities.
L59
11. Does this hospice operate under the same certification
12. If “Yes” enter
L60
L61
number at more than one location?
number of locations.
o
o
Yes
No
14. If “Yes” enter the Medicare
13. Does this hospice operate as part of another entity that participates
L62
L63
certification number of the entity.
in the Medicare program?
o
o
Yes
No
SurveyOr SigNAture
title
DAte
According to the Paperwork reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
the valid OMB control number for this information collection is 0938-0379. the time required to complete this information collection is estimated to average 1 hour
per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
if you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PrA reports Clearance
Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
CMS-643 (06/08)
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Parent category: Medical